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Based on observation, this facility is not assuring that one of thirty smoke barriers is completed as required. This would compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone. This deficient practice affects all occupants of the building, including staff, visitors and patients that would use the dining area. This facility has a capacity of 35 with a census of 17 patients.

Findings include:

Observation on 3/29/11, revealed the 2-hour seperation above the smoke doors in the Dining area corridor was not completed as required. The wall stopped at the ceiling tiles above the doors and did not exceed to the roof deck. According to the facility layout, this was a required barrier.

Based on observation, the facility failed to maintain the corridor walls to be rated and to extend from floor to roof deck. This deficient practice affects 2 of 30 smoke compartments. The facility has a capacity of 35 and a census of 17 patients.

Findings include:

1. Observation on 3/29/11, revealed of the facility's corridor rated wall located outside the Bistro revealed a 2 inch open conduit with computer cables not sealed.

2. Observation on 3/29/11, revealed of the facility's corridor rated wall across from the Bistro contained a 3 1/2 inch hole, 1/2 inch hole with telephone cord not sealed, and an 1 1/2 open conduit with computer cables not sealed.

Based on observation, the facility is not ensuring that the doors are free of impediments that would prevent the doors from being closed. This deficient practice affects occupants in 1 of 30 smoke zones, as the doors would not prevent the spread of fire and smoke. This facility has a capacity of 35 and a census of 17 patients.

Findings include:

Observation on 3/29/11, the Soiled Utility room (#1244) in the Women's Center had a ' kick-down ' located at the base of the door that could prevent the door from being closed in an emergency.

Based on observation, this facility is not assuring that 6 of 30 smoke compartments are free of penetrations that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone. This deficient practice affects all occupants of the building, including staff, visitors and patients. This facility has a capacity of 35 with a census of 17 patients.

Findings include:

1. Observation on 3/29/11, revealed above the Out-Patient Surgery Suite west double doors contained an approximate 2 inch by 5 inch hole had not been sealed.

2. Observation on 3/29/11, revealed above the Out-Patient Surgery Suite south double doors contained an approximate 3 inch by 4 inch hole with metal flex conduit had not been sealed.

3. Observation on 3/29/11, revealed above the Surgery pacu double doors contained 1/2 penetrations surrounding medical gas copper pipes.

4. Observation on 3/29/11, revealed above the Nurse's Lounge double doors contained 1/2 inch penetration surrounding metal flex conduit.

5. Observation on 3/29/11, revealed above the OB and 2nd floor West smoke doors contained an 1/2 inch penetration surrounding a cable.

6. The 100 hall smoke barrier had three conduits with holes ranging from one-half to one inch in size. The holes were packed with insulation instead of a fire-rated product. According to the facility layout, this was a required barrier. Administrative Staff A and Maintenance Staff A confirmed these observations.

Based on observation, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected 3 of 30 smoke compartments and could affect vistors and staff. This facility has a capacity of 35 and a census of 17 patients.

Findings include:

1. Observation of the Lower tunnel area (storage room) on 3/29/11, revealed that the room walls and ceiling contained several holes and penetrations (1/2 inch to 1 inch in size)throughout.

2. Observation of the Boiler room on 3/29/11, revealed the entrance door was not equipped with a self-closing device and the south door was not rated and without positive latching hardware.

3. Observation of the Purchasing room (Storage room) on 3/29/11, revealed the double doors are not equipped with self-closing devices.

4. Observation of the Air Handler 5 room (Storage room) on 3/29/11, revealed the north wall contained an 1/2 inch penetration surrounding a 4 inch pipe, and 1/2 inch penetration surrounding a 1 inch pipe and cable bundle.

5. Observation of the Kitchen storage room on 3/29/11, revealed not all the walls and door were one hour rated.

Based on observation, this facility is not providing a clear path of egress for one of three exits in the Kitchen. This facility has a capacity of 35 with a census of 17.

Findings include:

Observation on 3/29/11, revealed the Kitchen west exit was blocked by a roller cart and several boxes, not providing a clear path of egress in case of an emergency.

Based on observation and record review, the facility failed to document the emergency egress lighting annually. This deficient practice affects 30 of 30 smoke compartments and all occupants of the facility. This facility has a capacity of 35 and a census of 17 patients.

Findings include:

Observation and record review of the facility's maintenance records on 3/29/11, revealed that there was no documentation regarding the testing of the emergency battery lighting system for the 90 minute annual test.

Based on observation, the facility did not provide a directional exit sign at the end of the East exit corridor for one of four exits on 2nd floor. This deficient practice effects patients, staff and visitors on 2nd floor OB wing. This facility has a capacity of 35 and a census of 17 patients.

Observation on 3/29/11, the 2nd floor (OB Wing) East exit did not have a directional exit sign. According to the facility layout, which is used in conjunction with the emergency procedures, this designated exit is a required exit.

Based on observation and record review, the facility is not conducting fire drills at least quarterly on each shift. This deficient practice affects all occupants including staff, visitors and residents, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. This facility has a capacity of 35 and a census of 17 patients.

Findings include:

Observation and review of the facility ' s fire drill records on 3/29/11, revealed the evening and night shift fire drills were not conducted on 2nd and 4th quarter for the year 2010.

(A)
Based on observation and record review, the facility failed to maintain the testing of smoke detectors for sensitivity in accordance with NFPA 72, 7-3.2.1. All of the smoke detectors throughout the building were affected and all occupants of the building could be affected by the deficient practice. The facility census is 35 with a capacity of 17.

Findings include:

Observation and record review on 3/29/11, the facility's documentation of the sensitivity test only contained the test percentages of the smoke detectors and did not include the sensitivity range set forth by the manufacturer.

(B)
Based on observation, this facility is not assuring that the fire alarm system is installed in accordance with NFPA 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer that three feet to air supply or air return. This affects 2 of 30 smoke zones and could affect all occupants in those zones. This facility has a capacity of 35 and a census of 17 patients.

Findings include:

Observation on 3/29/11, the following areas contained air supply vents that were located within three feet of the smoke detectors: in the Health Records (Basement) and Lab draw room.

Based on observation, this facility is not maintaining the sprinkler system in accordance with the 1998 edition of NFPA 25, and the 1999 edition of NFPA 13 by ensuring sprinkler heads are not covered and are the proper heads for their location. This can affect the operation of the heads by obstructing spray patterns, delaying the response time or preventing the operation of the heads that can compromise the effectiveness of the fire suppression system. This deficient practice can place all occupants at risk in the event of a fire. The census was 35 with a capacity of 17.

Findings include:

1. Observation on 3/29/11, the sprinkler head located in the Director of Information System's office was not visible due to the location. This head was covered up by the ceiling tile.
2. Observation on 3/29/11, the sprinkler heads located in Kitchen's freezer contained orange substance and could not be identified as the correct sprinkler heads for this area.

Based on observation, the facility failed to provide draperies, curtains and window blinds that were flame resistant in accordance with provisions of NFPA 101, 10.3. This affects 1 of 30 smoke compartments in the building and has the potential of affecting all the staff using the 3rd floor office area. This facility has a capacity of 35 and a census of 17 patients.

Findings include:

Observations of the blinds in the Director of Information Systems office on 3/29/11, showed they were not metal and were not tagged as being flame retardant.

Based on observation, the facility failed to maintain the 3 feet clearance for the electrical panels as required. The deficient practice would affect 1 of 30 smoke compartments of building. The facility has 35 certified beds and at the time of the survey the facility census was 17.

Findings include:

Observation on 3/29/11, revealed the electrical panels located in the Kitchen were blocked by trash receptacles.

Based on observation and record review, the facility failed to maintain the paperwork of the emergency generator power supply as required. The deficient practice would affect all smoke compartments of building and all of the residents and staff. The facility has 35 certified beds and at the time of the survey the facility census was 17.

Findings include:

Observation and documentation review on 3/29/11, revealed that proper documentation of the generator weekly and monthly inspections did not provide the end run times.

Based on observation, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition, placing the Staff and Patients of the facility at risk in the event of a fire. This would affect 2 of 30 smoke compartments. The facility had a capacity of 35 and a census of 17 at the time of the survey.

Findings Include:

Observations on 3/29/11, revealed the facility failed to provide Ground Fault Circuit Interrupter electrical outlets in the following areas: Clean Laundry room and 3rd floor Kitchenette.

Based on observation, this facility is not assuring that one of thirty smoke barriers is completed as required. This would compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone. This deficient practice affects all occupants of the building, including staff, visitors and patients that would use the dining area. This facility has a capacity of 35 with a census of 17 patients.

Findings include:

Observation on 3/29/11, revealed the 2-hour seperation above the smoke doors in the Dining area corridor was not completed as required. The wall stopped at the ceiling tiles above the doors and did not exceed to the roof deck. According to the facility layout, this was a required barrier.

Based on observation, the facility failed to maintain the corridor walls to be rated and to extend from floor to roof deck. This deficient practice affects 2 of 30 smoke compartments. The facility has a capacity of 35 and a census of 17 patients.

Findings include:

1. Observation on 3/29/11, revealed of the facility's corridor rated wall located outside the Bistro revealed a 2 inch open conduit with computer cables not sealed.

2. Observation on 3/29/11, revealed of the facility's corridor rated wall across from the Bistro contained a 3 1/2 inch hole, 1/2 inch hole with telephone cord not sealed, and an 1 1/2 open conduit with computer cables not sealed.

Based on observation, the facility is not ensuring that the doors are free of impediments that would prevent the doors from being closed. This deficient practice affects occupants in 1 of 30 smoke zones, as the doors would not prevent the spread of fire and smoke. This facility has a capacity of 35 and a census of 17 patients.

Findings include:

Observation on 3/29/11, the Soiled Utility room (#1244) in the Women's Center had a ' kick-down ' located at the base of the door that could prevent the door from being closed in an emergency.

Based on observation, this facility is not assuring that 6 of 30 smoke compartments are free of penetrations that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone. This deficient practice affects all occupants of the building, including staff, visitors and patients. This facility has a capacity of 35 with a census of 17 patients.

Findings include:

1. Observation on 3/29/11, revealed above the Out-Patient Surgery Suite west double doors contained an approximate 2 inch by 5 inch hole had not been sealed.

2. Observation on 3/29/11, revealed above the Out-Patient Surgery Suite south double doors contained an approximate 3 inch by 4 inch hole with metal flex conduit had not been sealed.

3. Observation on 3/29/11, revealed above the Surgery pacu double doors contained 1/2 penetrations surrounding medical gas copper pipes.

4. Observation on 3/29/11, revealed above the Nurse's Lounge double doors contained 1/2 inch penetration surrounding metal flex conduit.

5. Observation on 3/29/11, revealed above the OB and 2nd floor West smoke doors contained an 1/2 inch penetration surrounding a cable.

6. The 100 hall smoke barrier had three conduits with holes ranging from one-half to one inch in size. The holes were packed with insulation instead of a fire-rated product. According to the facility layout, this was a required barrier. Administrative Staff A and Maintenance Staff A confirmed these observations.

Based on observation, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected 3 of 30 smoke compartments and could affect vistors and staff. This facility has a capacity of 35 and a census of 17 patients.

Findings include:

1. Observation of the Lower tunnel area (storage room) on 3/29/11, revealed that the room walls and ceiling contained several holes and penetrations (1/2 inch to 1 inch in size)throughout.

2. Observation of the Boiler room on 3/29/11, revealed the entrance door was not equipped with a self-closing device and the south door was not rated and without positive latching hardware.

3. Observation of the Purchasing room (Storage room) on 3/29/11, revealed the double doors are not equipped with self-closing devices.

4. Observation of the Air Handler 5 room (Storage room) on 3/29/11, revealed the north wall contained an 1/2 inch penetration surrounding a 4 inch pipe, and 1/2 inch penetration surrounding a 1 inch pipe and cable bundle.

5. Observation of the Kitchen storage room on 3/29/11, revealed not all the walls and door were one hour rated.

Based on observation, this facility is not providing a clear path of egress for one of three exits in the Kitchen. This facility has a capacity of 35 with a census of 17.

Findings include:

Observation on 3/29/11, revealed the Kitchen west exit was blocked by a roller cart and several boxes, not providing a clear path of egress in case of an emergency.

Based on observation and record review, the facility failed to document the emergency egress lighting annually. This deficient practice affects 30 of 30 smoke compartments and all occupants of the facility. This facility has a capacity of 35 and a census of 17 patients.

Findings include:

Observation and record review of the facility's maintenance records on 3/29/11, revealed that there was no documentation regarding the testing of the emergency battery lighting system for the 90 minute annual test.

Based on observation, the facility did not provide a directional exit sign at the end of the East exit corridor for one of four exits on 2nd floor. This deficient practice effects patients, staff and visitors on 2nd floor OB wing. This facility has a capacity of 35 and a census of 17 patients.

Observation on 3/29/11, the 2nd floor (OB Wing) East exit did not have a directional exit sign. According to the facility layout, which is used in conjunction with the emergency procedures, this designated exit is a required exit.

Based on observation and record review, the facility is not conducting fire drills at least quarterly on each shift. This deficient practice affects all occupants including staff, visitors and residents, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. This facility has a capacity of 35 and a census of 17 patients.

Findings include:

Observation and review of the facility ' s fire drill records on 3/29/11, revealed the evening and night shift fire drills were not conducted on 2nd and 4th quarter for the year 2010.

(A)
Based on observation and record review, the facility failed to maintain the testing of smoke detectors for sensitivity in accordance with NFPA 72, 7-3.2.1. All of the smoke detectors throughout the building were affected and all occupants of the building could be affected by the deficient practice. The facility census is 35 with a capacity of 17.

Findings include:

Observation and record review on 3/29/11, the facility's documentation of the sensitivity test only contained the test percentages of the smoke detectors and did not include the sensitivity range set forth by the manufacturer.

(B)
Based on observation, this facility is not assuring that the fire alarm system is installed in accordance with NFPA 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer that three feet to air supply or air return. This affects 2 of 30 smoke zones and could affect all occupants in those zones. This facility has a capacity of 35 and a census of 17 patients.

Findings include:

Observation on 3/29/11, the following areas contained air supply vents that were located within three feet of the smoke detectors: in the Health Records (Basement) and Lab draw room.

Based on observation, this facility is not maintaining the sprinkler system in accordance with the 1998 edition of NFPA 25, and the 1999 edition of NFPA 13 by ensuring sprinkler heads are not covered and are the proper heads for their location. This can affect the operation of the heads by obstructing spray patterns, delaying the response time or preventing the operation of the heads that can compromise the effectiveness of the fire suppression system. This deficient practice can place all occupants at risk in the event of a fire. The census was 35 with a capacity of 17.

Findings include:

1. Observation on 3/29/11, the sprinkler head located in the Director of Information System's office was not visible due to the location. This head was covered up by the ceiling tile.
2. Observation on 3/29/11, the sprinkler heads located in Kitchen's freezer contained orange substance and could not be identified as the correct sprinkler heads for this area.

Based on observation, the facility failed to provide draperies, curtains and window blinds that were flame resistant in accordance with provisions of NFPA 101, 10.3. This affects 1 of 30 smoke compartments in the building and has the potential of affecting all the staff using the 3rd floor office area. This facility has a capacity of 35 and a census of 17 patients.

Findings include:

Observations of the blinds in the Director of Information Systems office on 3/29/11, showed they were not metal and were not tagged as being flame retardant.

Based on observation, the facility failed to maintain the 3 feet clearance for the electrical panels as required. The deficient practice would affect 1 of 30 smoke compartments of building. The facility has 35 certified beds and at the time of the survey the facility census was 17.

Findings include:

Observation on 3/29/11, revealed the electrical panels located in the Kitchen were blocked by trash receptacles.

Based on observation and record review, the facility failed to maintain the paperwork of the emergency generator power supply as required. The deficient practice would affect all smoke compartments of building and all of the residents and staff. The facility has 35 certified beds and at the time of the survey the facility census was 17.

Findings include:

Observation and documentation review on 3/29/11, revealed that proper documentation of the generator weekly and monthly inspections did not provide the end run times.

Based on observation, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition, placing the Staff and Patients of the facility at risk in the event of a fire. This would affect 2 of 30 smoke compartments. The facility had a capacity of 35 and a census of 17 at the time of the survey.

Findings Include:

Observations on 3/29/11, revealed the facility failed to provide Ground Fault Circuit Interrupter electrical outlets in the following areas: Clean Laundry room and 3rd floor Kitchenette.