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Based on observation and interview, the facility did not provide a common separation wall with rated doors, rated doors, rated doors, rated doors, rated doors, rated doors, rated doors, doors with positive-latching hardware, and sealed wall penetrations. This deficiency occurred in 5 of the 7 smoke compartments, and had the potential to affect 28 of the 39 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On September 6, 2011 at 8:55 am surveyor #28616 observed in the SC-2 smoke compartment on the 2nd floor in the exit passageway, that the doors in the 2-hour rated separation wall could not be verified of having at least a 90 minute rating.The pair of separation doors included a vinyl astragal which was not part of the tested assembly. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4 and 8.2.3.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

2. On September 6, 2011 at 12:20 pm surveyor #28616 observed in the SC-1 smoke compartment on the 1st floor in the corridor, that the doors in the 2-hour rated separation wall could not be verified of having at least a 90 minute rating.The pair of separation doors included a vinyl astragal which was not part of the tested assembly. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4 and 8.2.3.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

3. On September 6, 2011 at 12:21 pm surveyor #28616 observed in the SC-1 smoke compartment on the 1st floor in the corridor, that the doors in the 2-hour rated separation wall could not be verified of having at least a 90 minute rating. The pair of separation doors included an aluminum astragal which was not part of the tested assembly. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4 and 8.2.3.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

4. On September 6, 2011 at 12:29 pm surveyor #28616 observed in the SC-2 smoke compartment on the 1st floor in the corridor, that the doors in the 2-hour rated separation wall could not be verified of having at least a 90 minute rating. The pair of separation doors included an aluminum astragal which was not part of the tested assembly. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4 and 8.2.3.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

5. On September 6, 2011 at 12:35 pm surveyor #28616 observed in the SC-2 smoke compartment on the 1st floor in the dining room, that the door in the 2-hour rated separation wall could not be verified of having at least a 90 minute rating. The door was observed to be damaged and de-laminating which affected the listed fire rating. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4 and 8.2.3.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

6. On September 6, 2011 at 1:20 pm surveyor #28616 observed in the SC-2 smoke compartment on the 1st floor in the kitchen, that the doors in the 2-hour rated separation wall could not be verified of having at least a 90 minute rating. When in the closed position the pair of separation doors had a 5/8" gap. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4 and 8.2.3.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

7. On September 6, 2011 at 1:22 pm surveyor #28616 observed in the SC-2 smoke compartment on the 1st floor in the dishwash room, that the door in the 2-hour rated separation wall could not be verified of having at least a 90 minute rating. The 90 minute rated door had two open screw holes on each side where hardware had been replaced. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4 and 8.2.3.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

8. On September 6, 2011 at 1:04 pm surveyor #28616 observed in the SC-2 smoke compartment on the 1st floor in the kitchen, that the separation doors would not positively self-latch when released. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. One of the pair of doors only had a surface mounted bolt and the doors would not positively self-latch. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

9. On September 6, 2011 at 8:15 am surveyor #28616 observed in the SC-6 smoke compartment on the 2nd floor in the day room, that penetration(s) were not sealed according to an approved method. The deficiency included intumecent fire caulk used at the duct penetration of the wall which would affect the damper function. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4; and 8.2.3.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

10. On September 6, 2011 at 9:45 am surveyor #28616 observed in the SC-3 smoke compartment on the 2nd floor in the corridor, that penetration(s) were not sealed according to an approved method. The deficiency included intumecent fire caulk used at the duct penetration of the wall which would affect the damper function. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4; and 8.2.3.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

11. On September 6, 2011 at 12:40 pm surveyor #28616 observed in the SC-2 smoke compartment on the 1st floor in the dining room, that penetration(s) were not sealed according to an approved method. The deficiency included (2) 1" holes penetrated by wires. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4; and 8.2.3.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

12. On September 6, 2011 at 12:44 pm surveyor #28616 observed in the SC-2 smoke compartment on the 1st floor in the dining room, that penetration(s) were not sealed according to an approved method. The deficiency included a wire mold penetration. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4; and 8.2.3.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

13. On September 6, 2011 at 12:50 pm surveyor #28616 observed in the SC-2 smoke compartment on the 1st floor in the dining room, that penetration(s) were not sealed according to an approved method. The deficiency included a 1" hole with communication wire. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4; and 8.2.3.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

14. On September 6, 2011 at 3:06 pm surveyor #28616 observed in the SC-1 smoke compartment on the 1st floor in the corridor to CBRF, that penetration(s) were not sealed according to an approved method. The deficiency included a 2" unsealed square hole at a channel penetration. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4; and 8.2.3.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

15. On September 6, 2011 at 12:55 pm surveyor #28616 observed in the SC-2 smoke compartment on the 1st floor in the dining room, that penetration(s) were not sealed according to an approved method. The deficiency included (1) 6" diameter pipe with plaster and duct tape and (1) 4" diameter pipe with plaster and duct tape. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4; and 8.2.3.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Electrician) and G (CMS Safety Engineer).

16. On September 6, 2011 at 12:57 pm surveyor #28616 observed in the SC-2 smoke compartment on the 1st floor in the dining room, that penetration(s) were not sealed according to an approved method. The deficiency included hot and cold plumbing pipe penetrations. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4; and 8.2.3.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Electrician) and G (CMS Safety Engineer).

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Based on observation and interview, the facility did not provide and maintain the required building construction type with and sealed floor penetrations. This deficiency occurred in 3 of the 7 smoke compartments, and had the potential to affect 28 of the 39 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On September 6, 2011 at 9:25 am surveyor #28616 observed in the SC-5 smoke compartment on the 2nd floor in the storage office, that there were penetration(s) through the floor that were not fire stopped according to an approved method. The deficiency included (4) pipes that were sealed with silicone caulk at the floor/ceiling penetration. Penetrations adversely affected the ability of the building to compartmentalize fires to a single floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6 and 8.2.3.2.4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

2. On September 6, 2011 at 12:00 pm surveyor #28616 observed in the SC-1 smoke compartment on the 1st floor in the janitor closet, that there were penetration(s) through the floor that were not fire stopped according to an approved method. The deficiency included (2) heater pipes. Penetrations adversely affected the ability of the building to compartmentalize fires to a single floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6 and 8.2.3.2.4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

3. On September 6, 2011 at 12:45 pm surveyor #28616 observed in the SC-2 smoke compartment on the 1st floor in the dining room, that there were penetration(s) through the floor that were not fire stopped according to an approved method. The deficiency included plumbing drain and supply pipes. Penetrations adversely affected the ability of the building to compartmentalize fires to a single floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6 and 8.2.3.2.4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

4. On September 6, 2011 at 2:54 pm surveyor #28616 observed in the SC-1 smoke compartment on the 1st floor in the electrical closet, that there were penetration(s) through the floor that were not fire stopped according to an approved method. The deficiency included an unsealed 1" hole at a conduit penetration. Penetrations adversely affected the ability of the building to compartmentalize fires to a single floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6 and 8.2.3.2.4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

5. On September 6, 2011 at 5:06 pm surveyor #28616 observed in the SC-B smoke compartment on the basement floor in the air handler room, that there were penetration(s) through the floor that were not fire stopped according to an approved method. The deficiency included a 6" diameter and a 4" diameter hole. Penetrations adversely affected the ability of the building to compartmentalize fires to a single floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6 and 8.2.3.2.4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

6. On September 6, 2011 at 5:25 pm surveyor #28616 observed in the SC-B smoke compartment on the basement floor in the basement storage, that there were penetration(s) through the floor that were not fire stopped according to an approved method. The deficiency included (3) 4' diameter holes. Penetrations adversely affected the ability of the building to compartmentalize fires to a single floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6 and 8.2.3.2.4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

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Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with and a smoke-tight corridor ceiling (in a sprinkled smoke zone). This deficiency occurred in 2 of the 7 smoke compartments, and had the potential to affect 17 of the 39 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On September 6, 2011 at 9:48 am surveyor #28616 observed in the SC-4 smoke compartment on the 2nd floor in the day room, that the corridor separation construction did not resist the passage of smoke because of one or more unsealed holes. The holes included (2) 3" square holes in the concrete block wall. Corridors in sprinkled smoke compartments can have either walls or ceiling with construction that resists the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

2. On September 6, 2011 at 9:55 am surveyor #28616 observed in the SC-3 smoke compartment on the 2nd floor in the stair D, that the corridor separation construction did not resist the passage of smoke because of one or more unsealed holes. The holes included (1) 1" unsealed hole with wires. Corridors in sprinkled smoke compartments can have either walls or ceiling with construction that resists the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

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Based on observation and interview, the facility did not provide corridor separation doors with smoke-tight corridor frames, louver-free corridor doors, and doors that would close when pushed or pulled. This deficiency occurred in 3 of the 7 smoke compartments, and had the potential to affect 17 of the 39 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On September 6, 2011 at 10:08 am surveyor #28616 observed in the SC-3 smoke compartment on the 2nd floor in the clinical education 2.051, that the door had a frame that would not resist the passage of smoke because the door and frame were warped. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

2. On September 6, 2011 at 11:59 am surveyor #28616 observed in the SC-1 smoke compartment on the 1st floor in the janitor closet, that the door had a 8" x 24" size louver which did not resist the passage of smoke between the corridor and room. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

3. On September 6, 2011 at 3:52 pm surveyor #28616 observed in the SC-1 smoke compartment on the 1st floor in the janitor closet, that the door had a 8" x 24" size louver which did not resist the passage of smoke between the corridor and room. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

4. On September 6, 2011 at 10:12 am surveyor #28616 observed in the SC-3 smoke compartment on the 2nd floor in the employee break room, that the door to the corridor was held open with a 5 gallon water jug. The door would not release with a push or pull. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

5. On September 6, 2011 at 3:24 pm surveyor #28616 observed in the SC-1 smoke compartment on the 1st floor in the reception office, that the door to the corridor was held open with a rubber door stop. The door would not release with a push or pull. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

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Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with sealed wall penetrations. This deficiency occurred in 1 of the 7 smoke compartments, and had the potential to affect 28 of the 39 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On September 6, 2011 at 7:55 am surveyor #28616 observed in the SC-5 smoke compartment on the 2nd floor in the corridor, that penetration(s) in a vertical shaft were not sealed according to according to an approved method. The deficiency included an open conduit and a 1" hole with wires. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

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Based on observation and interview, the facility did not provide hold-open devices on doors in rated walls that included an adjacent smoke detector. This deficiency occurred in 1 of the 7 smoke compartments, and had the potential to affect 28 of the 39 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On September 6, 2011 at 1:30 pm surveyor #28616 observed in the SC-2 smoke compartment on the 1st floor in the dishwash room, that the fire barrier door was magnetically held open and did not have an adjacent smoke detector that was interconnected to the fire alarm system. The ceiling on the dining room side of the door was 24" above the top of the door frame. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

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Based on observation and interview, the facility did not provide and maintain smoke barrier door assemblies that meet code requirements for separation of smoke compartments with compliant smoke doors, and smoke-tight seals at meeting edges. This deficiency occurred in 1 of the 7 smoke compartments, and had the potential to affect 28 of the 39 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On September 6, 2011 at 2:42 pm surveyor #28616 observed in the SC-1 smoke compartment on the 1st floor in the corridor to dining, that the smoke barrier door was not compliant. The door had (15) open holes where hardware had been removed. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.6 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

2. On September 6, 2011 at 2:30 pm surveyor #28616 observed in the SC-1 smoke compartment on the 1st floor in the dining room, that the pair of cross-corridor smoke barrier doors had a gap greater than 1/8" at their meeting edges that was not sealed with an effective astragal to resist the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.6 and 8.3.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

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Based on observation and interview, the facility did not provide enclosures around exit stairs with doors with positive-latching hardware, and exit stairwells without openings to unoccupied rooms. This deficiency occurred in of the 7 smoke compartments, and had the potential to affect 28 of the 39 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On September 6, 2011 at 11:55 am surveyor #28616 observed in the SC-1 smoke compartment on the 1st floor in the stair C enclosure, that the door would not positively self-latch when released. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

2. On September 6, 2011 at 9:04 am surveyor #28616 observed in the SC-2 smoke compartment on the 2nd floor in the clean linen room, that an opening in an exit enclosure was from an unoccupied space. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.3.2.1(d). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

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Based on observation and interview, the facility did not provide and maintain all stairs with door assemblies, to meet code requirements with rated stairwell construction. This deficiency occurred in 5 of the 7 smoke compartments, and had the potential to affect 28 of the 39 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On September 6, 2011 at 8:57 am surveyor #28616 observed in the SC-2 smoke compartment on the 2nd floor in the exit passageway, that a bulletin board had been installed in the exit passageway which is not permitted. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.2.3 and 7.2.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

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Based on observation and interview, the facility did not provide and maintain the exit access travel distance to exits as with egress paths within the required travel distance . This deficiency occurred in 1 of the 7 smoke compartments, and had the potential to affect 10 of the 39 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On September 6, 2011 at 4:48 pm surveyor #28616 observed in the SC-1 smoke compartment on the 1st floor in the therapy room, that the space exceeded the allowable area for one exit. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.6 and 7.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

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Based on observation and interview, the facility did not provide egress paths at all times with doors that opened with under 50 pounds of force, travel interruption at stairs that go below the level of exit discharge, doors that were unlockable in the egress path, and level walking surface at doorways. This deficiency occurred in 7 of the 7 smoke compartments, and had the potential to affect 28 of the 39 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On September 6, 2011 at 10:15 am surveyor #28616 observed in the SC-3 smoke compartment on the 2nd floor in the stair E, that the door in the path of egress would not open when a force of greater than 75 pounds was applied, which exceeded the maximum 50 pounds needed to open an existing exit door. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.4.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

2. On September 6, 2011 at 10:17 am surveyor #28616 observed in the SC-3 smoke compartment on the 2nd floor in the stair D, that the travel down the stairwell was not interrupted by an effective means to prevent travel past the level of discharge. This observed situation was not compliant with NFPA 101 (2000 edition), 7.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

3. On September 6, 2011 at 1:12 pm surveyor #28616 observed in the SC-1 smoke compartment on the 1st floor in the stair B, that the travel down the stairwell was not interrupted by an effective means to prevent travel past the level of discharge. This observed situation was not compliant with NFPA 101 (2000 edition), 7.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

4. On September 6, 2011 at 3:33 pm surveyor #28616 observed in the SC-1 smoke compartment on the 1st floor in the main entrance, that the door was locked from the egress side. The main entrance doors were locked with a deadbolt after 9 pm every evening. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.2.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

5. On September 6, 2011 at 3:18 pm surveyor #28616 observed in the SC-1 smoke compartment on the 1st floor in the stair B, that the floor on one side of the door was 5/8" above the level floor. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.3, exception 2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

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Based on observation and interview, the facility failed to provide and maintain patient spaces that can be exited without the use of a key or locked as permitted by the code, such as delayed egress. This deficiency occurred in 1 of the 7 smoke compartments, and would affect 5 of the 29 patients in the facility on the day of the survey.

FINDINGS INCLUDE:
On September 7, 2011 at 9:30 am surveyor #28616 observed in the second floor SC-7smoke compartment in stair I that a delayed egress lock (DEL) was installed in a building that was not fully sprinkled. The current installation would activate when approached by at risk patients; this installation is not acceptable. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.6.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

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Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with sprinklers that were too far from the ceiling, and sprinklers free of obstructions near the ceiling. This deficiency occurred in 7 of the 7 smoke compartments, and had the potential to affect 28 of the 39 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On September 6, 2011 at 8:05 am surveyor #28616 observed in the SC-6 smoke compartment on the 2nd floor in the day room, that the sprinkler was placed farther than 22" below the ceiling. This situation was observed in the active construction area where the ceiling had been removed and the fire protection sprinkler heads were not relocated. This situation would delay release of water and does not satisfy listing. This observed situation was not compliant with NFPA 13 (1999 edition), 5-5.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

2. On September 6, 2011 at 3:38 pm surveyor #28616 observed in the SC-1 smoke compartment on the 1st floor in the closet, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included boxes and durable medical supplies. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

3. On September 6, 2011 at 4:30 pm surveyor #28616 observed in the SC-1 smoke compartment on the 1st floor in the closet, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included several stored boxes. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

4. On September 6, 2011 at 8:50 am surveyor #28616 observed in the SC-7 smoke compartment on the 2nd floor in the electrical closet, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The exception to not provide fire sprinkler protection requires that the room be fire rated. The room was not fire rated and conduit penetrations were only sealed with joint compound. This observed situation was not compliant with NFPA 101 (2000 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

5. On September 6, 2011 at 4:20 pm surveyor #28616 observed in the SC-1 smoke compartment on the 1st floor in the closet, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The closet spaces that were constructed in the corridor were 42" x 10'-9", 36" x 12'-0" and 36" x 7'-6". This observed situation was not compliant with NFPA 101 (2000 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

6. On September 6, 2011 at 4:24 pm surveyor #28616 observed in the SC-1 smoke compartment on the 1st floor in the walk-in safe, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The abandoned vault was 36" x 5'-0" and was being used as a closet. This observed situation was not compliant with NFPA 101 (2000 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

7. On September 6, 2011 at 10:04 am surveyor #28616 observed in the SC-3 smoke compartment on the 2nd floor in the electrical closet, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The exception to not provide fire sprinkler protection requires that the room be fire rated. The room was not fire rated were the inspection revealed only gypsum board on the finish side of the wall construction. This observed situation was not compliant with NFPA 101 (2000 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Facility Manager) and G (CMS Safety Engineer).

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Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have sprinklers free of corrosion, sprinkler gauges with the required maintenance, sprinklers free of lint, and the appropriate quantity of spare sprinklers. This deficiency occurred in 7 of the 7 smoke compartments, and had the potential to affect 28 of the 39 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On September 6, 2011 at 4:34 pm surveyor #28616 observed in the SC-1 smoke compartment on the 1st floor in the therapy area closet, that the sprinkler showed signs of corrosion. This observed situation was not compliant with NFPA 25 (998 edition), 2-2.1 .1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

2. On September 6, 2011 at 11:30 am surveyor #28616 observed that during a review of documents the facility could not verify that the sprinkler water pressure gauge had been replaced or calibrated within the last 5 years. During a review of documents the facility could not verify that the sprinkler system hydrolic calculations were accurately represented at the riser location. A tag required to be mechanically attached accurately describing the hydraulic design data was not current. This observed situation was not compliant with NFPA 25 (1998 edition), 2-3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

3. On September 6, 2011 at 11:40 am surveyor #28616 observed that during a review of documents the facility could not verify that the sprinkler water pressure gauge had been replaced or calibrated within the last 5 years. This observed situation was not compliant with NFPA 25 (1998 edition), 2-3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

4. On September 6, 2011 at 2:38 pm surveyor #28616 observed in the SC-1 smoke compartment on the 1st floor in the corridor to dining, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

5. On September 6, 2011 at 11:37 am surveyor #28616 observed that the cabinet of spare sprinklers did not contain two spare heads for the each type of sprinkler that were observed in the facility. Spare sprinklers were not provided for sprinkler head types identified in the therapy area and bent deflector sprinkler head types identified in the second floor patient room and office. This observed situation was not compliant with NFPA 25 (1998 edition), 2-4.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

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Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with missing fire damper. This deficiency occurred in 2 of the 7 smoke compartments, and had the potential to affect 28 of the 39 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On September 6, 2011 at 7:50 am surveyor #28616 observed in the SC-5 smoke compartment on the 2nd floor in the corridor, that a fire damper was not installed in an air duct that penetrated the rated wall. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1 and NFPA 90A (1999 edition), 3-3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

2. On September 6, 2011 at 1:30 pm surveyor #28616 observed that the ventilation system used the second floor corridor in the patient wings as a plenum for air returning to the air handling unit. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1 , 9.2 and NFPA 90A, 2-3.11.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Director) and G (CMS Safety Engineer).

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Based on observation and interview, the facility did not provide interior walls and partitions made of noncombustible or limited-combustible materials with non-combustible wall materials. This deficiency occurred in 7 of the 7 smoke compartments, and had the potential to affect 28 of the 39 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On September 6, 2011 at 12:42 pm surveyor #28616 observed in the SC-2 smoke compartment on the 1st floor in the dining room, that a wall was made with combustible materials, which is not permitted in non-combustible types of building construction. The wall was constructed with wood framing and exterior grade plywood. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

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Based on observation and interview, the facility used life support systems and did not provide a Type I essential electrical system with a compliant type 1 electrical system. This deficiency occurred in 7 of the 7 smoke compartments, and had the potential to affect 28 of the 39 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On September 6, 2011 at 1:20 pm surveyor #28616 observed that the facility admitted patients that depend on life support equipment and did not have a Type 1 emergency electrical system. The system failed to provide dedicated critical branch and life safety branch power in lieu of the installed zone emergency power design. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.9.1 and NFPA 99 (1999 edition), 3-4.2.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

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Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with fixed wiring rather than extension cords, and closed electrical raceways. This deficiency occurred in 3 of the 7 smoke compartments, and had the potential to affect 28 of the 39 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On September 6, 2011 at 3:45 pm surveyor #28616 observed in the SC-1 smoke compartment on the 1st floor in the office 1.049, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to a microwave oven and refrigerator. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

2. On September 6, 2011 at 3:54 pm surveyor #28616 observed in the SC-1 smoke compartment on the 1st floor in the kichenette, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to a refrigerator. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

3. On September 6, 2011 at 3:58 pm surveyor #28616 observed in the SC-1 smoke compartment on the 1st floor in the office 1.033, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to a refrigerator and an iPod. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

4. On September 6, 2011 at 4:01 pm surveyor #28616 observed in the SC-1 smoke compartment on the 1st floor in the office 1.031, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to a lamp and charger. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

5. On September 6, 2011 at 4:15 pm surveyor #28616 observed in the SC-1 smoke compartment on the 1st floor in the office 1.017, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to a lamp. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

6. On September 6, 2011 at 4:58 pm surveyor #28616 observed in the SC-1 smoke compartment on the 1st floor in the therapy area office, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to a lamp. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

7. On September 6, 2011 at 9:29 am surveyor #28616 observed in the SC-5 smoke compartment on the 2nd floor in the corridor, that a 10" x 10" electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 70 (1999 edition), 517-12. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

8. On September 6, 2011 at 2:48 pm surveyor #28616 observed in the SC-2 smoke compartment on the 1st floor in the dining room, that a 4" x 4" electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 70 (1999 edition), 517-12. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Environment of Care), staff E (Facility Manager) and G (CMS Safety Engineer).

9. On September 6, 2011 at 12:44 pm surveyor #28616 observed in the SC-2 smoke compartment on the 1st floor in the dining room, that a 4x4 and flexible conduit electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 70 (1999 edition), 517-12. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Electrician) and G (CMS Safety Engineer).

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