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Based on visual observation the facility failed to assure the fire rating of the fire and smoke barriers walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke from one compartment to the another. This deficient practice has the potential to affect 2 of 2 patients.

Findings:

During the facility tour, between the hours of 10:00 a.m. and 3:30 p.m. The fire wall in the renovated section of the 4th floor was observed having flex duct, wire, conduit, and numerous unsealed penetrations throughout the wall. The facility did not have the original Fire Marshal plans on site for the existing sections of the building. I was unable to determine through visual inspection the remainder of the walls.

Interview with the maintenance supervisor revealed the facility was not aware of unsealed penetrations.

Based on visual observation the facility failed to maintain the separation of hazardous areas from other parts of the building, including the egress corridor. Hazardous areas are required to be constructed to resist the passage of smoke and have self closing doors. The deficient practice has the potential to affect 2 of 2 patients.

Findings:

During the facility tour, between the hours of 10:00 a.m. and 3:30 p.m. the following storage areas did not have closures on the doors: 4th floor: mechanical room, room by exam 6, door across from room 403. Also door stops were observed on the 4th floor door next to the restroom by the fire wall cross corridor doors and the 5th floor electrical room behind the nurses station.

Interview with the maintenance supervisor revealed the facility was not aware of the door closures and the door stop requirements.

Based on visual observation the facility failed to assure the complete, supervised, automatic sprinkler system was inspected and tested in accordance with the requirements of NFPA 13. This deficiency has the potential to affect 2 of 2 residents.

Findings:

During the facility tour between the hours of 10:00 a.m. and 3:30 p.m. review of the sprinkler inspections revealed the system was yellow tagged by the contractor for not having the required internal inspection of the system. Also the facility was not documenting in house monthly gauge inspections.
The maintenance supervisor stated he checked the gauges monthly, but was unaware of the required documentation.

Based on visual observation and interview with staff the facility failed to have, on site, the Fire Marshal stamped set of drawing for the original construction of the building. This deficiency could cause harm to 2 of 2 patients.

Findings: During facility tour between the hours of 10:00 a.m. and 3:30 p.m. interview with the administrator and maintenance supervisor revealed the facility did not have the Fire Marshal stamped set of plans for the original construction of the building. The plans reviewed during the survey were of the 2006 -07 renovations of sections of the 4th and 5th floors.
Fire Marshal approved plans provide information regarding National Fire Protection Association requirements such as locations and fire resistance ratings of fire and smoke walls, corridor and door width, suite requirements, construction types, vertical openings, exiting, fire alarm, sprinkler system.

Based on visual observation the facility failed to assure that the elevators, for emergency personnel, are installed as required by ASME/ANSI A17.3. The response time for responding rescue personnel could be delayed when the elevator equipment does not have the required programming. This deficiency could have the potential to affect 2 of 2 patients.

Findings:

During the facility tour, between the hours of 10:00 a.m. and 3:30 p.m. the 1st floor elevator lobby was observed not having a smoke detector installed for elevator recall.

Interview with the supervisor revealed the facility was not aware a smoke detector was required in the elevator lobby.