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Based on observation and staff interview, the facility fails to assure that barrier walls are maintained and are free of penetrations. The deficient practice compromises the fire resistance rating of the wall and would not prevent the passage of fire or smoke to other areas of the building, affecting all residents in 1 of 6 smoke zones. The Hospital has a capacity of 25 with a census of 15 and the LTCU has a capacity of 37 with a census of 35 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 2/17/14, at 3:05 p.m., it is observed that the 2 hour fire barrier wall separating the Assisted Living and LTCU has an unsealed penetration around the sprinkler pipe.

Maintenance Supervisor was present and acknowledged the unsealed penetration in the rated wall.

NFPA Standard: Floor-ceiling assemblies and walls used as fire barriers, including supporting construction, shall be of a design that has been tested to meet the conditions of acceptance of NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials. Fire barriers shall be continuous in accordance with 8.2.2.2 per NFPA 101, 8.2.3.1.1. Space between wires and similar building service equipment that pass through fire barriers shall be protected by filling the space with a material that is capable of maintaining the fire resistance of the fire barrier or shall be protected by an approved device that is designed for the specific purpose 2000 NFPA 101, 8.2.3.2.4.

Based upon observation and staff interview, the facility fails to assure that spaces between penetrating items and smoke barriers are filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. The deficient practice would not prevent the passage of smoke to other areas of the building, affecting all residents and 12 patients in 4 of 6 smoke zones. The Hospital has a capacity of 25 with a census of 15 and the LTCU has a capacity of 37 with a census of 35 at the time of the survey.

Findings include:

During the tour conducted on 2/17/14 the following is observed:

-1) At 3:35 p.m., there are unsealed gaps around cables in the smoke barrier wall in the dietary hall that will not resist the passage of smoke.

-2) At 3:50 p.m., there are unsealed gaps around conduit in the smoke barrier wall between the Acute hall and the ER that will not resist the passage of smoke.

Maintenance Supervisor was present and acknowledged the findings.

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1

Based on observation and staff interview, the facility fails to ensure that all hazardous areas have self closing doors that automatically latch. This deficient practice would not prevent the passage of fire or smoke to other areas of the building, affecting 0 residents in 1 of 6 smoke zones. The Hospital has a capacity of 25 with a census of 15 and the LTCU has a capacity of 37 with a census of 35 at the time of the survey.

Findings Include:

During the tour conducted on 2/17/14, at 3:30 p.m., it is observed that the fire rated double doors to the laundry room are not automatically latching.

Maintenance Supervisor was present and acknowledged the findings.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1.

Based upon a review of records and staff interview, the facility fails to assure that fire drills are held at unexpected times, under varying conditions and at least once per shift per quarter. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all residents and occupants in the event of a fire, affecting all residents and patients in 6 of 6 smoke zones. The Hospital has a capacity 25 of with a census of 15 and the LTCU has a capacity of 37 with a census of 35 at the time of the survey.

Findings include:

During the tour conducted on 2/17/14, a review of records, at 11:15 a.m., for the last 5 quarters revealed the following:

-1) No drills were conducted for the 1st and 2nd quarters of 2013.

-2) Drills for the 3rd and 4th quarters of 2013 and 1st quarter of 2014 on the 1st shift were held between 9:26 a.m. and 9:36 a.m..

-3) A silent drill was conducted at 7:30 p.m. during the 3rd quarter of 2013 for the 2nd shift.

Maintenance Supervisor was present and acknowledged the results of the record review.

NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 19.7.1.2

Based on staff interview and record review, the facility did not assure that the fire alarm system is in accordance with NFPA 72 and chapter 9.6.4 of NFPA 101 by ensuring that an approved central station appropriately and continuously monitors the fire alarm and summons an organized fire department upon receipt of a fire alarm transmission. This deficient practice affects all patients and residents in 6 of 6 smoke zones. The Hospital has a capacity of 25 and a census of 15 and the LTCU has a capacity of 37 with a census of 35 at the time of the survey.

Findings include:

During the tour conducted on 2/17/14, at 2:15 p.m., it is observed that the fire alarm control panel is in trouble mode due to communication trouble with the dialer.

Maintenance Supervisor was present and acknowledged the finding.

NFPA Standard: If the remote supervising station is at a location other than the public fire service communications center, alarm signals shall be immediately retransmitted to the public fire service communications center. 1999 NFPA 72, 5-4.6.1

Based upon records review, observation, and staff interview the facility fails to assure that the sprinkler heads are free of corrosion, foreign materials, paint, physical damage and installed in the proper orientation in accordance with NFPA 25. This deficient practice could result in an unexpected failure of the sprinkler system, affecting 0 patients and residents in 1 of 6 smoke zones. The Hospital has a capacity of 25 with a census of 15 and the LTCU has a capacity of 37 with a census of 35 at the time of this survey.

Findings include:

During the tour conducted on 2/17/14, at 3:30 p.m., it is observed that a sprinkler head above the dryers in the laundry room has an accumulation of foreign materials.

Maintenance Supervisor was present and acknowledged the findings.

NFPA Standard: Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. 1998 NFPA 25, 2-2.1.1

NFPA Standard: Corrective maintenance includes, but is not limited to, replacing loaded, corroded, or painted sprinklers; replacing missing or loose pipe hangers; cleaning clogged fire pump impellers; replacing valve seats and gaskets; restoring heat in areas subject to freezing temperatures where water-filled piping is installed; and replacing worn or missing fire hose or nozzles. 1998 NFPA 25, 1-11.3

Based on observation and staff interview, the facility fails to assure that means of egress are continuously maintained free of all obstructions or impediments. The deficient practice would prevent the full instant use of the egress pathway, affecting 0 patients and residents in 1 of 6 smoke zones. The Hospital has a capacity of 25 with a census of 15 and the LTCU has a capacity of 37 with a census of 35 at the time of the survey.

Findings include:

During the tour conducted on 2/17/14, at 3:25 p.m., it is observed that there are several items stored in the service corridor.

Maintenance Supervisor was present and acknowledged the findings.

NFPA Standard: Means of egress are continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects obstruct exits, access to, egress from, or visibility of exits. 7.1.10

Based on observation and staff interview the facility fails to assure that all electrical wiring complies with NFPA 70. This deficient practice could result in an electrical short causing a fire, affecting approximately 12 patients in 3 of 6 smoke zones. The Hospital has a capacity of 25 with a census of 15 and the LTCU has a capacity of 37 with a census of 35 at the time of this survey.

Findings Include:

During the tour on 2/17/14 the following is observed:

-1) At 2:00 p.m., there is an open junction box on the ceiling in the basement by the maintenance office.

-2) At 3:45 p.m., there is an open junction box above the ceiling by patient room 2.

-3) At 3:55 p.m., there is a open junction box above the ceiling by the X-ray room.

Maintenance Supervisor was present and acknowledged the findings.

NFPA standard: All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 379-22, Exception. 1999 NFPA 70, 370-28(3)(c).

NFPA Standard: Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2

Based on observation and staff interview, the facility fails to assure that barrier walls are maintained and are free of penetrations. The deficient practice compromises the fire resistance rating of the wall and would not prevent the passage of fire or smoke to other areas of the building, affecting all residents in 1 of 6 smoke zones. The Hospital has a capacity of 25 with a census of 15 and the LTCU has a capacity of 37 with a census of 35 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 2/17/14, at 3:05 p.m., it is observed that the 2 hour fire barrier wall separating the Assisted Living and LTCU has an unsealed penetration around the sprinkler pipe.

Maintenance Supervisor was present and acknowledged the unsealed penetration in the rated wall.

NFPA Standard: Floor-ceiling assemblies and walls used as fire barriers, including supporting construction, shall be of a design that has been tested to meet the conditions of acceptance of NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials. Fire barriers shall be continuous in accordance with 8.2.2.2 per NFPA 101, 8.2.3.1.1. Space between wires and similar building service equipment that pass through fire barriers shall be protected by filling the space with a material that is capable of maintaining the fire resistance of the fire barrier or shall be protected by an approved device that is designed for the specific purpose 2000 NFPA 101, 8.2.3.2.4.

Based upon observation and staff interview, the facility fails to assure that spaces between penetrating items and smoke barriers are filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. The deficient practice would not prevent the passage of smoke to other areas of the building, affecting all residents and 12 patients in 4 of 6 smoke zones. The Hospital has a capacity of 25 with a census of 15 and the LTCU has a capacity of 37 with a census of 35 at the time of the survey.

Findings include:

During the tour conducted on 2/17/14 the following is observed:

-1) At 3:35 p.m., there are unsealed gaps around cables in the smoke barrier wall in the dietary hall that will not resist the passage of smoke.

-2) At 3:50 p.m., there are unsealed gaps around conduit in the smoke barrier wall between the Acute hall and the ER that will not resist the passage of smoke.

Maintenance Supervisor was present and acknowledged the findings.

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1

Based on observation and staff interview, the facility fails to ensure that all hazardous areas have self closing doors that automatically latch. This deficient practice would not prevent the passage of fire or smoke to other areas of the building, affecting 0 residents in 1 of 6 smoke zones. The Hospital has a capacity of 25 with a census of 15 and the LTCU has a capacity of 37 with a census of 35 at the time of the survey.

Findings Include:

During the tour conducted on 2/17/14, at 3:30 p.m., it is observed that the fire rated double doors to the laundry room are not automatically latching.

Maintenance Supervisor was present and acknowledged the findings.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1.

Based upon a review of records and staff interview, the facility fails to assure that fire drills are held at unexpected times, under varying conditions and at least once per shift per quarter. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all residents and occupants in the event of a fire, affecting all residents and patients in 6 of 6 smoke zones. The Hospital has a capacity 25 of with a census of 15 and the LTCU has a capacity of 37 with a census of 35 at the time of the survey.

Findings include:

During the tour conducted on 2/17/14, a review of records, at 11:15 a.m., for the last 5 quarters revealed the following:

-1) No drills were conducted for the 1st and 2nd quarters of 2013.

-2) Drills for the 3rd and 4th quarters of 2013 and 1st quarter of 2014 on the 1st shift were held between 9:26 a.m. and 9:36 a.m..

-3) A silent drill was conducted at 7:30 p.m. during the 3rd quarter of 2013 for the 2nd shift.

Maintenance Supervisor was present and acknowledged the results of the record review.

NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 19.7.1.2

Based on staff interview and record review, the facility did not assure that the fire alarm system is in accordance with NFPA 72 and chapter 9.6.4 of NFPA 101 by ensuring that an approved central station appropriately and continuously monitors the fire alarm and summons an organized fire department upon receipt of a fire alarm transmission. This deficient practice affects all patients and residents in 6 of 6 smoke zones. The Hospital has a capacity of 25 and a census of 15 and the LTCU has a capacity of 37 with a census of 35 at the time of the survey.

Findings include:

During the tour conducted on 2/17/14, at 2:15 p.m., it is observed that the fire alarm control panel is in trouble mode due to communication trouble with the dialer.

Maintenance Supervisor was present and acknowledged the finding.

NFPA Standard: If the remote supervising station is at a location other than the public fire service communications center, alarm signals shall be immediately retransmitted to the public fire service communications center. 1999 NFPA 72, 5-4.6.1

Based upon records review, observation, and staff interview the facility fails to assure that the sprinkler heads are free of corrosion, foreign materials, paint, physical damage and installed in the proper orientation in accordance with NFPA 25. This deficient practice could result in an unexpected failure of the sprinkler system, affecting 0 patients and residents in 1 of 6 smoke zones. The Hospital has a capacity of 25 with a census of 15 and the LTCU has a capacity of 37 with a census of 35 at the time of this survey.

Findings include:

During the tour conducted on 2/17/14, at 3:30 p.m., it is observed that a sprinkler head above the dryers in the laundry room has an accumulation of foreign materials.

Maintenance Supervisor was present and acknowledged the findings.

NFPA Standard: Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. 1998 NFPA 25, 2-2.1.1

NFPA Standard: Corrective maintenance includes, but is not limited to, replacing loaded, corroded, or painted sprinklers; replacing missing or loose pipe hangers; cleaning clogged fire pump impellers; replacing valve seats and gaskets; restoring heat in areas subject to freezing temperatures where water-filled piping is installed; and replacing worn or missing fire hose or nozzles. 1998 NFPA 25, 1-11.3

Based on observation and staff interview, the facility fails to assure that means of egress are continuously maintained free of all obstructions or impediments. The deficient practice would prevent the full instant use of the egress pathway, affecting 0 patients and residents in 1 of 6 smoke zones. The Hospital has a capacity of 25 with a census of 15 and the LTCU has a capacity of 37 with a census of 35 at the time of the survey.

Findings include:

During the tour conducted on 2/17/14, at 3:25 p.m., it is observed that there are several items stored in the service corridor.

Maintenance Supervisor was present and acknowledged the findings.

NFPA Standard: Means of egress are continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects obstruct exits, access to, egress from, or visibility of exits. 7.1.10

Based on observation and staff interview the facility fails to assure that all electrical wiring complies with NFPA 70. This deficient practice could result in an electrical short causing a fire, affecting approximately 12 patients in 3 of 6 smoke zones. The Hospital has a capacity of 25 with a census of 15 and the LTCU has a capacity of 37 with a census of 35 at the time of this survey.

Findings Include:

During the tour on 2/17/14 the following is observed:

-1) At 2:00 p.m., there is an open junction box on the ceiling in the basement by the maintenance office.

-2) At 3:45 p.m., there is an open junction box above the ceiling by patient room 2.

-3) At 3:55 p.m., there is a open junction box above the ceiling by the X-ray room.

Maintenance Supervisor was present and acknowledged the findings.

NFPA standard: All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 379-22, Exception. 1999 NFPA 70, 370-28(3)(c).

NFPA Standard: Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2