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Based on observation and testing, the facility failed to provide walls constructed with at least 1/2 hour fire resistance rating.

Findings include:

While inspecting corridor walls on April 17, 2012 at 10:25 p.m., the surveyor observed penetrations around computer wiring in the corridor walls above every patient room. These deficient practices have the potential of effecting the entire facility. The administrator was notified during the exit conference.

Based on observations the facility failed to provide the required 30 minute fire resistance rating for smoke barrier walls in accordance with 19.3.7.3, 19.1.6.3, 19.1.6.4.

Finding include:

While inspecting smoke barrier walls on April 17, 2012 at 10:45 a.m., the maintenance supervisor and the surveyor observed the smoke barrier walls had penetrations around computer wiring above the corridor doors, next to medical records.

This deficient practice has the potential of affecting the entire facility.

The administrator was notified during the exit conference.

Based on observation and testing, the facility failed to provide the one hour fire rated construction (with 45 minute fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4.

Findings include:

On April 17, 2012 at 10:45 a.m., the maintenance person and the the surveyor found the following deficient items in hazardous areas:

1. Penetration around computer wiring in the rated wall around medical records.
2. Penetrations around computer wiring and sprinkler pipes in the rated wall above the door in the
purchasing storage room.
3. Storage room near radiology did not have a door closure installed.
4. Medical records storage room on the 2nd floor did not have a door closure installed.

This deficient practice has the potential of affecting the entire facility.

The administrator was notified during the exit conference.

Based on observation and record review, the facility failed to properly test and maintained the automatic sprinkler system contrary to NFPA 13, NFPA 25.

Findings include:

On April 17, 2012 at 12:30 p.m., the facility could not provide documentation stating that they had performed the quarterly test on the sprinkler system. The maintenance supervisor advised that he was not aware that this had to be done quarterly.

This deficient practice has the potential of affecting the entire facility.

The administrator was notified during the exit conference.

Based on observations, the facility failed to provide clear and unobstructed means of egress as directed in NFPA 101 chapter 7.1.10.1.

Findings include:

On April 17, 2012 at 11:00 a.m., the maintenance person and the surveyor found the following means of egress were partially blocked:
1. The exit corridor near the lab entrance was partially blocked by a bed, chairs and a table.
2. The exit corridor behind surgery on the 2nd floor was blocked by old furniture, beds, chairs and
wooden pallets.

This deficient practice has the potential of affecting the entire facility.

The administrator was notified during the exit conference.

Based on observations the facility failed to provide the required monthly generator testing in accordance with NFPA 99.

Findings include:

While reviewing generator testing documentation on April 17, 2012 at 11:30 a.m., the facility failed to provide the yearly, monthly, and weekly generator testing documentation for the facilities generator.

This deficient practice has the potential of affecting the entire facility.

The administrator was notified during the the exit conference.

Based on observation and testing, the facility failed to provide walls constructed with at least 1/2 hour fire resistance rating.

Findings include:

While inspecting corridor walls on April 17, 2012 at 10:25 p.m., the surveyor observed penetrations around computer wiring in the corridor walls above every patient room. These deficient practices have the potential of effecting the entire facility. The administrator was notified during the exit conference.

Based on observations the facility failed to provide the required 30 minute fire resistance rating for smoke barrier walls in accordance with 19.3.7.3, 19.1.6.3, 19.1.6.4.

Finding include:

While inspecting smoke barrier walls on April 17, 2012 at 10:45 a.m., the maintenance supervisor and the surveyor observed the smoke barrier walls had penetrations around computer wiring above the corridor doors, next to medical records.

This deficient practice has the potential of affecting the entire facility.

The administrator was notified during the exit conference.

Based on observation and testing, the facility failed to provide the one hour fire rated construction (with 45 minute fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4.

Findings include:

On April 17, 2012 at 10:45 a.m., the maintenance person and the the surveyor found the following deficient items in hazardous areas:

1. Penetration around computer wiring in the rated wall around medical records.
2. Penetrations around computer wiring and sprinkler pipes in the rated wall above the door in the
purchasing storage room.
3. Storage room near radiology did not have a door closure installed.
4. Medical records storage room on the 2nd floor did not have a door closure installed.

This deficient practice has the potential of affecting the entire facility.

The administrator was notified during the exit conference.

Based on observation and record review, the facility failed to properly test and maintained the automatic sprinkler system contrary to NFPA 13, NFPA 25.

Findings include:

On April 17, 2012 at 12:30 p.m., the facility could not provide documentation stating that they had performed the quarterly test on the sprinkler system. The maintenance supervisor advised that he was not aware that this had to be done quarterly.

This deficient practice has the potential of affecting the entire facility.

The administrator was notified during the exit conference.

Based on observations, the facility failed to provide clear and unobstructed means of egress as directed in NFPA 101 chapter 7.1.10.1.

Findings include:

On April 17, 2012 at 11:00 a.m., the maintenance person and the surveyor found the following means of egress were partially blocked:
1. The exit corridor near the lab entrance was partially blocked by a bed, chairs and a table.
2. The exit corridor behind surgery on the 2nd floor was blocked by old furniture, beds, chairs and
wooden pallets.

This deficient practice has the potential of affecting the entire facility.

The administrator was notified during the exit conference.

Based on observations the facility failed to provide the required monthly generator testing in accordance with NFPA 99.

Findings include:

While reviewing generator testing documentation on April 17, 2012 at 11:30 a.m., the facility failed to provide the yearly, monthly, and weekly generator testing documentation for the facilities generator.

This deficient practice has the potential of affecting the entire facility.

The administrator was notified during the the exit conference.