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Based on observations, the facility failed to maintain 3 of 11 Smoke Barriers free of penetrations by failing to properly use fire caulk and failing to tape and mudd drywall seams. This affects 6 of 8 smoke zones, affecting approximately 8 patients and 50 staff members. The facility had a capacity of 25 patients and a census of 15 patients.

Findings include:

Observations on 9-22-10, revealed the following:

1. The smoke barrier that separates the Tunnel from the West Basement Wing revealed center of conduit penetration (approximately 1/4 inch in size) located above the suspended ceiling.

2. The smoke barrier near the Pulmonary Function Testing Room revealed a center of conduit penetration (approximately 1/2 inch in size) and a 12 inch drywall seam failed to be mudded and taped, located above the suspended ceiling.

3. The smoke barrier that separates the Administration Wing from the Old West Wing revealed a center of conduit penetration (approximately 2 inches in size) located above the suspended ceiling.

Maintenance Staff A confirmed these findings.

Based on observations, the facility failed to maintain 3 of 11 smoke barrier doors to close and latch properly. This affects 3 of 8 smoke zones, affecting approximately 7 patients and 30 staff members. The facility had a capacity of 25 patients and a census of 15 patients.

Findings include:

Observations on 9-22-10 revealed the following:

1. The set of smoke barrier doors located north of the Outpatient Registration Area failed to close and latch properly into the door frame when tested.

2. The set of smoke barrier doors that separate the Lobby from the Old Emergency Room failed to close and latch properly in the door frame when tested.

3. The set of smoke barrier doors that separate the Administration Wing from the Old West Wing failed to close and latch properly into the door frame when tested.

Maintenance Staff A confirmed these findings.

Based on observations and interview, the facility failed to maintain 4 of 18 hazardous rooms by not sealing penetrations, installing self closing devices on the doors and not maintaining the doors to properly close and latch. This affects 4 of 8 smoke zones, affecting approximately 8 patients and 42 staff members. The facility had a capacity of 25 patients and a census of 15 patients.

Findings include:

Observations and staff interview on 9-22-10 revealed the following:

1. The door to the West Medical Records Store Room in the Basement failed to be equipped with an Underwriters Laboratory (U.L.) listed self-closing device.

2. The door to the Acute Care Soiled Utility Room failed to properly close and latch into the door frame when tested.

3. The Surgery Electrical Room revealed a center of conduit penetration (approximately 1/2 inch in size) located in the corridor wall side of the room.

4. The Air Handler Room in the Basement revealed a 1 foot by 2 foot open duct penetration located in the corridor wall, above the suspended ceiling. Per conversation with Maintenance Staff A, this duct was to be removed during the recent renovation project.

Maintenance Staff A confirmed these findings.

Based on observations, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1998 edition by not documenting the required number of inspections. This affects all occupants throughout the facility. The facility had a capacity of 25 patients and a census of 15 patients.

Findings include:

Observations on 9-22-10, revealed the facility failed to properly document a quarterly sprinkler inspection during the 3rd quarter of 2010. The 3rd quarter of 2009 inspection was completed on 8-31-09.

Maintenance Staff A confirmed this finding.

Based on observations, the facility failed to provide drapery, curtains, including cubicle curtains in accordance with provisions of 10.3.1 of the life safety code and NFPA 13, Standard for Installation of Sprinkler Systems, 1999 edition by allowing vinyl mini blind window coverings to be used. This affects 2 of 8 smoke zones, affecting approximately 39 staff members due to the fact that this deficiency took place in non-patient areas. The facility had a capacity of 25 patients and a census of 15 patients.

Findings include:

Observations on 9-22-10 revealed vinyl mini-blind window covering in the P.T. Reception Office and the Kitchen.

Maintenance Staff A confirmed these findings.

Based on observations, the facility failed to properly maintain the storage of compressed medical gases in accordance with Section 4.3.1.1.2, NFPA 99, Health Care Facilities, 1999 edition by not properly securing oxygen bottles This affects 1 of 8 smoke zones, affecting approximately 7 patients and 10 staff members. The facility had a license of 25 patients and a census of 15 patients.

Findings include:

Observation on 9-22-10 revealed 1 oxygen bottle that were not properly secured in the Respiratory Therapy Room.

Maintenance Staff A confirmed this finding.

Based on observations, 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 by not covering electrical junction boxes and allowing unapproved electrical items to be plugged into surge protectors. This affects 2 of 8 smoke zones, affecting approximately 43 staff members due to the fact that these deficiencies occurred in non-patient areas all occupants within the affected zone. This zone was not a patient occupied area, simple a staff lounge. The facility had a capacity of 25 patients and a census of 15 patients.

Findings include:

Observations on 9-22-10 revealed the following:

1. An open electrical junction box with an exposed wire was observed above the suspended ceiling located near a the entrance to the Cafeteria.

2. A microwave oven was observed being plugged into a surge protector in the Kitchen.

3. A fan and coffee pot was observed being plugged into a surge protector in the Accounting Office.

Maintenance Staff A confirmed these findings.

Based on observations, the facility failed to maintain 3 of 11 Smoke Barriers free of penetrations by failing to properly use fire caulk and failing to tape and mudd drywall seams. This affects 6 of 8 smoke zones, affecting approximately 8 patients and 50 staff members. The facility had a capacity of 25 patients and a census of 15 patients.

Findings include:

Observations on 9-22-10, revealed the following:

1. The smoke barrier that separates the Tunnel from the West Basement Wing revealed center of conduit penetration (approximately 1/4 inch in size) located above the suspended ceiling.

2. The smoke barrier near the Pulmonary Function Testing Room revealed a center of conduit penetration (approximately 1/2 inch in size) and a 12 inch drywall seam failed to be mudded and taped, located above the suspended ceiling.

3. The smoke barrier that separates the Administration Wing from the Old West Wing revealed a center of conduit penetration (approximately 2 inches in size) located above the suspended ceiling.

Maintenance Staff A confirmed these findings.

Based on observations, the facility failed to maintain 3 of 11 smoke barrier doors to close and latch properly. This affects 3 of 8 smoke zones, affecting approximately 7 patients and 30 staff members. The facility had a capacity of 25 patients and a census of 15 patients.

Findings include:

Observations on 9-22-10 revealed the following:

1. The set of smoke barrier doors located north of the Outpatient Registration Area failed to close and latch properly into the door frame when tested.

2. The set of smoke barrier doors that separate the Lobby from the Old Emergency Room failed to close and latch properly in the door frame when tested.

3. The set of smoke barrier doors that separate the Administration Wing from the Old West Wing failed to close and latch properly into the door frame when tested.

Maintenance Staff A confirmed these findings.

Based on observations and interview, the facility failed to maintain 4 of 18 hazardous rooms by not sealing penetrations, installing self closing devices on the doors and not maintaining the doors to properly close and latch. This affects 4 of 8 smoke zones, affecting approximately 8 patients and 42 staff members. The facility had a capacity of 25 patients and a census of 15 patients.

Findings include:

Observations and staff interview on 9-22-10 revealed the following:

1. The door to the West Medical Records Store Room in the Basement failed to be equipped with an Underwriters Laboratory (U.L.) listed self-closing device.

2. The door to the Acute Care Soiled Utility Room failed to properly close and latch into the door frame when tested.

3. The Surgery Electrical Room revealed a center of conduit penetration (approximately 1/2 inch in size) located in the corridor wall side of the room.

4. The Air Handler Room in the Basement revealed a 1 foot by 2 foot open duct penetration located in the corridor wall, above the suspended ceiling. Per conversation with Maintenance Staff A, this duct was to be removed during the recent renovation project.

Maintenance Staff A confirmed these findings.

Based on observations, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1998 edition by not documenting the required number of inspections. This affects all occupants throughout the facility. The facility had a capacity of 25 patients and a census of 15 patients.

Findings include:

Observations on 9-22-10, revealed the facility failed to properly document a quarterly sprinkler inspection during the 3rd quarter of 2010. The 3rd quarter of 2009 inspection was completed on 8-31-09.

Maintenance Staff A confirmed this finding.

Based on observations, the facility failed to provide drapery, curtains, including cubicle curtains in accordance with provisions of 10.3.1 of the life safety code and NFPA 13, Standard for Installation of Sprinkler Systems, 1999 edition by allowing vinyl mini blind window coverings to be used. This affects 2 of 8 smoke zones, affecting approximately 39 staff members due to the fact that this deficiency took place in non-patient areas. The facility had a capacity of 25 patients and a census of 15 patients.

Findings include:

Observations on 9-22-10 revealed vinyl mini-blind window covering in the P.T. Reception Office and the Kitchen.

Maintenance Staff A confirmed these findings.

Based on observations, the facility failed to properly maintain the storage of compressed medical gases in accordance with Section 4.3.1.1.2, NFPA 99, Health Care Facilities, 1999 edition by not properly securing oxygen bottles This affects 1 of 8 smoke zones, affecting approximately 7 patients and 10 staff members. The facility had a license of 25 patients and a census of 15 patients.

Findings include:

Observation on 9-22-10 revealed 1 oxygen bottle that were not properly secured in the Respiratory Therapy Room.

Maintenance Staff A confirmed this finding.

Based on observations, 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 by not covering electrical junction boxes and allowing unapproved electrical items to be plugged into surge protectors. This affects 2 of 8 smoke zones, affecting approximately 43 staff members due to the fact that these deficiencies occurred in non-patient areas all occupants within the affected zone. This zone was not a patient occupied area, simple a staff lounge. The facility had a capacity of 25 patients and a census of 15 patients.

Findings include:

Observations on 9-22-10 revealed the following:

1. An open electrical junction box with an exposed wire was observed above the suspended ceiling located near a the entrance to the Cafeteria.

2. A microwave oven was observed being plugged into a surge protector in the Kitchen.

3. A fan and coffee pot was observed being plugged into a surge protector in the Accounting Office.

Maintenance Staff A confirmed these findings.