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Based on facility tour and staff interview and verification the facility failed to ensure that if the building had a common wall with a nonconforming building, the common wall is a fire barrier having at least a two-hour fire resistance rating constructed of materials as required for the addition with regards to fire dampers in duct work. Potentially all persons in the area could be affected. The facility had a census of 39 patients at the time of the survey.

Findings included:

On 10/17/12 between 1:40 P.M. and 3:20 P.M. tour of the third floor of the facility was conducted with Staff AA. Observation of the two hour fire rated barrier revealed the following:

1. Observation above the ceiling tiles near room SCU1 revealed two 24 inch by 30 inch ducts that were not protected by a fire damper.

2. Observation above the ceiling tiles, above the cross corridor doors near room 306S, a 12 inch round duct was not protected by a fire damper.

3. Observation above the ceiling tiles at room 307S revealed two 12 inch round ducts. One duct was provided with fire damper protection but had exposed wires. The other duct had no fire damper protection. Staff AA present on tour was not able to verify that the damper connected to the exposed wiring would function.

3. Observation of the two hour fire rated wall, above the ceiling in room 310S, a 12 inch duct was not protected by a fire damper.

4. Observation above the ceiling tiles by room 324S revealed a 24 inch by 30 inch duct was not protected by a fire damper.

Staff present on tour verified the observations and findings.

Based on review of facility information, facility tour, staff interview and verification, the facility failed to ensure that building construction type and height met the requirement for health care occupancies limited to specific types of building construction. Potentially all persons in the area could be affected. The facility had a census of 39 patients at the time of the survey.

Findings included:

On 10/16/12 between 11:00 A.M. and 12:00 P.M., review of facility construction information and interview of Staff AA revealed the facility occupied the entire second floor and part of the third floor of the building. Review of facility construction type revealed it to be Type II(222) and V(111).

On 10/16/12 between 1:40 P.M. and 4:40 P.M. tour of the second and third floor of the facility was conducted with Staff AA. Observation above the ceiling at sections of structural steel beams revealed the following:

Third Floor:

1. Observation of a steel support beam revealed a 3 inch by 4 inch section of missing fireproofing. Metal clips for hangers attached to the steel beams had no fireproofing in place.

2. Observation of a steel support beam near the cross corridor fire doors between rooms 324S and 310S revealed two areas, 3 inches square and 1 inch square missing fireproofing material.

3. Observation of a steel support beam above the cross corridor fire doors near room 344 S was missing areas of fireproofing material.

4. Observation of a steel beam in the back corridor across from room 344B, near exit light 16 was missing areas of fireproofing material.

5. Observation of a steel beam in room 325S revealed two areas missing fireproofing material , one area was 12 inches by 4 inches and the second area was 4 inches by 2 inches.

Second Floor:

6. Observed near room 30S revealed a steel support beam with missing fireproofing material around metal clips attached to the steel beam and an area 1 inch square missing fireproofing material.

7. Observed above the cross corridor doors, behind a sprinkler pipe, an area one inch square of unprotected steel beam.

8. Observed near room 217, an area 1 inch by 4 inches of steel beam with missing fireproofing material.

9. Observed in room 217, an area 4 inches by 8 inches of steel support beam missing fireproofing material.

Staff AA present on tour verified the observations.

Based on facility observation, review of facility schematics and staff interview and verification, the facility failed to ensure that corridors were separated from use areas by walls constructed with at least ½ hour fire resistance rating in non-sprinklered buildings where walls properly extend above the ceiling. Potentially all persons utilizing the area could be affected. The facility had a census of 18 patients at the time of survey.

Findings included:

On 10/16/12 between 1:40 P.M. and 3:45 P.M., tour of the facility was conducted with Staff AA and AB. Tour of the facility revealed it was divided into two units identified as 7A and 7B. The north wing of Unit 7A contained the administrative offices and larger storage areas. The south wing of 7A contained the special care unit.

Observation of the areas revealed only the special care unit was provided with automatic sprinkler system protection. Observation of the corridor walls, above the ceiling tiles, between the special care unit and the administrative offices revealed the corridor wall did not extend to the roof decking above.

Review of the facility schematic revealed the area was once an open area where a nursing station was located. The nursing station had been enclosed to construct a pharmacy. Staff present on tour verified the schematic did not accurately reflect the current construction of the floor. Staff further verified the corridor was not provided sprinkler protection and that the corridor wall did not extend above the ceiling tiles to the roof decking.

Based on facility observation and staff interview and verification, the facility failed to ensure that atriums were used in accordance with 8.2.5.6. Potentially all persons in the area could be affected. The facility had a census of 39 patients at the time of the survey.

Findings included:

On 10/18/12 between 8:30 A.M. and 10:00 A.M. observation of the atrium was conducted with Staff AA. Observation of the area from the third floor revealed that offices with windows opened onto the atrium. Observation of the third floor windows from the atrium side revealed the presence of sprinkler system heads at the top of each window. Under the windows were wooden window boxes. Observation of the second floor windows facing the atrium revealed there were no sprinkler system heads at the outside of the windows.

Observation inside the offices opening to the atrium on the third floor revealed the presence of an automatic sprinkler system. The sprinkler heads were placed near the center of the rooms and were not within a foot of the window glass. Staff AA verified the second floor offices were the same configuration with regards to sprinkler head placement. Staff AA verified the windows in the offices could be opened to the atrium.

Based on facility observation and staff interview and verification, the facility failed to ensure that hazardous areas were protected in accordance with 8.4, regarding protection provided with automatic extinguishing systems without fire-resistive separation, the space protected shall be enclosed with smoke partitions in accordance with 8.2.4. Doors were to be self-closing or automatic closing in accordance with 7.2.1.8. Potentially all persons in the area could be affected. The facility had a census of 39 patients at the time of the survey.

Findings included:

On 10/18/12 between 8:30 A.M. and 10:45 A.M. tour of the second and third floor storage areas was conducted with Staff AA. Although each of the storage area were provided with automatic sprinkler protection, the following observations of the rooms were noted:

1. Located on the third floor, in room 310S, which was designated as a nutrition kitchen, an open grid tile was observed in the ceiling. Observation of the open grid ceiling tile revealed it would allow for the passage of smoke.

2. At 9:25 A.M., observation of the second floor, room 261, revealed the room to be a storage area for nursing supplies. Observation of the ceiling tiles in the room revealed the presence of an open grid ceiling tile.

3. Observation of room 267 on the second floor revealed the room was a storage area. Observation of the ceiling tile revealed the presence of an open grid ceiling tile

4. Observation of room 205, the pharmacy storage area, revealed the presence of open grid ceiling tile.

5. Observation of a room designated as the storage area for broken equipment, revealed the presence of such items as four IV poles, thin mattress pads and two fans. The room door to the storage room had no closing device in place.

6. At 9:40 A.M. observation of room 209, designated to be the storage area for medical supplies, revealed the presence of an open grid ceiling tile.

Interview of Staff AA, present on the tour, verified the open grid ceiling tiles would allow for the passage of smoke out of the room.

Based on facility observation and staff interview and verification, the facility failed to ensure that exit access was arranged so that exits are readily accessible at all times in accordance with section 7.1. Potentially all persons in the area could be affected. The facility had a census of 39 patients at the time of the survey.

Findings included:

On 10/17/12 between 1:40 P.M. and 4:40 P.M. observation of the third floor means of egress was conducted with Staff AA. Observation of the third floor revealed the exit signs lead to a corridor where two exit signs were noted. The first exit sign in the path of egress indicated the way was to a center stair. The center stair discharged onto the first floor of the building but did not discharge to the public way.

Observation of the second sign and the path of egress revealed it required continuation past the initial exit sign, through corridor doors into another occupancy of the building and to an exit where discharge was to the public way. Interview of Staff AA regarding the exit passage ways verified that staff, patients and families would generally take the first and closest exit.

Based on review of facility information and staff interview and verification, the facility failed to ensure that heating, ventilating, and air conditioning comply with the provisions of section 9.2 and were installed in accordance with the manufacturer's specifications with regards to dampers. Potentially all persons in the area could be affected. The facility had a census of 39 patients at the time of the survey.

Findings included:

On 10/16/12 between 11:00 A.M. and 12:00 P.M., review of facility testing documentation was completed. Documentation of facility testing included a recent damper inspection report. Review of the report indicated that at least five fire/smoke dampers could not be tested due to lack of access panels at or near the damper locations. The following locations were noted to require the placement of an access panel:

1. Next to room 250, inside a bathroom, it was determined that two fire dampers were present and that access panels 12 inches square and 10 inches square were needed in order to confirm the presence and function of the dampers.

2. Located on the third floor, above a fire door near room 324S, it was determined that a fire damper was present and that an access panel 14 inches square was needed in order to confirm the presence and function of the damper.

3. Located on the third floor, outside room 303S, it was determined an access panel was needed in order to confirm the presence and function of the damper.

4. Located on the third floor, near room 344S, it was determined that a motorized fire./smoke damper was present and that an access panel 14 inches square was needed in order to confirm the presence and function of the damper.

Interview of Staff AA at the time of the document review verified that smoke/fire damper testing was not completed due to the need to build the access panels. Staff AA stated the installation of the panels was scheduled for 10/23/12.

Based on facility observation and staff interview and verification, the facility failed to ensure trash or linen gravity chutes were installed as a limited access gravity chute by installing a key in either the chute intake door or the entry door into the service room. Limited access waste chutes were to be installed so they could be used only by authorized personnel. Potentially all persons in the area could be affected. The facility had a census of 39 patients at the time of the survey.

Findings included:

On 10/18/12 at 8:50 A.M. tour of the third floor revealed the presence of room S28 which housed the trash and linen gravity chutes. Upon approach to the room, the key was observed in the lock of the door which would allow any person in the corridor to enter the room. No staff were in the immediate area of the room. Staff AA verified the staff left the key in the door lock to the room for convenience.

Entrance into room S28 revealed the doors to the soiled linen and the trash chutes were unlocked and were not in the closed and latched position. Staff AA pushed the door to the chutes closed so that they would latch.

Upon leaving the room, Staff AA placed the key on a hook, on the wall, outside the room next to the door.