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Based on observation the facility failed to provide the two hour fire separation between nonconforming building in accordance with 18.1.1.4.1,18.1.1.4.2, 19.1.1.4.1, and 19.1.1.4.2.

Findings include:

While inspecting the separation wall on October 23, 2012 at 1:00 p.m., the surveyor and Maintenance Director observed the two hour fire separation lacked the 90 minute rated doors and contained wood construction.

This deficient practices have the potential of effecting the entire facility.
The Maintenance Director and the Administrator were notified during an exit conference.

Based on observation the facility failed to provide the correct building construction type in accordance with 19.1.6.2,19.1..3, 19.1.6.4, and 19.3.5.1

Findings include:

While inspecting the construction type on October 23, 1012 at 1:30 p.m., the surveyor and Maintenance Director observed an un-rated acoustical ceiling assembly protecting un-rated structural steel throughout the entire facility.

This deficient practice have the potential of effecting the entire facility. The Maintenance Director and the Administrator were notified during an exit conference.

Based on observation the facility failed to provide partitions that resist the passage of smoke in a fully sprinkled building in accordance with 19.3.6.1, 19.3.6.2.1, and 19.3.5.

Findings include:

While inspecting corridor walls on October 23, 2012 at 1:35 p.m., the surveyor observed penetrations in the following corridor walls:

1). Corridor walls on 1st floor lobby hallway had numerous penetrations.
2). Corridor walls on 1st floor had numerous penetration around newly installed plumbing pipes
throughout the facility.
3). 2nd floor east wing had numerous penetrations in the corridor walls.
4). 2nd floor corridor walls near the east wing biohazard room did not extend to the deck.
5). Corridor walls in the south corridor had numerous penetrations and non-rated products used to seal
this smoke resistive partition.

These deficient practices have the potential of effecting the entire facility.
The Maintenance Director and the Administrator were notified during an exit conference.

Based on observation and testing, the facility failed to provide partitions that have a fire resistance rating of at least one hour in accordance with 8.2.5.6 and 19.3.1.1.

Findings include:

While inspecting vertical openings on October 23, 2012 at 1:20 p.m., the surveyor observed deficient items in the following vertical shafts:

1). East wing stairwell had penetrations in the 1 hour enclosure.
2). West wing stairwell had penetrations in the 1 hour enclosure.
3). Central stairwell had penetrations in the 1 hour enclosure.

These deficient practices have the potential of effecting the entire facility.
The Maintenance Director and the Administrator were notified during an exit conference.

Based on observation the facility failed to provide doors that automatically close by zone or throughout the facility upon activation of the required manual fire alarm system in accordance with 18.2.2.2.6, 19.2.2.2.6, and 7.2.1.8.2.

Findings include:

While inspecting smoke barrier doors on October 23. 2012 at 1:45 p.m., the surveyor and Maintenance Director observed the smoke barrier doors near the cafeteria did not close upon or on activation of the fire alarm system.

These deficient practices have the potential of effecting the entire facility.
The Maintenance Director and the Administrator were notified during an 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 October 23, 2012 at 11:30 a.m., the Maintenance Director and the surveyor observed that all smoke barrier walls had numerous penetrations around newly installed plumbing pipes throughout the entire facility.

This deficient practice has the potential of affecting the entire building. The Administrator and Maintenance Director were notified during the survey and in the exit conference.

Based on observation 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:

While inspecting hazardous areas on October 23, 2012 at 11:45 a.m., the Maintenance Director and the surveyor observed that the following hazardous areas had penetrations:

1). Soiled Linen Room on 2nd floor East Wing had numerous penetrations.
2). Treatment Room # 2026 was being used for storage. Did not have rated doors or door closure
device.

This deficient practice has the potential of affecting the entire building. The Administrator and Maintenance Director were notified during the survey and in the exit conference.

Based on observations the facility failed to provide the required 1-hour fire resistance rating and a continuous path of escape of a stairwell.

While inspecting stairwells on October 23, 2012 at 10:45 a.m., the surveyor observed that the East, West and Central Stairwell held combustible and flammable storage under the staircase.

Actual code NFPA 101 " Life Safety Code " Section 7.2.2.5.3. States, There shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress.

This deficient practice has the potential of affecting the entire facility. The Administrator was notified during the survey as well as during the exit conference.

Based on observation and testing, the facility failed to provide a properly tested and maintained fire alarm system in accordance with NFPA 72 Section 1-5.6

Findings include:

While inspecting the fire alarm system on October 23, 2012 at 2:00 p.m., the Maintenance Director and surveyor found location of the main panel to be lacking a hard wired smoke detector.

This deficient practice has the potential of affecting the entire building. The administrator and Maintenance Director were notified during the survey and in the exit conference.

Based on observations the facility failed to provide the required monthly generator testing in accordance with NFPA 99, 3.4.4.1 and NFPA 110.

Findings include:

While reviewing generator testing documentation on October 23, 2012 at 10:30 a.m., the facility failed to provide the weekly generator testing documentation for the last 12 months.

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 the exit conference.

Based on observation the facility failed to provide the two hour fire separation between nonconforming building in accordance with 18.1.1.4.1,18.1.1.4.2, 19.1.1.4.1, and 19.1.1.4.2.

Findings include:

While inspecting the separation wall on October 23, 2012 at 1:00 p.m., the surveyor and Maintenance Director observed the two hour fire separation lacked the 90 minute rated doors and contained wood construction.

This deficient practices have the potential of effecting the entire facility.
The Maintenance Director and the Administrator were notified during an exit conference.

Based on observation the facility failed to provide the correct building construction type in accordance with 19.1.6.2,19.1..3, 19.1.6.4, and 19.3.5.1

Findings include:

While inspecting the construction type on October 23, 1012 at 1:30 p.m., the surveyor and Maintenance Director observed an un-rated acoustical ceiling assembly protecting un-rated structural steel throughout the entire facility.

This deficient practice have the potential of effecting the entire facility. The Maintenance Director and the Administrator were notified during an exit conference.

Based on observation the facility failed to provide partitions that resist the passage of smoke in a fully sprinkled building in accordance with 19.3.6.1, 19.3.6.2.1, and 19.3.5.

Findings include:

While inspecting corridor walls on October 23, 2012 at 1:35 p.m., the surveyor observed penetrations in the following corridor walls:

1). Corridor walls on 1st floor lobby hallway had numerous penetrations.
2). Corridor walls on 1st floor had numerous penetration around newly installed plumbing pipes
throughout the facility.
3). 2nd floor east wing had numerous penetrations in the corridor walls.
4). 2nd floor corridor walls near the east wing biohazard room did not extend to the deck.
5). Corridor walls in the south corridor had numerous penetrations and non-rated products used to seal
this smoke resistive partition.

These deficient practices have the potential of effecting the entire facility.
The Maintenance Director and the Administrator were notified during an exit conference.

Based on observation and testing, the facility failed to provide partitions that have a fire resistance rating of at least one hour in accordance with 8.2.5.6 and 19.3.1.1.

Findings include:

While inspecting vertical openings on October 23, 2012 at 1:20 p.m., the surveyor observed deficient items in the following vertical shafts:

1). East wing stairwell had penetrations in the 1 hour enclosure.
2). West wing stairwell had penetrations in the 1 hour enclosure.
3). Central stairwell had penetrations in the 1 hour enclosure.

These deficient practices have the potential of effecting the entire facility.
The Maintenance Director and the Administrator were notified during an exit conference.

Based on observation the facility failed to provide doors that automatically close by zone or throughout the facility upon activation of the required manual fire alarm system in accordance with 18.2.2.2.6, 19.2.2.2.6, and 7.2.1.8.2.

Findings include:

While inspecting smoke barrier doors on October 23. 2012 at 1:45 p.m., the surveyor and Maintenance Director observed the smoke barrier doors near the cafeteria did not close upon or on activation of the fire alarm system.

These deficient practices have the potential of effecting the entire facility.
The Maintenance Director and the Administrator were notified during an 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 October 23, 2012 at 11:30 a.m., the Maintenance Director and the surveyor observed that all smoke barrier walls had numerous penetrations around newly installed plumbing pipes throughout the entire facility.

This deficient practice has the potential of affecting the entire building. The Administrator and Maintenance Director were notified during the survey and in the exit conference.

Based on observation 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:

While inspecting hazardous areas on October 23, 2012 at 11:45 a.m., the Maintenance Director and the surveyor observed that the following hazardous areas had penetrations:

1). Soiled Linen Room on 2nd floor East Wing had numerous penetrations.
2). Treatment Room # 2026 was being used for storage. Did not have rated doors or door closure
device.

This deficient practice has the potential of affecting the entire building. The Administrator and Maintenance Director were notified during the survey and in the exit conference.

Based on observations the facility failed to provide the required 1-hour fire resistance rating and a continuous path of escape of a stairwell.

While inspecting stairwells on October 23, 2012 at 10:45 a.m., the surveyor observed that the East, West and Central Stairwell held combustible and flammable storage under the staircase.

Actual code NFPA 101 " Life Safety Code " Section 7.2.2.5.3. States, There shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress.

This deficient practice has the potential of affecting the entire facility. The Administrator was notified during the survey as well as during the exit conference.

Based on observation and testing, the facility failed to provide a properly tested and maintained fire alarm system in accordance with NFPA 72 Section 1-5.6

Findings include:

While inspecting the fire alarm system on October 23, 2012 at 2:00 p.m., the Maintenance Director and surveyor found location of the main panel to be lacking a hard wired smoke detector.

This deficient practice has the potential of affecting the entire building. The administrator and Maintenance Director were notified during the survey and in the exit conference.

Based on observations the facility failed to provide the required monthly generator testing in accordance with NFPA 99, 3.4.4.1 and NFPA 110.

Findings include:

While reviewing generator testing documentation on October 23, 2012 at 10:30 a.m., the facility failed to provide the weekly generator testing documentation for the last 12 months.

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 the exit conference.