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Based on observation, record review and interview, this facility failed to provide a firewall with a two-hour fire rating and fire doors with a 90 minute fire rating between the Hospital and the Business portion of the facility. The wall failed to be complete in all areas and was penetrated above the lay-in ceiling tile with building services (pipes, wiring), leaving unfilled gaps that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone. This deficient practice affects all occupants including staff, visitors and patients. This facility has a capacity of 87 and a census of 58 patients.
Findings are:
Observations on 4/3/13 from 1:00 pm through 4:00 pm revealed:

1. The first level 2 hr separation between St James and St Benedict the doors failed to have a fire rating label.

2. The wall above the doors contained a gray caulking material. Interview with Maintenance Staff B on 4/3/13 at 1:40 pm revealed no documentation for the caulking could be provided stating it met the specifications for a 2 hour fire wall.

3. In Room 1236 the 2 hour wall failed to be complete.

Observations on 4/4/13 at 10:38 am between 10:00 am and 10:38 am revealed:

4. The Fire doors 1159A failed to close and latch in the 2 hour wall.

5. Fire doors in the 2 hour wall 1221A failed to close and latch when tested.

Maintenance Staff B confirmed all observations at the times of the observations.

NFPA Standard: Health care occupancies in buildings housing other occupancies shall be completely separated from them by construction having a fire resistance rating of not less than 2 hours as provided for additions in 18/19.1.1.4. 2000 NFPA 101, 18/19.1.2.3

Based on observation and staff interview, the facility failed to ensure that corridor doors fit tightly within the doorframe to resist the passage of smoke. This deficient practice affects approximately 23 patients, as the doors would not prevent the spread of fire and smoke. This facility has a capacity of 87 and a census of 58 patients.
Findings are:
Observations on 4/4/13 from 10:30 am through 4:00 pm revealed:

1. The double doors to the York room failed to close and latch.

2. The door to Case Management 1202 contained unsealed holes.

Maintenance Staff B confirmed all observations at the times of the observations
NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 18.3.6.3.1, 18.3.6.2 and 18.3.6.3

Based on observation and staff interview, the facility failed to ensure that vertical openings between floors are enclosed with a fire resistance rating of at least one hour. This deficient practice affects all occupants of the southeast wing on three floors of the building, including staff, visitors and patients, who may need to use this designated exit in the event of an emergency. This facility had a census or 58 patients.
Findings are:

1. Observation on 4/3/13 at 2:47 revealed the magnetically locked stairwell door 0135 failed to have a latch installed. The door entered a three story stairwell. The door would not latch if the magnetic lock released with the activation of the fire alarm or sprinkler system.

2. Observations on 4/3/13 and 4/4/13 throughout the building revealed numerous penetrations in the roof-ceiling assemblies that were unsealed resulting in not meeting the fire separation requirement.
All observations were confirmed by Maintenance Staff B at the times of each observation.

NFPA Standard: Requires a minimum one-hour fire resistance rating in shafts between floors. 2000 NFPA 101, 19.3.1.1 and 8.2.5.4

Based on observation and staff interview the facility failed to maintain all nine smoke barriers. Maintaining all smoke separations free of penetrations that compromise the fire-resistance rating of the walls and could allow the passage of smoke and fire to another smoke zone. This deficient practice affects all staff, visitors and patients of the lower level and first level smoke zones. This facility has a capacity of 87 and a census of 58 patients.
Findings are:
Observations on 4/3/13 from 1:40 pm through 4:00 pm revealed:

1. Smoke Separation by Room 100 not smoke sealed at the top.

2. Smoke barrier by the York Room contained unsealed holes around a wire above the doors. The barrier failed to be smoke sealed at the top.

3. The smoke barrier wall in Room 0124 was covered with Styrofoam sheets above the ceiling.

4. Smoke barrier in Room 0175 contained large holes around conduits and pipes.

5. Holes in the 0172 Smoke barrier around pipes and conduits. Also unapproved foam in the wall, no documentation for use in a smoke/fire barrier could be provided.

6. Smoke barrier 0149 incomplete and not sealed in the LOCO Mat Room.

7. Smoke barrier wall in the Whitney room contained unsealed holes around conduits.

8. Smoke barrier by 0140A contained holes unsealed and unapproved foam.

9. Smoke barrier wall in Room by 0124

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1
NFPA Standard: Requires smoke walls to have a fire resistance rating of at least a half hour and to be continuous from floor to roof deck and from outside wall to outside wall. 2000 NFPA 101, 19.3.7.3

Based on observation and interview, the facility failed to maintain doors in smoke barriers to be smoke resisting and automatic closing. The smoke doors affected four of the six smoke compartments on the first level. This deficient practice could affect approximately 33 patients, all staff and any patients using the center core dining room. The facility census was 58.
Findings are:

Observations on 4/4/13 from 10:30 am through 4:00 pm revealed:

1. Smoke doors 1160B failed to be flush at the top of the doors.

2. The Smoke barrier doors by Room 153 failed to be flush at the top.

3. Double doors 0172 contained a greater than 1/8th inch between the leafs.

NFPA Standard: Requires doors in smoke barriers to be self-closing and have at least a 20-minute rating, 2000 NFPA 101, 19.3.7.6

Based on observation and staff interview, the facility failed to ensure that hazardous areas are separated from other areas by partitions and self-closing doors to ensure a one-hour fire-resistance rating. This deficient practice affects all occupants throughout the building, where the ceiling, walls and doors would not stop the spread of fire and smoke, in the event of a fire. This facility has a capacity of 87 and a census of 58 patients.
Findings are:
Observations on 4/3/13 from 1:00 pm through 4:00 pm revealed:

1. The corridor door to Storage room 0124 corridor held open with a wood chock.
2. Electrical room 1232 unsealed holes in the 2 hour wall and around the conduits.

3. The new Supply Room no self-closing device on the door.

4. Room 0527 IT Storage unsealed holes in the ceiling around pipes n conduits.

5. Trash chute Room 0172 corridor door failed to close and latch. Unsealed holes in the walls and around conduits. Wall not complete.

6. Foam in the Housekeeping Storage walls. Foam in the smoke barrier wall.

Observations on 4/4/13 from 10:30 am through 4:00 pm revealed:

1. Storage Room 1159 contained unsealed holes in the ceiling and walls around the Med Gas pipes and conduits.

2. DME Storage room 1161 walls contained a large amount of foam in the wall around pipes.

3. Room 1176 contained a hole around large conduit penetrating through the floor/roof assembly.

4. The Storage Closet Perkins Place contained 5 unsealed holes in the ceiling and walls.

5. Room 1210 the door failed to have a positive latching device installed. The latch had been removed.

6. Room 1215 Clean Storage revealed walls contained unsealed holes around wires.

7. Room 148 door failed to close and latch no self-closing device installed on the door. Room used for storage of beds and wheel chairs.

8. Holes in the west wall of Rm 0158 around vents and wires, in addition the wall contained unapproved foam.

9. Ped's Wash area /Supply Storage room failed to have a self-closing device installed on the door.

10. DME Ped ' s Storage room door failed to have a self-closing device installed.

11. The Double doors to Activities Storage failed to have positive latching devices with an automatic flush bolt. Doors could be pulled into the open position without turning the knob.

12.Housekeeping Storage room door 0103 failed to be smoke tight and failed to close and latch.

13.Room 0116 contained foam in the walls.

14.The Light Bulb Storage room contained unsealed penetrations in the floor-ceiling and the walls.

15.Foam in the wall of the old St James boiler room.

16.The boiler room 0133A failed to be separated from the exiting corridor with a large hole in the east wall. The hole was drawing air from the exit corridor through a grate in the suspended ceiling in the exit corridor.

17.The Activities Storage room double doors failed to have positive latching installed.

Interview with Maintenance Staff B 4/3/13 from 1:00 pm through 4:00 pm and 4/4/13 from 10:30 am through 4:00 pm confirmed the observations at the time of the observations. In addition no documentation for the foam found in walls and ceiling could be provided.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating and/or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 18.3.2.1, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Based on observation and staff interview, the facility failed to provide a delayed egress device that would release within 15 seconds upon application of force that is continuously applied for more than 3 seconds. In addition the facility failed to provide signage for the operation of the delayed egress with 30 second release times. This deficient practice affects all 5 patients, staff and visitors in the Pediatrics that may need to evacuate the building. This facility has a capacity of 87 and a census of 58 patients.
Findings are:
Observations on 4/3/13 from 1:00 pm through 4:00 pm revealed:

1. The magnetically locked doors 0150 with 30 second delay opening failed to have signage for the operation of the doors. Interview with Maintenance Staff B on 4/3/13 at 2:43 pm revealed the door had a 30 second delay to open.

Observations on 4/4/13 from 10:30 am through 4:00 pm revealed:

2. Magnetically locked door 1207 failed to alarm and go into the opening process when tested.

3. The exit door magnetically locked into the stairwell by Room 161 failed to have signage for the operation.

4. The Whitney room contained a magnetically locked egress door without a push to exit button.

Interview with Maintenance Staff B 4/3/13 from 1:00 pm through 4:00 pm and 4/4/13 from 10:30 am through 4:00 pm confirmed the observations at the time of the observations.
NFPA Standard: Exits and exit access shall be located and arranged so that exits are readily accessible at all times. 2000 NFPA 101, 7.5.1.1
NFPA Standard: Approved, listed, delayed-egress locks shall be permitted to be installed on doors serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7, provided that the following criteria are met: doors shall unlock upon actuation of an approved, supervised automatic sprinkler system or any heat detector or activation of not more than two smoke detectors of an approved, supervised automatic fire detection system; the doors shall unlock upon loss of power; an irreversible process shall release the lock within 15 seconds upon application of a force not to exceed 15 pounds nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only; on the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 inch high and not less than 1/8 inch wide on a contrasting background that reads as follows: PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS. 2000 NFPA 101, 7.2.1.6.1
NFPA Standard: Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side, except delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path. 2000 NFPA 101, 19.2.2.2.4
NFPA Standard: A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 inches and not more than 48 inches above the finished floor. Doors shall be operable with not more than one releasing operation. 2000 NFPA 101, 7.2.1.5.4

Based on record review and interview the facility failed to document the emergency egress lighting monthly and annually. This deficient practice affects all of the facility and all occupants of the facility. The facility had no patients at the time of the inspection.
Findings are:
On 4/11/13 at 10:45 am interview with the Outpatient Therapy Scheduler revealed the facility was testing the emergency lights monthly but failed to document the tests. In addition the facility was unaware that a 1 ? hour test was required annually.
No documentation of emergency light testing could be provided on 4/11/13.

NFPA Standard: A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 and 1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 2000 NFPA 101, 7.9.3

Based on observation and record review the facility failed to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25, by failing to maintain the system with an acceptable clearance around sprinkler heads to prevent obstructions to spray patterns. The facility also failed to maintain the same type of sprinkler heads within a compartment. These items could affect the operation of the heads by obstructing spray patterns, delaying the response time, and causing the heads or the entire sprinkler system to be inoperable. This deficient practice affects all occupants in this facility with a capacity of 87 and a census of 58.
Findings are:
Observations on 4/3/13 from 1:00 pm through 4:00 pm revealed:

1. First level New Supply Room, a sprinkler head with no escutcheon.

2. Transitional Living Apt 4 escutcheons missing. Different sprinkler heads in the apt with wall removed. The larger room contained 3 quick response and 1 regular sprinkler head.

3. The privacy curtain blocked the sprinkler head in Room 112.

4. Clean Storage room 1215 a sprinkler head was blocked by a large container.

5. The alcove by Room 1224 failed to have a sprinkler head installed.

6. Trash collection room 117 the escutcheon was missing from a sprinkler head.

Interview with Maintenance Staff B on 4/3/13 from 1:00 pm through 4:00 pm and 4/4/13 from 10:30 am through 4:00 pm confirmed the observations at the time of the observations.
NFPA Standard: Automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25 per NFPA 101, 9.7.5. Obstructions shall not prevent sprinkler discharge from reaching the protected area. Continuous or non-continuous obstructions that interrupt the water discharge in a horizontal plane more than 18 inches below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with this section. The requirements of this section shall also apply to obstructions 18 in. or less below the sprinkler for light and ordinary hazard occupancies per NFPA 13, 5-6.5.3. Water flow alarm devices including, but not limited to, mechanical water motor gongs, vane-type water flow devices, and pressure switches that provide audible or visual signals shall be tested quarterly per 1998 NFPA 25, 2-3.3
NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1

Based on observation and interview, the facility failed to maintain the self-closing devices on the entire laundry chute and trash chute openings in compliance with NFPA 82 and NFPA 101, 8.4. The linen chute did not have a one-hour enclosure, which put staff in the basement and all patients on three floors at risk. The facility census was 58.
Findings are:
1. Observations on 4/3/13 at 2:30 pm revealed the Trash Room by 0172 revealed the room was not 1 hour fire rated with holes in the walls. In addition the corridor door failed to close and latch when tested.

2. Observation on 4/4/13 at 2:37 pm, the Soiled Linen Chute room 0129 contained an unsealed hole in the wall. In addition the chute doors failed to be self-closing.

3. Observation on 4/4/13 at 10:48 am revealed the Trash collection room 1167 Trash Chute door failed to close and latch and did not self-close.

4. Observation on 4/4/13 at 1055 am revealed the Trash collection room 1174 Trash Chute door failed to be self-closing and was found in the open position.

5. Observation on 4/4/13 at 11:42 am revealed the Soiled Linen and Trash Chute room 1217 chute doors failed to close and latch. The chute doors stay in the open position.

6. Observation on 4/4/13 at 11:52 am revealed the Soiled Linen and Trash Chute room 1229 chute doors failed to close and latch. The chute doors stay in the open position without self-closing. In addition the room door failed to close and latch.

Interview with Maintenance Staff B 4/3/13 from 1:00 pm through 4:00 pm and 4/4/13 from 10:30 am through 4:00 pm confirmed the observations at the time of the observations.
NFPA Standard: Requires a minimum one-hour fire resistance rating in shafts between floors. 2000 NFPA 101, 18/19.3.1.1 and 8.2.5
NFPA Standard: Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means: Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with 8.2, protect the area with automatic extinguishing systems in accordance with 9.7, or both where the hazard is severe or where otherwise specified by Chapters 12 through 42. 2000 NFPA 101, 8.4.1.1

Based on observations and staff interview the facility failed to maintain all exit corridors clear of storage and obstructions for instant emergency use. This deficient practice affects all patients of the lower level having to use the exiting corridors in an emergency for evacuation. This deficient practice was observed throughout the two days of touring.
Findings are:

1. Observations on 4/3/13 at 1:01 pm revealed wheel chairs, and walkers outside 0174 obstructing the exit corridor. Observations on 4/3/2013 at 2:06 pm and 2:30 pm revealed wheel chairs, walkers, equipment, and rehab tricycles obstructing the exit corridor. Interview with Therapist B on 4/4/13 at 2:30 pm revealed that the equipment is stored in the exit corridor throughout the day as there is not enough room in the rehab room.

2. Observations on 4/3/13 at 1:03 pm revealed storage of 6 beds a large stack of telephone books and a pallet of telephone books obstructing egress in the west and northwest exit corridors lower level. Observation on 4/4/13 at 10:08 am the same stack, and pallet of telephone books remained stored in the northwest exit corridor. In addition on 4/4/13 at 10:08 am 5 different beds were obstructing the northwest exit corridor and the west exit corridor.

3. Observations on 4/4/13 at 3:46 pm am the same stack, and pallet of telephone books remained stored in the northwest exit corridor. In addition 3 different beds were obstructing the northwest exit corridor and the west exit corridor.

Interview with Maintenance Staff B on 4/3/13 at 1:15 pm confirmed that the exit corridors in the lower level west end contained beds stored as there were not enough storage areas.

NFPA Standard: Exits and exit access shall be located and arranged so that exits are readily accessible at all times. 2000 NFPA 101, 7.5.1.1
NFPA Standard: 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. 2000 NFPA 101, 7.1.10.1

Based on record review and interview, this facility failed to maintain one of two emergency generators by monthly testing to at least 30% of the nameplate rating or conducting an annual load bank test. The deficient practice of not providing complete and verifiable documentation on the inspection, testing, and maintenance of the generator does not ensure proper operation and prompt repair affecting all occupants in the building. This facility had a census of 58 patients at the time of the survey.
Findings are:

1. Record review conducted on 4/8/13 of the facility ' s generator inspection testing and maintenance records for the two generators, revealed that the documentation did not indicate the Old St James generator was tested monthly at 30% of the 200 KW nameplate rating for at least 30 minutes with an additional cool-down period. The facility was also unable to provide evidence of an annual load bank test in lieu of the 30% monthly test. The deficient practice was confirmed by Maintenance Staff A on 4/8/13 via telephone.

NFPA Standard: Level 1 and level 2 Emergency Power Supply Sources (EPSS)s, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes using one of the following methods: Under operating temperature conditions or at not less than 30% of the EPS nameplate rating or loading that maintains the minimum exhaust temperatures as recommended by the manufacturer. 1999 NFPA 110, 6-4.1 and 6-4.2

NFPA Standard: Diesel powered EPS installations that do not meet 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads. 1999 NFPA 110, 6-4.2.2

NFPA Standard: Type defines the maximum time, in seconds, that the EPSS will permit the load terminals of the transfer switch to be without acceptable electrical power. Table 2-2.2 provides the types defined by this standard. Table 2-2.2 Types of EPSSs - Type 10 -10 seconds 1999 NFPA 110, 2-2.2

Based on observation and interview, the facility failed to prohibit the use of power strips as a substitute for adequate wiring, and to maintain all electrical in accordance with NFPA 70, (the National Electrical Code) in patient computer areas. This deficient practice affected 25 patients on the 1st floor living compartments and all outpatients on the lower level by increasing the potential for an electrical fire. The facility census was 58.

Findings are:

1. Observations on 4/4/13 at 11:10 am revealed a computer plugged into a temporary power strip in the Perkins Place.

2. Observations on 4/4/13 at 11:20 am revealed a computer plugged into a temporary power strip in the Ameritas Room.

3. Observation on 4/4/13 at 1:10 pm revealed an open junction box above the ceiling in Room 0158.

Interview with Maintenance Staff B on 4/4/13 from 10:30 am through 4:00 pm confirmed the observations at the time of the observations.

NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8