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Based on observation the facility failed to provide a building that has an approved building construction type. Building type II (000) is only permitted if the entire facility is protected by an automatic sprinkler system.

Findings:

During facility tour on May 17, 2010 between 10:30 a.m. and 1:30 p.m., it was observed that this part of the building has a construction type of II (111) and is not sprinkled. The rest of the facility is partly sprinkled and has a construction type of II (111). The common wall between the two different construction types is a fire barrier walls. Building type II (111) is permitted if the facility is not protected by an automatic sprinkler system and not over one story in height.

1. A hole (30 inches x 36 inches) in the solid protected ceiling was observed not sealed. This hole is by the doors going into the main part of the hospital.

Based on observation the facility failed to provide proper protection to all hazardous areas. Hazardous areas shall be constructed of at least one-hour fire rated walls and forty-five minute fire rated doors. The door to these rooms shall be self-closing. The door to 1 of 3 hazardous areas was not self-closing. This deficiency affects 26 residents in the facility

Findings:

During a tour of the facility on May 17, 2010 between 10:30 a.m. and 1:00 p.m., the door to the Supply Room 1 in the administration area was not self-closing. The door does not have a closer on it.

Based on observation the facility failed to provide corridors that are clear and unobstructed for the complete width of the corridor for 2 of 2 halls in 1 of 1 smoke compartments of the facility. This deficiency affects all 26 patients in the facility.

Note: NFPA 101, 2000 edition
NFPA 101:7.3. The width of means of egress shall be measured in the clear at the narrowest point of the exit component under consideration. Exception: Projections not more than 31/2 in. on each side shall be permitted at 38 in. and below.

Findings:

During facility tour on May 17, 2010 between 10:30 a.m. and 1:00 p.m. pull down charting desks were observed in the corridor of each hall. The charting desk (28 inches wide and 18 inches deep) protrude 22 inches from the wall in the open position.

Charting desk were observed opened and unattended in the following areas:
1. Next to room 110
2. Next to room 116
3. Next to room 120

The wall mounted charting desks in the corridors that are left unattended and in the open position can cause a safety hazard. In the open position the desk are more likely to be hit by equipment, bed, and people.

Based on observation, the facility failed to provide oxygen cylinders that are protected from damage.
This deficiency could affect all 26 patients in the facility.

NFPA 99:4-3.1.1.1 states, cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over

Findings:

During a tour of the facility on May 17, 2010 between 11:00 a.m. and 11:30 a.m. an oxygen cylinders was observed not being secured. One E type oxygen cylinders was lying on the floor in the hallway going to the administration area without being secured.