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Based on visual observation the facility failed to assure the construction of fire barriers walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke from one compartment to the other in the facility. The deficient practice had the potential to affect 482 of 482 residents.

Findings:

During the facility tour on 8/7/2012, between the hours of 8:00 am and 3:00 pm, it was observed that the fire barrier was not continuous in the following following locations:

1st Floor Dietary Hall - fire barrier wall, above the cross corridor doors, is not complete to the deck above

Atrium - fire barrier wall, above the cross corridor doors (separating the hospital and clinic) has a 2" wide vertical gap above the ceiling tile to the deck above

Additionally, the fire barrier doors (separating the atruim and the concourse corridor) does not have an astragal installed that would limit the transfer of smoke.

Based on visual observation this sprinklered facility failed to assure that the smoke compartmentation of the membrane between the egress corridor and rooms adjacent to the egress corridor, were not compromised. Repairs to assure the protection of occupants and the integrity of the means of egress are essential in case of a fire or other smoke emergency. The deficient practice had the potential to affect of residents.

Findings:

During the facility tour on 8/7/2012, between the hours of 8:00 am and 3:00 pm, it was observed that the following locations were open to the corridor and not protected by smoke detection:

2nd floor Vending area (outside Endoscopy Suite)
Radiology Suite by Room 113 and Room 123
CT Scan Area by Room 173
Concourse Corridor Sitting Area (by stairwell)

Based on visual observation the facility failed to maintain the separation of hazardous areas from other parts of the building. Hazardous areas are required to be constructed to resist the passage of smoke. The deficient practice had the potential to affect 482 of 482 residents.

Findings:

During the facility tour on 8/14/2012, between the hours of 8:00 am and 3:00pm, it was observed that a storage room, outside the atruim, does not meet the requirements for hazardous areas. The following deficiencies were noted:

1. Fire alarm notification devices are not installed for protection.
2. The door is not approved to provide a fire rating.
3. The door does not have a self-closing device installed.
4. The storage height exceeds within the 18" below the sprinkler heads.
*Note: A pre-action sprinkler system is installed, however, the notification to the fire alarm only provides a supervisory signal, but no audible alarm.

Based on visual observation the facility failed to assure that the construction of suites in the facility does not exceed the maximum square footage. When areas exceed construction requirements the possibility is greater that the travel distance will be exceed 100 feet. The deficient practice had the potential to affect 23 of 482 residents.


Findings:

During the facility tour on 8/7/2012, between the hours of 8:00am and 3:00pm, it was observed that two sets of double doors, separating the Pre-Op Suite and Post-Op Suite were not designed to latch in the frame, which would exceed the maximum 10,000 square feet allowed.

Based on visual observation the facility failed to assure that the fire alarm system was installed in accordance with the Life Safety Code and NFPA 72. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency.

Findings:

During the facility tour on 8/7/2012, between the hours of 9:00 am and 3:00 am, it was observed that the following areas had a smoke detector installed withiin three feet of an air diffuser:
Ultrasound Suite/Clean Supply Room
Surgery Suite Corridor/EVS 2H236

Based on visual observation the facility failed to assure that a complete, supervised automatic sprinkler system was installed according to NFPA 13. The automatic sprinkler system gives a sense of security to offer an advance warning in fire and/or smoke emergency. This deficient practice could potentially affect of residents.

Findings:

During the facility tour on 8/8/2012, between the hours of 9:00am and 3:00pm, it was observed that the medical gas Tank Storage Room on the first floor was not sprinklered.