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Based on surveyor observation and staff interview, the facility failed to maintain the Type I protected construction type of the building. This deficient practice affects 4 residents in 1 of 32 smoke zones. The facility has a capacity of 221 and a census of 136.

Findings include:

Observations and interview on 05/03/12, revealed there were 3 trusses located near the elevator lift rail in the Tower Penthouse with approximately 6-inch by 6-inch areas of missing fireproofing material.

Maintenance Staff A and Administrative Staff A observed this finding.

Based on observation and interview, the facility failed to maintain smoke barrier doors. This deficient practice affects 8 residents in 2 of 32 smoke zones. The facility has a capacity of 221 and a census of 136.

Findings include:

Observations and interview on 05/04/12, revealed the smoke doors located in the Endoscopy A North area failed to close and latch properly.

Maintenance Staff A and Administrative Staff A observed this finding.

Based on surveyor observation and staff interview, the facility failed to maintain the battery-backup emergency lights. This deficient practice affects 8 residents in 2 of 32 zones. The facility has a capacity of 221 and a census of 136.

Findings include:

Observations and interview on 05/03/12 & 05/04/12, revealed the following deficiencies:

1. The ER Penthouse emergency light failed to function when the test button was pressed.
2. The C-East BioTech area emergency light failed to function when the test button was pressed.

Maintenance Staff A and Administrative Staff A observed these findings.

Based on surveyor observation and staff interview, the facility failed to provide exit signs at each end of exit corridors. This deficient practice affects 12 residents in 3 of 32 zones. The facility has a capacity of 221 and a census of 136.

Findings include:

Observations and interview on 05/03/12, revealed the following deficiencies:

1. There was no exit sign to indicate egress to the east on the west side of the 4-Mid to 4-West fire doors.
2. There was no exit sign to indicate egress to the east in the 2-West hallway.
3. There was no exit sign to indicate egress to the east in the 3-West Blank Psychology area.

Maintenance Staff A and Administrative Staff A observed these findings.

Based on surveyor observation and staff interview, the facility failed to provide smoke detectors in accordance with National Fire Protection Association (NFPA) 72. This deficient practice affects 24 residents in 6 of 32 smoke zones in the facility. The facility has a capacity of 221 and a census of 136.

Findings include:

Observations and interview on 05/03/12 & 05/04/12, revealed the following deficiencies:

1. The smoke detector located in the 1-West Nuclear Medicine Holding Area was positioned within 3-feet of an HVAC vent.
2. The smoke detector located in the Endoscopy A North Pyxis Room was positioned within 3-feet of a HVAC vent.
3. The smoke detectors (2) located in the A-Mid Outpatient Surgery Waiting Area were positioned within 3-feet of HVAC vents.
4. The smoke detector located in the A-Mid Outpatient Surgery Breakroom was positioned within 3-feet of a HVAC vent.
5. The smoke detector located in the A-Mid Outpatient Surgery Backroom was positioned within 3-feet of a HVAC vent.
6. The smoke detector located in the Radiology Manager's Office was positioned within 3-feet of a HVAC vent.
7. The smoke detector located in the A-South Surgery Men's Locker Room was positioned within 3-feet of a HVAC vent.
8. The smoke detector located in the A-South Surgery West Hall near 106/123 was positioned within 3-feet of a HVAC vent.
9. The smoke detector located in the OR1 Procurement Room was positioned within 3-feet of a HVAC vent.
10. The smoke detector located in the B-East North West Conference Room was positioned within 3-feet of a HVAC vent.

Maintenance Staff A and Administrative Staff A observed this finding.

Based on surveyor observation and staff interview, the facility failed to provide a sprinkler system in accordance with National Fire Protection Association (NFPA) 13. This deficient practice affects 12 residents in 3 of 32 zones. The facility has a capacity of 221 and a census of 136.

Findings include:

Observations on 05/04/12 revealed the following deficiencies:

1. The Small Tissue Block Room was not covered by the sprinkler system.
2. The sprinkler head in the Vet-Lab Room was positioned only 2-inches from the wall instead of the 4-inches (minimum) required by code.
3. The Dock Area was not covered by the sprinkler system.

Maintenance Staff A and Administrative Staff A observed these findings.

Based on surveyor observation and staff interview, the facility failed to maintain fire extinguishers in accordance with National Fire Protection Association (NFPA) 10. This deficient practice affects 4 residents in 1 of 32 smoke zones. The facility has a capacity of 221 and a census of 136.

Findings include:

Observations on 05/04/12, revealed the K-Class fire extinguisher located in the Serving Area was not positioned within 30-feet of the cooking surfaces.

Maintenance Staff A and Administrative Staff A observed this finding.

Based on surveyor observation and staff interview, the facility failed to provide proper signage for the fire extinguisher cabinets. This deficient practice affects 40 residents in 10 of 32 zones in the building. The facility has a capacity of 221 and a census of 136.

Findings include:

Observations and interview on 05/03/12, revealed the following deficiencies:
1. The fire extinguisher cabinets near 5505, 5052, 573, 427, 405, 305, 317, 328, 215, & 216 were labeled as being hose cabinets and these cabinets no longer contain hoses.
2. The fire extinguisher cabinet located in 2-Mid across from the Copy Room was labeled as having a fire extinguisher but did not contain an extinguisher.

Maintenance Staff A and Administrative Staff A observed this finding.

Based on surveyor observation and staff interview, the facility failed to maintain the electrical system in accordance with National Fire Protection Association (NFPA) 70. This deficient practice affects 40 residents in 10 of 32 smoke zones. The facility has a capacity of 221 and a census of 136.

Findings include:

Observations and interview on 05/03/12, revealed the following deficiencies:
1. There was a sink located within approximately 1 foot of an electrical panel in the 5 West Housekeeping Equipment Room.
2. There was a sink located within approximately 1-foot of an electrical panel in the 4-West Electrical Room.
3. There was a sink located within approximately 3 feet of an electrical panel in the 4-East north side east end Housekeeping Closet.
4. There was storage obstructing electrical panels in the Electrical Closet located across from 307 in 3-East.
5. There was a sink located within 3 feet of an electrical panel in 033 in 3-East.
6. There were exposed electrical wires in 004 in 3-East.
7. There was a sink located within 3 feet of an electrical panel in the 2-East north hall Janitor Closet near 217.
8. The X-Ray electrical panel was not labeled as Out of Service.
9. There was a sink within 3-feet of an electrical panel in the 1-East north hall Janitor Closet across from 115.
10. There was an open knock-out in the electrical junction box located above the door in the ER War Room.
11. There were open junction boxes in the 1-West Mammography Liebert Room Mechanical Room.

Maintenance Staff A and Administrative Staff A observed these findings.