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Based on observations, records review, and staff interview, it was determined that the facility failed to ensure that all smoke compartmentation requirements were met.

Findings were:

During a tour of this facility with staff M on 08/09/2010 at 11:40 a.m. it was noted that the smoke barriers were not adequate in size to accommodate all patients on this floor.

An interview with staff M confirmed the findings.

Based on observations and staff interview, it was determined that the facility failed to ensure that all smoke barrier walls met the one half hour fire resistance rating.

Findings were:

During a tour of this facility with staff M on 08/09/2010 at 11:40 a.m. it was noted that the smoke barrier wall had a penetration that was not properly sealed near to patient room #910.

An interview with staff M confirmed the findings.

Based on observations and staff interview, it was determined that the facility failed to ensure that all hazardous areas were properly protected.

Findings were:

During a tour of this facility with staff M on 08/09/2010 at 11:25 a.m. the following hazardous area deficiencies were noted:
a. a soiled utility room opened into a patient room in the High Observation area and was not provided with a self closing door;
b. the soiled linen room did not have a labeled fire door and frame;
c. the rolling fire shutter in the supply room corridor opening was not provided with a fusible link on both sides of the door; and
d. the sill of the rolling fire door was not constructed of the same materials as the door assembly and was not considered to be fire rated.

An interview with staff M confirmed the findings.

Based on observations and staff interview, it was determined that the facility failed to ensure that all exit requirements were met.

Findings were:

During a tour of this facility with staff M on 08/09/2010 at 11:35 a.m. the following stairwell and exit deficiencies were noted:
a. some of the guards in the stairwells were not at least 42" in height;
b. some of the guards in the stairwells had spaces that a 4" sphere could pass through;
c. the stairwell ground floor exit on the East End was not provided with an all weather surface to the public way;
d. the exit for the West End stairwell exits internal to the building and the exit passageway has several un-occupiable rooms (such as storage rooms, mechanical rooms, etc.), which have doors that open onto the passageway. Some of these doors were blocked in the open position; and
e. the ground floor exit door for the East End stairwell had three latches to operate to open the door.

An interview with staff M confirmed the findings.

Based on observations and staff interview, it was determined that the facility failed to ensure that the corridor width was maintained.

Findings were:

During a tour of this facility with staff M on 08/09/2010 at 11:15 a.m. it was noted that a crash cart was being stored in the corridor.

An interview with staff M confirmed the findings.

Based on observations, testing, and staff interview, it was determined that the facility failed to ensure that all emergency lighting requirements were being met.

Findings were:

During a tour of this facility with staff M on 08/09/2010 at 12:40 p.m. it was noted that the outside exits were not provided with emergency lighting of 1 1/2 hour duration.

An interview with staff M confirmed the findings.

Based on observations and staff interview, it was determined that the facility failed to ensure that all exits were properly identified.

Findings were:

During a tour of this facility with staff M on 08/09/2010 at 11:45 a.m. it was noted that the East End Stairwell at the ground floor exit door was not properly identified with directional and exit signs.

An interview with staff M confirmed the findings.

Based on observations, records review, and staff interview, it was determined that the facility failed to ensure that all fire alarm maintenance and testing requirements were being met.

Findings were:

During a tour of this facility with staff M on 08/09/2010 at 1:15 p.m. it was noted that the battery test results were not listed among the fire alarm testing documents.

An interview with staff M confirmed the findings.

Based on observations and staff interviews, it was determined that the facility failed to ensure that all automatic sprinkler system requirements were being met.

Findings were:

During a tour of this facility with staff M on 08/09/2010 at 12:35 p.m. it was noted that the automatic sprinkler system's water supply line was not provided with a supervised post indicator valve.

An interview with staff M confirmed the findings.

Based on observations and staff interview, it was determined that the facility failed to ensure that all medical gas storage requirements were being met.

Findings were:

During a tour of this facility with staff M on 08/09/2010 at 11:45 a.m. it was noted that the area used for medical gas storage was not a rated room and had more than 12 cylinders in inventory.

An interview with staff M confirmed the findings.

Based on observations and staff interview, it was determined that the facility failed to meet the requirements for alcohol dispensers in health care occupancies.

Findings were:

During a tour of this facility with staff M on 08/09/2010 at 11:20 a.m. it was noted that aerosol alcohol dispensers were located in the corridor.

An interview with staff M confirmed the findings.

Based on observations and staff interview, it was determined that the facility failed to ensure that the emergency power system met the requirements for Type I EES.

Findings were:

During a tour of this facility with staff M on 08/09/2010 at 1:30 p.m. it was noted that the EES system was required to have a separate transfer operation for the critical branch, life safety branch, and emergency system in accordance with NFPA 99,3.4.2.2.2.

An interview with staff M confirmed the findings.

Based on observations and staff interview, it was determined that the facility failed to ensure that all electrical wiring and equipment met the requirements.

Findings were:

During a tour of this facility with staff M on 08/09/2010 at 1:35 p.m. it was noted that the emergency generator sets location was not provided with battery powered emergency lighting system.

An interview with staff M confirmed the findings.