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Based on observations the facility failed to provide the required two hour fire rated wall separating a non-conforming building from the hospital.

Findings Include:

While inspecting the EVS building on 5/19/2010 at 3:15 p.m., the surveyor observed the firewall separating the facility type 2 (222) construction from the EVS building type 5 (000) construction with unsealed penetrations and a non-fire rated door.

This deficient practice has the potential of affecting 1 of 14 smoke compartments. No patient rooms or patient treatment areas can be affected by this deficiency. The administrator and the maintenance director were notified during the survey as well as in the exit conference.

Based on observations the facility failed to provide the required 2 hour fire protection for structural steel for a 4 story building with a construction type of 2 (222).

Findings Include:

While inspecting the non-sprinkled 3rd Floor Main Hall nurses station on 5/18/2010 at 11:45 a.m., the surveyor observed unprotected steel above the lay-in ceiling located in the dictation area of the nurses station.

This deficient practice has the potential of affecting the 3rd and 4th Floor. Three patient treatment areas on the 3rd Floor Main Hall have the potential to be affected by this deficiency. The administrator and the maintenance director were notified during the survey as well as in the exit conference.

Based on observations the facility failed to provide the required ½ hour fire resistance rating for corridor walls in a non-sprinkled smoke compartment.

Findings Include:

While inspecting corridor walls on 5-18 and 5-19, 2010 the surveyor observed the following corridor walls with unsealed penetrations throughout.
1. While inspecting the 3rd Floor at 1:00 p.m., the 3 Main East Hallway, 3 North Center Hallway, 3 Main 312 to 326 Hallway, and 3 Center Quality Management Hallway was observed with unsealed penetrations throughout.
2. While inspecting the 2nd Floor at 3:00 p.m., the 2 East Hallway and the 2 Main Center Hallway was observed with unsealed penetrations throughout.
3. While inspecting the 1st Floor at 9:30 a.m., the corridor walls around Room 176 , First Floor Main Corridor, and the CCU Corridor wall was observed with unsealed penetrations throughout.

This deficient practice has the potential of affecting the 1st, 2nd, and 3rd Floors. The administrator and the maintenance director were notified during the survey as well as in the exit conference.

Based on observations the facility failed to provide the required 2 hour fire rating for vertical openings in a 4 story building.

Findings Include:

While inspecting vertical shafts on 5/19/2010 at 4:00 p.m., the surveyor observed the east wing elevator shaft, the west wing elevator shaft, and the MOB elevator shaft with unsealed penetrations throughout.

This deficient practice has the potential of affecting the 1st, 2nd, 3rd and 4th Floors. The administrator and the maintenance director were notified during the survey as well as in the exit conference.

Based on observations the facility failed to provide the required self closing door for a 2 hour fire rated stairway.

Findings Include:

While inspecting stairway doors on 5/18/2010 at 1:20 p.m., the surveyor observed the 2nd Floor Nursery Unit stairway door did not close if opened more than half way of its swing due to binding or dragging.

This deficient practice has the potential of affecting the entire nursery unit. The administrator and the maintenance director were notified during the survey as well as in the exit conference.

Based on observations the facility failed to provide the required ½ hour rated construction for smoke barrier walls.

Findings Include:

While inspecting smoke barrier walls on 5-18, 5-19, 2010 the surveyor observed the following smoke barrier walls with unfinished construction or unsealed penetrations throughout.
1. On 5-18-2010 at 10:30 a.m., the Three East Smoke Barrier Wall at the nurse supervisor station was found with unsealed penetrations throughout.
2. On 5-18-2010 at 10:55 a.m., the Three West Smoke Barrier Wall was found with unsealed penetrations throughout.
3. On 5-18-2010 at 2:30 p.m., the Two East Smoke Barrier Wall was found with unsealed penetrations throughout.
4. On 5-18-2010 at 2:50 p.m., the Two Main Smoke Barrier Wall was found with unsealed penetrations throughout.
5. On 5-18-2010 at 4:20 p.m., the smoke barrier wall across from Room 171 on the Flowers Wing was found with unsealed penetration located inside the soiled linen room.
6. On 5-19-2010 at 10:00 a.m., the First Floor Smoke Barrier on the 154 through 165 Wing was found with unsealed penetrations throughout.
7. On 5-19-2010 at 11:55 a.m., the First Floor Smoke Barrier across from the pharmacy was found with unsealed penetrations throughout.

This deficient practice has the potential of affecting the entire facility. The administrator and the maintenance director were notified during the survey as well as in the exit conference.

Based on observations the facility failed to provide the required 1 hour fire rating for hazardous areas in non-sprinkled locations.

Findings Include:

While inspecting hazardous areas on 5-18 and 5-19, 2010 the surveyor observed the following hazardous areas with unfinished construction or unsealed penetrations throughout.
1. On 5-18 at 9:00 a.m., the 3rd Floor Mechanical Room Number 5 was observed with unsealed penetrations.
2. On 5-18 at 9:05 a.m., the 3rd Floor Mechanical Room Number 3 was observed with unsealed penetrations.
3. On 5-18-2010 at 10:15 a.m., the 2nd Floor Telemetry Room was observed with unsealed penetrations.
4. On 5-19-2010 at 9:15 a.m., the 1st Floor soiled Utility Room across from Room 151 was observed with unfinished construction and unsealed penetrations.
5. On 5-19-2010 at 9:35 a.m., the 1st Floor Sterile Supply Room was observed with unsealed penetrations throughout.
6. On 5-19-2010 at 9:55 a.m., the 1st Floor CCU Unit Soiled Linen Room was observed with unfinished construction and unsealed penetrations.
7. On 5-19-2010 at 10:35 a.m., the 1st Floor E.R. Soiled Linen Room was observed with unfinished construction and unsealed penetrations.
8. On 5-19-2010 at 1:55 p.m., the 1st Floor Lab Storage Room was observed without the required self-closing hardware on the door.
9. On 5-19-2010 at 3:10 p.m., the 1st Floor Fire Wall surrounding the boiler room was found with unsealed penetrations.
10. On 5-19-2010 at 3:25 p.m., the 1st Floor Chemical Lab Storage was observed without the required self closing hardware on the door.
11. On 5-19-2010 at 3:35 p.m., the 1st Floor Gas Fired Equipment Room behind the kitchen cooking equipment was observed with unfinished construction and unsealed penetrations throughout.
12. On 5-19-2010 at 3:55 p.m. the 1st Floor Mechanical Room #3 was observed with unsealed penetrations throughout.
13. On 5-19-2010 at 4:40 p.m., the 1st Floor Radiology Soiled Room was observed without fire rated construction, without a 45 minute fire rated door, and without self closing hardware on the door.


This deficient practice has the potential of affecting the entire facility. The administrator and the maintenance director were notified during the survey as well as in the exit conference.

Based on observations the facility failed to provide exits that terminate directly onto a public way.

Findings Include:

While inspecting the means of egress on 5-19-2010 at 3:00 p.m., the surveyor observed 5 required exit locations that terminate into an enclosed interior courtyard. These exits include the CCU exit, (2) Main Hall exits, the West 3 Stairway, and the Lab exit.

Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be required width and size to provide all occupants with safe access to a public way. 19.2.1, 7.7

This deficient practice has the potential of affecting the 8 of 14 smoke compartments. The administrator and the maintenance director were notified during the survey as well as in the exit conference.

Based on observations the facility failed to provide a continuous path of escape that provides protection against fire or smoke in an exit component.

Findings Include:

While inspecting stairways on 5/19/2010 at 3:50 p.m., the surveyor observed the business office stairway and the cafeteria stairway exiting into an exit passage corridor instead of into an exterior location leading to a public way. The corridor however was found with numerous unsealed penetrations throughout.

This deficient practice has the potential of affecting means of egress on the 2nd, 3rd, and 4th floors. The administrator and the maintenance director were notified during the survey as well as in the exit conference.

Based on observations the facility failed to continuously maintain the fire alarm system in an occupied health care facility in accordance with NFPA 101, Chapter 19, Section 19.3.4.3, 9.6.3, NFPA 72 Chapter 7, Section 7-1.1.1.

On May 19, 2010 at 4:15 p.m., the surveyor and maintenance director at North West Regional Medical Center performed a fire alarm test on the 3rd Floor. The manual pull station in the main wing of the 3rd Floor was initiated, upon initiation the surveyor observed all fire doors closing but no audible and visual notification devices initiated. At 4:20 p.m., the surveyor inspected the 4th floor, 3rd Floor, 2nd Floor, and the 1st Floor discovering the audible and visual notification devices were inoperable on all floor but the 1st Floor. At 4:40 p.m., the surveyor requested the fire alarm system to be reset and a manual station on the 2nd Floor Main Hall to be initiated, the system was then observed inoperable. At 4:50 p.m. the surveyor contacted the Division of Health Facilities Fire Safety and Construction and reported the findings and the number of residents inside the facility. At 5:15 p.m., the Immediate Jeopardy was announced. At 5:45 p.m., the Chief Operating Office and the Maintenance Director Submitted the AOC to the State Agency for approval. At 7:30 p.m., the Final draft of the AOC was completed and approved by the Mississippi State Department of Health. At 8:00 p.m., the maintenance director along with Johnson Controls, Fire Alarm Installer discovered a cut low voltage wire causing a short in the system. At 8:45 p.m., Johnson Controls corrected the wiring and issued a certification. At 8:50 p.m., the immediate jeopardy was abated.

This deficient practice has the potential of affecting the 100% of staff and residents inside the facility. The administrator and the maintenance director were notified during the survey and in the exit conference.

§482.41(b) (1) (i) Medicare-participating hospitals, regardless of size or number of beds, must comply with the hospital/healthcare Life Safety Code requirements for all inpatient care locations. Hospital departments and locations such as emergency departments, outpatient care locations, etc. must comply with hospital/healthcare Life Safety Code Requirements. Additionally, the hospital must be in compliance with all applicable codes referenced in the Life Safety Code.

Based on observations the facility failed to provide the required two hour fire rated wall separating a non-conforming building from the hospital.

Findings Include:

While inspecting the EVS building on 5/19/2010 at 3:15 p.m., the surveyor observed the firewall separating the facility type 2 (222) construction from the EVS building type 5 (000) construction with unsealed penetrations and a non-fire rated door.

This deficient practice has the potential of affecting 1 of 14 smoke compartments. No patient rooms or patient treatment areas can be affected by this deficiency. The administrator and the maintenance director were notified during the survey as well as in the exit conference.

Based on observations the facility failed to provide the required 2 hour fire protection for structural steel for a 4 story building with a construction type of 2 (222).

Findings Include:

While inspecting the non-sprinkled 3rd Floor Main Hall nurses station on 5/18/2010 at 11:45 a.m., the surveyor observed unprotected steel above the lay-in ceiling located in the dictation area of the nurses station.

This deficient practice has the potential of affecting the 3rd and 4th Floor. Three patient treatment areas on the 3rd Floor Main Hall have the potential to be affected by this deficiency. The administrator and the maintenance director were notified during the survey as well as in the exit conference.

Based on observations the facility failed to provide the required ½ hour fire resistance rating for corridor walls in a non-sprinkled smoke compartment.

Findings Include:

While inspecting corridor walls on 5-18 and 5-19, 2010 the surveyor observed the following corridor walls with unsealed penetrations throughout.
1. While inspecting the 3rd Floor at 1:00 p.m., the 3 Main East Hallway, 3 North Center Hallway, 3 Main 312 to 326 Hallway, and 3 Center Quality Management Hallway was observed with unsealed penetrations throughout.
2. While inspecting the 2nd Floor at 3:00 p.m., the 2 East Hallway and the 2 Main Center Hallway was observed with unsealed penetrations throughout.
3. While inspecting the 1st Floor at 9:30 a.m., the corridor walls around Room 176 , First Floor Main Corridor, and the CCU Corridor wall was observed with unsealed penetrations throughout.

This deficient practice has the potential of affecting the 1st, 2nd, and 3rd Floors. The administrator and the maintenance director were notified during the survey as well as in the exit conference.

Based on observations the facility failed to provide the required 2 hour fire rating for vertical openings in a 4 story building.

Findings Include:

While inspecting vertical shafts on 5/19/2010 at 4:00 p.m., the surveyor observed the east wing elevator shaft, the west wing elevator shaft, and the MOB elevator shaft with unsealed penetrations throughout.

This deficient practice has the potential of affecting the 1st, 2nd, 3rd and 4th Floors. The administrator and the maintenance director were notified during the survey as well as in the exit conference.

Based on observations the facility failed to provide the required self closing door for a 2 hour fire rated stairway.

Findings Include:

While inspecting stairway doors on 5/18/2010 at 1:20 p.m., the surveyor observed the 2nd Floor Nursery Unit stairway door did not close if opened more than half way of its swing due to binding or dragging.

This deficient practice has the potential of affecting the entire nursery unit. The administrator and the maintenance director were notified during the survey as well as in the exit conference.

Based on observations the facility failed to provide the required ½ hour rated construction for smoke barrier walls.

Findings Include:

While inspecting smoke barrier walls on 5-18, 5-19, 2010 the surveyor observed the following smoke barrier walls with unfinished construction or unsealed penetrations throughout.
1. On 5-18-2010 at 10:30 a.m., the Three East Smoke Barrier Wall at the nurse supervisor station was found with unsealed penetrations throughout.
2. On 5-18-2010 at 10:55 a.m., the Three West Smoke Barrier Wall was found with unsealed penetrations throughout.
3. On 5-18-2010 at 2:30 p.m., the Two East Smoke Barrier Wall was found with unsealed penetrations throughout.
4. On 5-18-2010 at 2:50 p.m., the Two Main Smoke Barrier Wall was found with unsealed penetrations throughout.
5. On 5-18-2010 at 4:20 p.m., the smoke barrier wall across from Room 171 on the Flowers Wing was found with unsealed penetration located inside the soiled linen room.
6. On 5-19-2010 at 10:00 a.m., the First Floor Smoke Barrier on the 154 through 165 Wing was found with unsealed penetrations throughout.
7. On 5-19-2010 at 11:55 a.m., the First Floor Smoke Barrier across from the pharmacy was found with unsealed penetrations throughout.

This deficient practice has the potential of affecting the entire facility. The administrator and the maintenance director were notified during the survey as well as in the exit conference.

Based on observations the facility failed to provide the required 1 hour fire rating for hazardous areas in non-sprinkled locations.

Findings Include:

While inspecting hazardous areas on 5-18 and 5-19, 2010 the surveyor observed the following hazardous areas with unfinished construction or unsealed penetrations throughout.
1. On 5-18 at 9:00 a.m., the 3rd Floor Mechanical Room Number 5 was observed with unsealed penetrations.
2. On 5-18 at 9:05 a.m., the 3rd Floor Mechanical Room Number 3 was observed with unsealed penetrations.
3. On 5-18-2010 at 10:15 a.m., the 2nd Floor Telemetry Room was observed with unsealed penetrations.
4. On 5-19-2010 at 9:15 a.m., the 1st Floor soiled Utility Room across from Room 151 was observed with unfinished construction and unsealed penetrations.
5. On 5-19-2010 at 9:35 a.m., the 1st Floor Sterile Supply Room was observed with unsealed penetrations throughout.
6. On 5-19-2010 at 9:55 a.m., the 1st Floor CCU Unit Soiled Linen Room was observed with unfinished construction and unsealed penetrations.
7. On 5-19-2010 at 10:35 a.m., the 1st Floor E.R. Soiled Linen Room was observed with unfinished construction and unsealed penetrations.
8. On 5-19-2010 at 1:55 p.m., the 1st Floor Lab Storage Room was observed without the required self-closing hardware on the door.
9. On 5-19-2010 at 3:10 p.m., the 1st Floor Fire Wall surrounding the boiler room was found with unsealed penetrations.
10. On 5-19-2010 at 3:25 p.m., the 1st Floor Chemical Lab Storage was observed without the required self closing hardware on the door.
11. On 5-19-2010 at 3:35 p.m., the 1st Floor Gas Fired Equipment Room behind the kitchen cooking equipment was observed with unfinished construction and unsealed penetrations throughout.
12. On 5-19-2010 at 3:55 p.m. the 1st Floor Mechanical Room #3 was observed with unsealed penetrations throughout.
13. On 5-19-2010 at 4:40 p.m., the 1st Floor Radiology Soiled Room was observed without fire rated construction, without a 45 minute fire rated door, and without self closing hardware on the door.


This deficient practice has the potential of affecting the entire facility. The administrator and the maintenance director were notified during the survey as well as in the exit conference.

Based on observations the facility failed to provide exits that terminate directly onto a public way.

Findings Include:

While inspecting the means of egress on 5-19-2010 at 3:00 p.m., the surveyor observed 5 required exit locations that terminate into an enclosed interior courtyard. These exits include the CCU exit, (2) Main Hall exits, the West 3 Stairway, and the Lab exit.

Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be required width and size to provide all occupants with safe access to a public way. 19.2.1, 7.7

This deficient practice has the potential of affecting the 8 of 14 smoke compartments. The administrator and the maintenance director were notified during the survey as well as in the exit conference.

Based on observations the facility failed to provide a continuous path of escape that provides protection against fire or smoke in an exit component.

Findings Include:

While inspecting stairways on 5/19/2010 at 3:50 p.m., the surveyor observed the business office stairway and the cafeteria stairway exiting into an exit passage corridor instead of into an exterior location leading to a public way. The corridor however was found with numerous unsealed penetrations throughout.

This deficient practice has the potential of affecting means of egress on the 2nd, 3rd, and 4th floors. The administrator and the maintenance director were notified during the survey as well as in the exit conference.

Based on observations the facility failed to continuously maintain the fire alarm system in an occupied health care facility in accordance with NFPA 101, Chapter 19, Section 19.3.4.3, 9.6.3, NFPA 72 Chapter 7, Section 7-1.1.1.

On May 19, 2010 at 4:15 p.m., the surveyor and maintenance director at North West Regional Medical Center performed a fire alarm test on the 3rd Floor. The manual pull station in the main wing of the 3rd Floor was initiated, upon initiation the surveyor observed all fire doors closing but no audible and visual notification devices initiated. At 4:20 p.m., the surveyor inspected the 4th floor, 3rd Floor, 2nd Floor, and the 1st Floor discovering the audible and visual notification devices were inoperable on all floor but the 1st Floor. At 4:40 p.m., the surveyor requested the fire alarm system to be reset and a manual station on the 2nd Floor Main Hall to be initiated, the system was then observed inoperable. At 4:50 p.m. the surveyor contacted the Division of Health Facilities Fire Safety and Construction and reported the findings and the number of residents inside the facility. At 5:15 p.m., the Immediate Jeopardy was announced. At 5:45 p.m., the Chief Operating Office and the Maintenance Director Submitted the AOC to the State Agency for approval. At 7:30 p.m., the Final draft of the AOC was completed and approved by the Mississippi State Department of Health. At 8:00 p.m., the maintenance director along with Johnson Controls, Fire Alarm Installer discovered a cut low voltage wire causing a short in the system. At 8:45 p.m., Johnson Controls corrected the wiring and issued a certification. At 8:50 p.m., the immediate jeopardy was abated.

This deficient practice has the potential of affecting the 100% of staff and residents inside the facility. The administrator and the maintenance director were notified during the survey and in the exit conference.

§482.41(b) (1) (i) Medicare-participating hospitals, regardless of size or number of beds, must comply with the hospital/healthcare Life Safety Code requirements for all inpatient care locations. Hospital departments and locations such as emergency departments, outpatient care locations, etc. must comply with hospital/healthcare Life Safety Code Requirements. Additionally, the hospital must be in compliance with all applicable codes referenced in the Life Safety Code.