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Based on visual observation the facility failed to provide smoke resistive smoke barrier doors. This deficient practice would allow for smoke and fire to travel from one smoke barrier to another potentially affecting 1 of 1 patient of the facility.

Findings:
During facility tour on 02/07/2012 between the hours of 8:00am and 12:00pm, the smoke barrier doors located in O.R. suite leading to breaak room had a 1/4 inch to 1/2 inch gap at the bottom were the doors edges meet causing the doors to not be smoke resistive.

Based on visual observation the facility failed to assure that hazardous areas are separated from all other use areas including the egress corridors by appropriately partitions that would resist the passage of smoke and fire and meet the required fire rating and potentially affecting 1 of 1 patient of the facility.
Findings:
During facility tour on 02/07/2012 between the hours of 8:00am and 12:00pm, The equipment/supply storage room did not have self-closing devices. Self-closing devices are required to maintain rating of the rooms.

Based on visual observation the facility failed to provide proper exiting requirements with-in the stairwell. This deficient practice would allow for the exit to be used and lead you to the roof and not out of the building to an exit and potentially affecting 1 of 1 patient of the facility.

Findings:
During facility tour on 02/07/2012 between the hours of 8:00am and 12:00pm, The door at the top of the stairs in the back 2nd floor stairwell that leads to the A/C roof doesn't lead to an exit and is not marked as " Not an Exit".

Based on visual observation and interview the facility failed to assure that the sprinkler system was inspected and tested in accordance with the Life Safety Code and NFPA 13 potentially affecting 1 of 1 patient of the facility.

Findings:
1) - During the facility tour on 02/07/2012, between the hours of 8:0am and 12:00pm, the sprinkler system riser room located on the outside of the facility near the back exit on the 1st floor, did not have freeze protected to protect the valves and the piping in the room from freezing. NFPA -13 requires that valves and piping for the sprinkler systems be maintained at a temp of 40 degrees and above.

2) - During facility tour on 02/07/2012 between the hours of 8:00am and 12:00pm, sprinkler heads through out facility including but not limited to common and residential rooms were missing escutcheon plates

3) - During facility tour on 02/07/2012 between the hours of 8:00am and 12:00pm, during interview with director of the facility a monthly maintenance log showing sprinkler system checks was not being conducted.

Based on visual observation, the facility failed to assure that the means of egress was free of obstructions or impediments to full instant use of the exit passage way. Obstructions, in the egress corridor, hinder occupant egress in emergency situations. This deficient practice could potentially affect 1 of 1 patient in the facility. Facility had 6 of the 6 corridors that were deficient.

Findings:
During the facility tour on 02/07/2012, between the hours of 8:00am and 12:00pm, corridors have medical equipment and storage such as vending machines, water coolers and water, portable x-ray machine, ultra sound machine and patient beds. That are being stored in the corridor for more than 30 minutes. Also bushes are in front of pull-station for fire alarm.

Based on observations, record review and confirmed through interview with the facility maintenance supervisor , the facility failed to assure that the testing program for the Emergency generator was maintained to include all readings required to demonstrate generator readiness.
This deficiency has the potential to affect 1 of 1 patient of the facility in 4 of 4 smoke compartments.

Findings:
1) - During record review of the generator log on 02/07/2012 between the hours of 8:00am and 12:00pm., there was no record of facility checking the amount of electrolyte solution in each battery reservoir.
6-3.6*
Storage batteries, including electrolyte levels, used in connection with Level 1 and Level 2 systems shall be inspected at intervals of not more than 7 days and shall be maintained in full compliance with manufacturer ' s specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects.

2) - During record review of the generator log on 02/07/2012 between the hours of 8:00am and 12:00pm, the required load test was not completed on 7 of the 12 months though-out the year. NFPA-99 &110 require the generator to run for 30 minutes on full load, plus the required cool down period.