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Based on observations the facility failed to provide the required positive latching 1-3/4 inch solid wood corridor door that is capable of resisting the passage of smoke.

Findings Include:

While inspecting corridor doors on September 30, 2010 at 10:40 a.m., the surveyor observed the following doors without positive latching hardware or smoke resistive construction
1. E.R. room #1 door was observed without positive latching hardware.
2. Clinic door #2 was observed without positive latching hardware.
3. Clinic door #2 was observed with unsealed air transfer grill.
4. Clinic door #3 was observed without positive latching hardware.
5. A hall storage room door was observed without positive latching hardware.
6. Storage room between patient rooms #5 and #6 door was observed without positive latching hardware.
7. A hall janitor ' s closet door was observed with unsealed air transfer grill in door.
8. B-hall janitor ' s closet door was observed with unsealed air transfer grill
9. Pharmacy dutch door was observed with unsealed gap.
Storage room adjacent to patient room #18 door was observed without positive latching hardware.

11. Laundry hall janitor ' s closet was observed with unsealed air transfer grill in door.
12. X-ray room door was observed without positive latching hardware.
13. E.R. entrance HVAC closet was observed with unsealed air transfer grills in door.

These deficient practices have the potential of affecting the 5 of 5 smoke compartments. The administrator and the maintenance director were notified during the survey as well as in the exit conference.

Based on observations the facility failed to provide the required fire rated viewing window in corridor walls in a non-sprinkled facility.

Findings Include:

While inspecting corridor walls on September 30, 2010 at 10:20 a.m., the surveyor observed the information window had an unrated glass in the main entrance corridor wall.

This deficient practice has the potential of affecting 1 of 5 smoke compartments. The administrator and the maintenance director were notified during the survey as well as in the exit conference.

Based on observations the facility failed to provide the required 1 hour fire rated construction in hazardous areas.

Findings Include:

While inspecting hazardous areas on September 30, 2010 at 11:15 a.m., the surveyor observed the following areas without the required fire rated construction or without self closing hardware on opening protectives.
1. Boiler room was observed with unsealed penetrations throughout perimeter firewall.
2. Laundry hallway linen storage room was observed without self closing hardware on firewall door.
3. Laundry room was observed without self closing hardware on firewall door.

These deficient practices have the potential of affecting 2 of 5 smoke compartments. The administrator and the maintenance director were notified during the survey as well as in the exit conference.

Based on observations the facility failed to provide the required 90 minute fire rated doors for 2 hour fire rated horizontal exits.

Findings Include:

While inspecting corridor walls and door on September 30, 2010 at 10:20 a.m., The surveyor observed the horizontal exit that separates the hospital from the nursing home with unsealed penetrations in the rated doors and without positive latching hardware.

This deficient practice has the potential of affecting the entire facility. The administrator and the maintenance director were notified during the survey as well as in the exit conference.

Based on observations the facility was using the newly renovated E.R. egress corridor as a return air or exhaust air system serving other areas of the building.

Findings Include:

While inspecting the newly renovated E.D. wing on September 30, 2010 at 12:00 p.m., the surveyor observed the E.R. HVAC closet with unsealed air transfer grilles in the door. After further inspection the egress corridor was observed being utilized as a return or exhaust air system serving adjoining areas. NFPA 90A, Standards for the Installation of Air Conditioning and Ventilating Systems, 1999 edition, Section 2-3.11.1, states, Egress corridors in health care, detention, and correctional, occupancies shall not be used as portions of a return, supply, or exhaust air system serving adjoining areas. An air transfer opening shall not be permitted in walls or in doors separating egress corridors from adjoining areas.

This deficient practice has the potential of affecting 5 of 5 smoke compartments. The administrator and the maintenance director were notified during the survey as well as in the exit conference.

Based on observations the facility failed to provide a remote audible alarm capable of monitoring the operational status of the emergency generator in accordance with NFPA 101, 1999 edition, Section 3-5.6, Remote Controls and Alarms and Table 3-5.5.2(d) Safety Indications and Shutdown, where there is no life support.

Findings Include:

While inspecting the generator on September 30, 2010 at 12:00 p.m., the surveyor observed the generator lacked remote common audible alarm powered by the storage battery as specified in Table 3-5.5.2(d), to monitor low coolant levels. This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel.

This deficient practice has the potential of affecting 5 of 5 smoke compartments. The administrator and the maintenance director were notified during the survey as well as in the exit conference.