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Based on observations during tour, review of floor plans, and staff interview, the facility failed to ensure the fire barriers which also served as a division for smoke compartmentation were constructed to provide at least a two hour fire resistance rating. The facility census was 9 patients at the time of the survey.

Findings include:

Tour of the facility's main building took place on 01/12/10 with the vice president of ancillary services (staff D) and director of plant operations (staff G).
Penetrations were observed in the two hour rated fire barrier above the ceiling tile and one set of doors failed to latch shut in the following locations:

Basement:
* One two and one half inch unsealed insulated line located in the support services director's room.
* One unsealed curved conduit and one straight conduit above ceiling tile of the southeast corner of the fire barrier in the cafeteria. Additionally, in the same corner a large approximated 8 X 16 inch opening was observed with insulated lines passing through.
* Above the double doors leading into therapy services an approximate three inch round penetration with wires passing through and a six inch by one eighth inch gap along the bottom of a duct which passed through the fire barrier.
* The double doors in the fire rated barrier leading into therapy services lacked a fire resistance rating. Additionally, the door frame was observed not to be fire rated also.

First floor:

* Above the fire rated doors in the medical surgical department a spray type foam approximately two inches wide by eight feet long was observed sprayed along the top corner where the drywall meets the ceiling. This foam was visually unable to be identified as fire resistance so staff G removed a small piece of it and placed a heat source to it and it was observed by staff G to melt. Staff G stated this foam was not fire resistive as it should be.
* The fire rated doors in the medical surgical department failed to latch when released from the hold open device.
* A half inch unsealed conduit was observed in patient room 100 of the medical surgical department.


These findings were verified and acknowledged by staff D and G during tour.

Based on observation during tour and staff verification it was determined this facility failed to ensure the smoke barriers were constructed to provide at least one half hour fire resistance rating as required in NFPA 101 chapter 19.3.7.3 in accordance with Section 8.3. The facility census was 9 at the time of the survey.

Findings include:

Tour of the facility's main building took place on 01/12/10 with the vice president of ancillary services (staff D) and director of plant operations (staff G).
Penetrations were observed in the one half hour smoke barrier in the following location:

First floor:
* Smoke barrier doors leading into the medical speciality north wing. Observation was made of the a gap greater than one eighth inch between the double smoke barrier doors when in the closed position.

This finding was verified by staff D and G during the tour.

Based on facility observation and staff interview and verification the facility failed to ensure that exit egress accesses were arranged so that exits were accessible at all times. The facility had a census of 9 patients at the time of the survey.

Findings included:

Tour of the facility's main building took place on 01/12/10 with the vice president of ancillary services (staff D) and director of plant operations (staff G).

Observation was made of a wooden ramp approximately 20 feet long connected to the exit egress from the sleep lab located on the north side of the facility. The bottom of the ramp ended in a grassy area which was covered with approximately 4-5 inches of snow. There was approximately 75 feet of uneven snow covered grass from the bottom of the ramp to the nearest paved common way.

Additionally, observation was made of the stairwell exit egress near the pharmacy department which had an approximate eight foot by five foot cement stoop just outside of the door. Snow covered grass surrounded the cement stoop. Approximately 34 feet of uneven snow covered grass separated the cement stoop from the nearest paved common way.

This finding was observed and acknowledged by staff D and G during tour when they verified there was no paved walk area to the common way.

Based on staff interview during and after tour it was determined this facility failed to provide documentation in order to verify the emergency lights are checked on a monthly and annual basis according to the National Fire Protection Agency (NFPA) Chapter 7.9.

Findings include:

Tour of the offsite business occupancy took place on 01/13/10 at approximately 9:30 AM with the vice president of ancillary services (staff D) and the director of plant operations (staff G). Three emergency lights were observed in the basement area and were checked for operation. Request was made during tour for the required documentation of the monthly and annual maintenance of these emergency lights. None was available at that time.
Additional requests were made during the afternoon of 01/13/10 and the morning of 01/14/10. No documentation was made available and the facility was unable to provide any evidence the emergency lights had been maintained as required by the NFPA regulations.

This was verified by staff D on 01/14/10 at approximately 11:00 AM.

Based on staff interview during and after tour it was determined this facility failed to provide documentation to verify the portable fire extinguishers were checked on a monthly basis according to the National Fire Protection Agency (NFPA) 10, Standard for Portable Fire Extinguishers.

Findings include:

Tour of the offsite business occupancy took place on 01/13/10 at approximately 9:30 AM with the vice president of ancillary services (staff D) and the director of plant operations (staff G). Three portable fire extinguishers were observed in the facility and verification was made of the required annual maintenance and testing for operation utilizing the inspection tags placed on the fire extinguisher. No evidence of monthly checks was documented on the inspection tags attached to the three fire extinguishers. Request was made during tour for the required documentation of the monthly maintenance of these portable fire extinguishers. None was available at that time for review.
Additional requests were made during the afternoon of 01/13/10 and the morning of 01/14/10. No documentation was made available and the facility was unable to provide any evidence the portable fire extinguishers had been maintained monthly as required by the NFPA regulations.

This was verified by staff D on 01/14/10 at approximately 11:00 AM.

Based on record review and staff interview, it was determined that this facility failed to maintain evidence that relative humidity (RH) was maintained equal to or greater than 35 per cent in two operating rooms and the procedure room. The facility census was 9 at the time of the survey.

Findings include:

Tour was conducted with the vice president of ancillary services (staff D) and plant operations manager staff (staff G) on 01/12/10. During tour of the surgery department no hygrometers were observed in the operating rooms. Staff G stated the RH in the two operating rooms and one procedure room was not measured by staff but is monitored from the central system. Staff G stated the humidity reading is obtained from one area of the duct system which then branches off into the two operating rooms and the procedure room, so all three rooms would be documented as having the same RH. Staff G stated no humidity readings are actually obtained from within each room. At approximately 3:35 PM staff G provided RH records from the past year of each room in question.

RH readings were less than 35 per cent on:
* the first seven days of January 2010.
* twenty five days of December 2009
* fourteen days of November 2009
* fifteen days of October 2009
* eight days of May 2009
* sixteen days of April 2009
* eighteen days of March 2009
* seventeen days of February
* eighteen days of January 2009

These findings were verified by staff G on 01/13/10 at approximately 1:15 PM.

Based on observation during tour and staff interview, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were located where airflow patterns would not prevent the normal operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. The facility census at the time of the survey was 9.

Findings include:

Tour of the facility's main building took place on 01/12/10 with the vice president of ancillary services (staff D) and director of plant operations (staff G).
Smoke detectors were observed to be located in areas where the airflow from the supply or return diffuser of the duct system may inhibit normal operation of the smoke detector. The following areas observed are:

Basement:

* One smoke detector in the business office area just outside the copy room.

First floor:

* Two smoke detectors in the radiology office and C.T. room
* Three smoke detectors in the emergency department, room numbers 1, 4 and 5.
* Three smoke detectors in three rooms in the lab.
* Two smoke detectors in the blood draw room.
* Three smoke detectors in medical speciality west, room numbers 1, 3 and 7.
* One smoke detector outside the surgery doors near the physician's lounge.
* One smoke detector in the lobby by the double doors.
* One smoke detector in the main operator room.

These findings were verified by staff D and G during tour on 01/12/10 at approximately 4:30 PM.

Based on staff interview during and after tour it was determined this facility failed to provide documentation in order to verify the generator was checked on a weekly and monthly basis according to the National Fire Protection Agency (NFPA) 99 3.4.4.1 and NFPA 110 6-4.2.

Findings include:

Tour of the offsite business occupancy took place on 01/13/10 at approximately 9:30 AM with the vice president of ancillary services (staff D) and the director of plant operations (staff G). A natural gas generator was observed outside the facility and a request was made for the documentation required for the weekly inspections and monthly load tests. None was available at that time for review.
Additional requests for the documentation were made during the afternoon of 01/13/10 and the morning of 01/14/10. No documentation was made available and the facility was unable to provide any evidence the generator had been maintained as required by the NFPA regulations.

This was verified by staff D on 01/14/10 at approximately 11:00 AM.

Based on observations during tour, review of floor plans, and staff interview, the facility failed to ensure the fire barriers which also served as a division for smoke compartmentation were constructed to provide at least a two hour fire resistance rating. The facility census was 9 patients at the time of the survey.

Findings include:

Tour of the facility's main building took place on 01/12/10 with the vice president of ancillary services (staff D) and director of plant operations (staff G).
Penetrations were observed in the two hour rated fire barrier above the ceiling tile and one set of doors failed to latch shut in the following locations:

Basement:
* One two and one half inch unsealed insulated line located in the support services director's room.
* One unsealed curved conduit and one straight conduit above ceiling tile of the southeast corner of the fire barrier in the cafeteria. Additionally, in the same corner a large approximated 8 X 16 inch opening was observed with insulated lines passing through.
* Above the double doors leading into therapy services an approximate three inch round penetration with wires passing through and a six inch by one eighth inch gap along the bottom of a duct which passed through the fire barrier.
* The double doors in the fire rated barrier leading into therapy services lacked a fire resistance rating. Additionally, the door frame was observed not to be fire rated also.

First floor:

* Above the fire rated doors in the medical surgical department a spray type foam approximately two inches wide by eight feet long was observed sprayed along the top corner where the drywall meets the ceiling. This foam was visually unable to be identified as fire resistance so staff G removed a small piece of it and placed a heat source to it and it was observed by staff G to melt. Staff G stated this foam was not fire resistive as it should be.
* The fire rated doors in the medical surgical department failed to latch when released from the hold open device.
* A half inch unsealed conduit was observed in patient room 100 of the medical surgical department.


These findings were verified and acknowledged by staff D and G during tour.

Based on observation during tour and staff verification it was determined this facility failed to ensure the smoke barriers were constructed to provide at least one half hour fire resistance rating as required in NFPA 101 chapter 19.3.7.3 in accordance with Section 8.3. The facility census was 9 at the time of the survey.

Findings include:

Tour of the facility's main building took place on 01/12/10 with the vice president of ancillary services (staff D) and director of plant operations (staff G).
Penetrations were observed in the one half hour smoke barrier in the following location:

First floor:
* Smoke barrier doors leading into the medical speciality north wing. Observation was made of the a gap greater than one eighth inch between the double smoke barrier doors when in the closed position.

This finding was verified by staff D and G during the tour.

Based on facility observation and staff interview and verification the facility failed to ensure that exit egress accesses were arranged so that exits were accessible at all times. The facility had a census of 9 patients at the time of the survey.

Findings included:

Tour of the facility's main building took place on 01/12/10 with the vice president of ancillary services (staff D) and director of plant operations (staff G).

Observation was made of a wooden ramp approximately 20 feet long connected to the exit egress from the sleep lab located on the north side of the facility. The bottom of the ramp ended in a grassy area which was covered with approximately 4-5 inches of snow. There was approximately 75 feet of uneven snow covered grass from the bottom of the ramp to the nearest paved common way.

Additionally, observation was made of the stairwell exit egress near the pharmacy department which had an approximate eight foot by five foot cement stoop just outside of the door. Snow covered grass surrounded the cement stoop. Approximately 34 feet of uneven snow covered grass separated the cement stoop from the nearest paved common way.

This finding was observed and acknowledged by staff D and G during tour when they verified there was no paved walk area to the common way.

Based on staff interview during and after tour it was determined this facility failed to provide documentation in order to verify the emergency lights are checked on a monthly and annual basis according to the National Fire Protection Agency (NFPA) Chapter 7.9.

Findings include:

Tour of the offsite business occupancy took place on 01/13/10 at approximately 9:30 AM with the vice president of ancillary services (staff D) and the director of plant operations (staff G). Three emergency lights were observed in the basement area and were checked for operation. Request was made during tour for the required documentation of the monthly and annual maintenance of these emergency lights. None was available at that time.
Additional requests were made during the afternoon of 01/13/10 and the morning of 01/14/10. No documentation was made available and the facility was unable to provide any evidence the emergency lights had been maintained as required by the NFPA regulations.

This was verified by staff D on 01/14/10 at approximately 11:00 AM.

Based on staff interview during and after tour it was determined this facility failed to provide documentation to verify the portable fire extinguishers were checked on a monthly basis according to the National Fire Protection Agency (NFPA) 10, Standard for Portable Fire Extinguishers.

Findings include:

Tour of the offsite business occupancy took place on 01/13/10 at approximately 9:30 AM with the vice president of ancillary services (staff D) and the director of plant operations (staff G). Three portable fire extinguishers were observed in the facility and verification was made of the required annual maintenance and testing for operation utilizing the inspection tags placed on the fire extinguisher. No evidence of monthly checks was documented on the inspection tags attached to the three fire extinguishers. Request was made during tour for the required documentation of the monthly maintenance of these portable fire extinguishers. None was available at that time for review.
Additional requests were made during the afternoon of 01/13/10 and the morning of 01/14/10. No documentation was made available and the facility was unable to provide any evidence the portable fire extinguishers had been maintained monthly as required by the NFPA regulations.

This was verified by staff D on 01/14/10 at approximately 11:00 AM.

Based on record review and staff interview, it was determined that this facility failed to maintain evidence that relative humidity (RH) was maintained equal to or greater than 35 per cent in two operating rooms and the procedure room. The facility census was 9 at the time of the survey.

Findings include:

Tour was conducted with the vice president of ancillary services (staff D) and plant operations manager staff (staff G) on 01/12/10. During tour of the surgery department no hygrometers were observed in the operating rooms. Staff G stated the RH in the two operating rooms and one procedure room was not measured by staff but is monitored from the central system. Staff G stated the humidity reading is obtained from one area of the duct system which then branches off into the two operating rooms and the procedure room, so all three rooms would be documented as having the same RH. Staff G stated no humidity readings are actually obtained from within each room. At approximately 3:35 PM staff G provided RH records from the past year of each room in question.

RH readings were less than 35 per cent on:
* the first seven days of January 2010.
* twenty five days of December 2009
* fourteen days of November 2009
* fifteen days of October 2009
* eight days of May 2009
* sixteen days of April 2009
* eighteen days of March 2009
* seventeen days of February
* eighteen days of January 2009

These findings were verified by staff G on 01/13/10 at approximately 1:15 PM.

Based on observation during tour and staff interview, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were located where airflow patterns would not prevent the normal operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. The facility census at the time of the survey was 9.

Findings include:

Tour of the facility's main building took place on 01/12/10 with the vice president of ancillary services (staff D) and director of plant operations (staff G).
Smoke detectors were observed to be located in areas where the airflow from the supply or return diffuser of the duct system may inhibit normal operation of the smoke detector. The following areas observed are:

Basement:

* One smoke detector in the business office area just outside the copy room.

First floor:

* Two smoke detectors in the radiology office and C.T. room
* Three smoke detectors in the emergency department, room numbers 1, 4 and 5.
* Three smoke detectors in three rooms in the lab.
* Two smoke detectors in the blood draw room.
* Three smoke detectors in medical speciality west, room numbers 1, 3 and 7.
* One smoke detector outside the surgery doors near the physician's lounge.
* One smoke detector in the lobby by the double doors.
* One smoke detector in the main operator room.

These findings were verified by staff D and G during tour on 01/12/10 at approximately 4:30 PM.

Based on staff interview during and after tour it was determined this facility failed to provide documentation in order to verify the generator was checked on a weekly and monthly basis according to the National Fire Protection Agency (NFPA) 99 3.4.4.1 and NFPA 110 6-4.2.

Findings include:

Tour of the offsite business occupancy took place on 01/13/10 at approximately 9:30 AM with the vice president of ancillary services (staff D) and the director of plant operations (staff G). A natural gas generator was observed outside the facility and a request was made for the documentation required for the weekly inspections and monthly load tests. None was available at that time for review.
Additional requests for the documentation were made during the afternoon of 01/13/10 and the morning of 01/14/10. No documentation was made available and the facility was unable to provide any evidence the generator had been maintained as required by the NFPA regulations.

This was verified by staff D on 01/14/10 at approximately 11:00 AM.