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Based on observations, the facility has failed to maintain the 2-hour fire separation between the I occupancy and S2 occupancy on the 1st. floor This deficient practice could affect the safety of all patients, staff and visitors in the event of a fire, as fire and smoke could pass from one occupancy to the other.

Findings include:
Observations during the facility tour on January 11, 2011 between 9:00 AM and 12:00 PM, it was revealed that
there were no fire rated doors in the 2 hour fire separation wall between the Group I occupancy and Group S2 parking ramp occupancy.

This deficient practice was confirmed by the Director of Facilities Services (KJ) at the time of discovery,

Based on observation the facility did not have corridor doors that meet the requirements of NFPA 101 LSC (00) Section 19.3.6.3.2. This deficient practice could affect the safety of all patients, staff and visitors.

Findings include:
During the facility tour on January 10 2011, between 1:00 PM and 3:30 PM, observation revealed that the corridor doors in the following areas are not smoke tight because open louvers in the bottom of the doors :

1) C level - Equipment Processing Storage Room
2) 3rd floor - IT Room.

This deficient practice was confirmed by the Director of Facilities Services (KJ) at the time of discovery,

3) 6th floor - conference room 2 does not have positive latching on corridor door.
4) 6th floor - Physician Recruitment Room that uses roller latch to keep door shut.

These deficient practices were confirmed by the Maintenance Engineer (RK) at the time of discovery.




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5) 6th floor - conference room, has no means of keep door shut
6) 6th floor - office that uses roller latch to keep door shut.

These deficient practices were confirmed by the Maintenance Engineer (RK) at the time of discovery.

Based on observation, the facility failed to maintain corridor openings as required by LSC(00) Section 19.3.1.1. This deficient practice could affect all residents, staff and visitors.

Findings include:
Observations during the facility tour on January 10 between 1:00 PM and 3:30 PM and January 11, 2011 between 9:00 AM and 12:00 PM, revealed that smoke barrier doors are held open with electric magnetic devices inter-connected to the fire alsrm sytem, but do not have automatic smoke detectors within 5 feet of the doors as required in the following areas:
1) 3rd floor - West smoke barrier door.
2) 3rd floor - North smoke barrier door.
3) 2nd floor - West smoke barrier door.
4) 2nd floor - North smoke barrier door.
5) A level - Dining Room door to corridor.
6) C level - smoke barrier door by stairwell C.

This deficient practice was confirmed by the Director of Facilities Services (KJ) at the time of discovery,

This STANDARD is not met as evidenced by:

Based on observation, the facility failed to maintain the hazardous rooms in accordance with the following requirements of 2000 NFPA 101, Section 19.3.2.1 . The deficient practice could affect all patients, staff and visitors.

Findings include:
Observations during the facility tour on January 10 between 1:00 PM and 3:30 PM and January 11, 2011 between 9:00 AM and 12:00 PM, revealed that:

1) The 6th floor - Eest Soiled utility Room wall does not go to the deck above.

2) Level B - storage room over 50 square feet:
The corridor wall does not go to the deck above and the corridor door is not equipped with a
self-closing device.

These deficient practices were confirmed by the Maintenance Engineer (RK) at the time of discovery.

Based on observation, the facility failed to maintain a fire resistance rating of at least two hours in the exit component accordance with the following requirements of 2000 NFPA 101, Section 19.3.1.1, 8.2.5.2 and 7.1.3.2.1. The deficient practice could affect all patients, staff and visitors.

Findings include:
Observations during the facility tour on January 10 between 1:00 PM and 3:30 PM and January 11, 2011 between 9:00 AM and 12:00 PM, revealed that the stairwell doors for the Center and East stairwells only have a one hour fire rating.

These deficient practices were confirmed by the Maintenance Engineer (RK) at the time of discovery.