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The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include: During the survey, the following are examples of what was observed:


1. Unsealed penetrations around the duct in the Smoke Barrier by Patient Room 216.

2. Unsealed penetrations around a group of wiring, and water lines, and a fire line, in the Smoke Barrier by Patient Room 210.


NFPA 101, 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

The facility failed to maintain stairways with at least 1 hour fire resistance rating. During the survey, the following are examples of what was observed:


Stairs "B" had unsealed penetrations at the deck, this was observed on the inside of the stairwell.


NFPA101, 19.3.1.1, 8.2.3.2.4, and 7.1.3.2.1 requires a fire resistance rating.

The facility failed to maintain the means of egress per code. Findings include:

During the survey, the following is an example of what was observed:
Stairwell "A" - the exit door opened approximately 3/4 of the way.


2000 NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
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The facility failed to conduct fire drills per code. Findings include:

During the survey, the following is an example of what was observed:
Per documentation and interview the facility was not including all staff on the first shift in the fire drills.

2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
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Sprinkler coverage was observed during the survey not adequately provided. Findings include: During the survey, the following are examples of what was observed:

A) Three sprinklers on the Loading Dock had corrosion build up around the seat.

1999 NFPA 25, 2-2.1.1 and 2-4.1.2 Sprinklers that are painted, corroded or damaged shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.


B) The facility had three canopies with cloth material, metal framing the facility could not provide certificate for the flame spread rating.


1999 NFPA 13, 5-13.8 Sprinklers shall be installed under exterior combustible roofs or canopies exceeding four feet in width, or over areas where combustibles are stored.

The facility failed to provide metal self-closing containers for disposing of cigarette butts and ashes from ashtrays. Findings include: During the survey, the following are examples of what was observed:

The designated smoking area located on the patio area outside by the Dining Room, was not provided with a metal container for disposing of the cigarette butts.


NFPA 101, 19.7.4 Ashtrays of noncombustible material and safe design, and metal self-closing containers for disposing of cigarette butts and ashes from ashtrays, shall be provided.

The facility failed to maintain the generator per code. Findings include:

During the survey, the following is an example of what was observed:
The Generator Transfer Switch Room did not have a battery back-up light for the transfer switches.

1999 NFPA 110, 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.
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The facility failed to provide receptacles for appliances. Findings include: During the survey, the following are examples of what was observed:


1. Microwave and Refrigerator was plugged into a overcurrent protection in Case Management Office Second Floor.

2. Refrigerator plugged into a overcurrent protection in the Nourishment Room by Nurses Staion "A".


Appliances, such as air conditioners and refrigerators, shall plug directly into a receptacle. 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99.