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Based on observation, record review and staff interview, the facility failed to separate a non-conforming building with a fire barrier having at least a 2 hour fire resistance rating. This failure had the potential to speed the progression of a fire from the CT Addition into the Hospital and increase the intensity of the fire due to the combustible wood construction of the CT Addition, which would affect the patient in the hospital. Facility census was 1.

Findings are:
Observation during the facility tour on 2/22/10, at 10:56 am, revealed the new CT Addition to be wood frame construction. The construction of the addition consisted of a steel exterior, 1 layer of 5/8 sheetrock and an approximately 6 inch dead space between the addition and the outside Hospital wall. Inside of the Operating Room, a window in the existing outside hospital wall that connected to the addition was filled with 1 layer of 5/8 sheetrock. The CT Addition was sprinkler protected. A UL listed 2 hour separation could not be verified to separate the Type V (000) wood frame addition from the Type II (000) constructed hospital. It could not be verified if 1 layer of 5/8 sheetrock was installed under the exterior steel on all sides of the addition.

Record review revealed that a waiver granted by CMS had expired 12/11/09.

In an interview conducted at the time of observation (2/22/10, at 10:56 am), Administration A confirmed the construction of the CT Addition and that 2 hour separation between the Hospital and the New CT Addition could not be confirmed. Administration A confirmed that a waiver granted by CMS had expired 12/11/09.

NFPA 101, 19.1.1.4 Additions. Additions shall be separated from any existing structure not conforming to the provisions with Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition.

Based on observation, record review and staff interview, the facility failed to meet the requirements of Type II (000) construction for the Hospital. This failure had the potential to allow fire to progress through the facility and weaken the structural steel, which would decrease structural stability and increase the likelihood of collapse, which would affect the patient in the hospital. Facility census was 1.

Findings are:
Observation during the facility tour on 2/22/10, from 10:13 am to 1:31 pm, revealed a suspended ceiling grid and laid-in ceiling tiles throughout the hospital. Observation above ceiling revealed non-protected structural steel, and that not all corridor walls extended to the roof deck. Patient Rooms were separated from the corridor by a hard ceiling. Ceiling tiles were stamped on the back with the words " fire resistive. " The Hospital was a non-sprinkled area.

Record review revealed a waiver granted by CMS until 12/31/2011 for this deficiency. Record review revealed no documentation to verify the fire resistance rating of the ceiling tiles.

In an interview conducted at the time of observation (2/22/10, from 10:13 am to 1:31 pm), Administration A confirmed the unprotected structural steel was visible above the non-rated suspended ceiling assembly in the corridors, and that these areas were not sprinkler protected. Maintenance A confirmed no documentation available to verify the fire resistance rating of the ceiling tiles.

NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 16.1.6.2.

Based on observation, record review and staff interview, the facility failed to separate use areas from the corridors by construction of at least ? hour for 2 of 3 smoke compartments. This failure would allow smoke and fire to migrate from the rooms to the egress corridor and would affect all visitors and staff that use the facility. Facility census was 1.

Findings are:
Observations during the facility tour on 2/22/10, from 11:09 am to 1:33 pm, above ceiling revealed:
1. The North Conference Room Wall revealed the wall did not extend to the roof deck in the non-sprinkler protected area.
2. Both sides of the " CJ " Corridor revealed the walls did not extend to the roof deck in the non-sprinkler protected area.

Record review revealed a waiver granted by CMS until 12/31/2011 for this deficiency.

Record review revealed no documentation of the fire resistance rating of the ceiling tiles in the facility corridors. Fire resistance rating of the ceiling tiles is required because the walls in the corridors did not extend to roof deck.

In an interview conducted at the times of observation (2/22/10, from 11:09 am to 1:33 pm), Administration A confirmed the walls did not extend to the roof deck, and that the areas were not sprinkler protected.

NFPA 101, 19.3.6.2.1 Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than ? hour.

Based on observation and staff interview, the facility failed to provide a means suitable for keeping a door closed and ensuring it would resist the passage of smoke for 1 of 38 doors sampled. This failure would allow smoke and fire to migrate from the room to the egress corridor, which would affect all visitors and staff. Facility census was 1.
Findings are:

Observation during the facility tour on 2/22/10, at 10:51 am revealed the Director of Nursing Office Door did not latch when pulled shut. When the door was in the closed position, a gap that exceeded 1/8 inch around the door jam existed.

During an interview at the time of observation (2/22/10, at 10:51 am), Maintenance A confirmed the door did not latch when pulled shut and that a gap over 1/8 inch existed.

Based on observation and staff interview, the facility failed to maintain a gap less than 1/8 inch at the meeting edges of 1 of 4 sets of smoke doors to resist the passage of smoke. This failure would allow smoke to migrate into another smoke compartment and would affect all visitors and staff. Facility census was 1.

Findings are:
Observation during the facility tour on 2/22/10, at 11:07 am, revealed a gap that exceeded 1/8 inch at the meeting edges of the Emergency Room Double Doors when the doors were in the closed position and would allow smoke to seep through the doors into another smoke compartment.
In an interview conducted at the time of observation (2/22/10 at 11:07 am), Administration A confirmed the gap between the doors exceeded 1/8 inch.

Based on observation, record review and staff interview, the facility failed to 1 hour separate non-sprinkled hazardous areas from use areas for 3 of 3 smoke compartments. This failure would allow smoke and fire to move through the hospital more rapidly due to combustible materials stored in hazardous rooms 56 and would affect the patient. Facility census was 1.

Findings are:
Observations during the facility tour on 2/22/10, from 11:03 am to 1:36 pm revealed:
1. The New CT Area was under construction during the survey. The doors that separated the New CT Area from the Hospital did not have a tag that specified the fire resistance rating of the doors.
2. The Hospital sprinkler protected store room near the laundry and pop machines revealed the wall that separated the store room from the non-sprinkled corridor did not extend to the roof deck.
3. The non-sprinkled Hospital Vending Corridor revealed the wall that separated the non-sprinkled laundry from the corridor did not extend to the roof deck.
4. The Hospital South Wall that separated the non-sprinkled laundry from the non-sprinkled corridor revealed the wall did not extend to the roof deck.
5. The non-sprinkled Hospital X-Ray Record Room revealed the room measured over 50 square feet with x-rays stored inside. The door did not have a tag that specified the fire resistance rating of the door.
6. The non-sprinkled Hospital Maintenance/Bio Med room revealed the room measured over 50 square feet with tools and storage inside. The door did not have a tag that specified the fire resistance rating of the door.
7. The non-sprinkled Hospital Decontamination Water/Storage area for pandemic supplies inside of the Conference Room revealed the storage area not separated from the Conference Room on the east side. The door on the west side of the storage area did not have a tag that stated the fire resistance rating of the door.
8. The non-sprinkled Hospital Central Sterile Storage Room revealed the room measured over 50 square feet with sterile medical shelf storage inside. Both doors did not have a tag that specified the fire resistance rating of the doors.
9. The non-sprinkled Hospital Soiled Linen Room Door near the Nursery revealed the door did not have a tag that specified the fire resistance rating of the door.
10. The non-sprinkled Clean Utility Room in the Acute Corridor revealed the room measured over 50 square feet with clean linen and medical supplies stored inside. The door did not have a tag that specified the fire resistance rating of the door.
11. The non-sprinkled Pharmacy Drug Storage Room revealed the room measured over 50 square feet with shelf storage for drugs inside. The door did not have a tag that specified the fire resistance rating of the door.

Record review revealed a waiver granted by CMS until 12/31/2011 for deficiencies 2-11.

In an interview conducted at the time of observations (2/22/10, from 11:03 am to 1:36 pm), Administration A confirmed the hazardous areas were not 1 hour separated from use areas.

Based on observation, record review and staff interview, the facility failed to install the automatic sprinkler system in accordance with NFPA 13. This failure had the potential for fire to damage the fire sprinkler water main and cut water off to other areas of the facility, which would affect the patient. Facility census was 1.

Findings are:
Observation during the facility tour on 2/22/10, at 11:18 am, in the Hospital Clean Linen Room in the Maintenance Corridor, revealed an unprotected sprinkler main. The Hospital is partially sprinkled and sprinkler mains run through both sprinkled and non-sprinkled areas.

Record review revealed a waiver granted by CMS until 12/31/2011 for this deficiency.

During an interview at the time of observation (2/22/10 at 11:18 am) Administration A confirmed the findings.

NFPA 101, 2000 Edition, 19.3.5: Where required by 19.1.61 health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.

NFPA 13, 8.15.3.3.1 Private service main aboveground piping shall not pass through hazardous areas and shall be located so that it is protected from mechanical and fire damage.

Based on observation and staff interview, the facility failed to use electrical wiring in accordance with the National Fire Protection Association 70 for 2 of 3 smoke compartments in the facility. This failure had the potential to cause an electrical fire and would affect all visitors and staff. Facility census was 1.
Findings are:

Observation during the facility tour on 2/22/10, from 10:54 am to 1:28 pm, revealed:
1. A power strip not tested in accordance with UL-60601-1 for a TV, video camera and a flashlight in the Emergency Room.
2. A mini-refrigerator plugged into a power strip in the Doctor's Lounge. The mini-refrigerator had the potential to overload the power strip and cause a fire.
3. A mini-refrigerator plugged into a power strip in X-Ray. The mini-refrigerator had the potential to overload the power strip and cause a fire.
4. A mini-refrigerator plugged into a power strip in CJ's Office. The mini-refrigerator had the potential to overload the power strip and cause a fire.

In an interview conducted at the times of observation (on 2/22/10 from 10:54 am to 1:28 pm), Administration A confirmed the findings and asked for clarification of correct use of the equipment.

Based on observation, record review and staff interview, the facility failed to separate a non-conforming building with a fire barrier having at least a 2 hour fire resistance rating. This failure had the potential to speed the progression of a fire from the CT Addition into the Hospital and increase the intensity of the fire due to the combustible wood construction of the CT Addition, which would affect the patient in the hospital. Facility census was 1.

Findings are:
Observation during the facility tour on 2/22/10, at 10:56 am, revealed the new CT Addition to be wood frame construction. The construction of the addition consisted of a steel exterior, 1 layer of 5/8 sheetrock and an approximately 6 inch dead space between the addition and the outside Hospital wall. Inside of the Operating Room, a window in the existing outside hospital wall that connected to the addition was filled with 1 layer of 5/8 sheetrock. The CT Addition was sprinkler protected. A UL listed 2 hour separation could not be verified to separate the Type V (000) wood frame addition from the Type II (000) constructed hospital. It could not be verified if 1 layer of 5/8 sheetrock was installed under the exterior steel on all sides of the addition.

Record review revealed that a waiver granted by CMS had expired 12/11/09.

In an interview conducted at the time of observation (2/22/10, at 10:56 am), Administration A confirmed the construction of the CT Addition and that 2 hour separation between the Hospital and the New CT Addition could not be confirmed. Administration A confirmed that a waiver granted by CMS had expired 12/11/09.

NFPA 101, 19.1.1.4 Additions. Additions shall be separated from any existing structure not conforming to the provisions with Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition.

Based on observation, record review and staff interview, the facility failed to meet the requirements of Type II (000) construction for the Hospital. This failure had the potential to allow fire to progress through the facility and weaken the structural steel, which would decrease structural stability and increase the likelihood of collapse, which would affect the patient in the hospital. Facility census was 1.

Findings are:
Observation during the facility tour on 2/22/10, from 10:13 am to 1:31 pm, revealed a suspended ceiling grid and laid-in ceiling tiles throughout the hospital. Observation above ceiling revealed non-protected structural steel, and that not all corridor walls extended to the roof deck. Patient Rooms were separated from the corridor by a hard ceiling. Ceiling tiles were stamped on the back with the words " fire resistive. " The Hospital was a non-sprinkled area.

Record review revealed a waiver granted by CMS until 12/31/2011 for this deficiency. Record review revealed no documentation to verify the fire resistance rating of the ceiling tiles.

In an interview conducted at the time of observation (2/22/10, from 10:13 am to 1:31 pm), Administration A confirmed the unprotected structural steel was visible above the non-rated suspended ceiling assembly in the corridors, and that these areas were not sprinkler protected. Maintenance A confirmed no documentation available to verify the fire resistance rating of the ceiling tiles.

NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 16.1.6.2.

Based on observation, record review and staff interview, the facility failed to separate use areas from the corridors by construction of at least ? hour for 2 of 3 smoke compartments. This failure would allow smoke and fire to migrate from the rooms to the egress corridor and would affect all visitors and staff that use the facility. Facility census was 1.

Findings are:
Observations during the facility tour on 2/22/10, from 11:09 am to 1:33 pm, above ceiling revealed:
1. The North Conference Room Wall revealed the wall did not extend to the roof deck in the non-sprinkler protected area.
2. Both sides of the " CJ " Corridor revealed the walls did not extend to the roof deck in the non-sprinkler protected area.

Record review revealed a waiver granted by CMS until 12/31/2011 for this deficiency.

Record review revealed no documentation of the fire resistance rating of the ceiling tiles in the facility corridors. Fire resistance rating of the ceiling tiles is required because the walls in the corridors did not extend to roof deck.

In an interview conducted at the times of observation (2/22/10, from 11:09 am to 1:33 pm), Administration A confirmed the walls did not extend to the roof deck, and that the areas were not sprinkler protected.

NFPA 101, 19.3.6.2.1 Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than ? hour.

Based on observation and staff interview, the facility failed to provide a means suitable for keeping a door closed and ensuring it would resist the passage of smoke for 1 of 38 doors sampled. This failure would allow smoke and fire to migrate from the room to the egress corridor, which would affect all visitors and staff. Facility census was 1.
Findings are:

Observation during the facility tour on 2/22/10, at 10:51 am revealed the Director of Nursing Office Door did not latch when pulled shut. When the door was in the closed position, a gap that exceeded 1/8 inch around the door jam existed.

During an interview at the time of observation (2/22/10, at 10:51 am), Maintenance A confirmed the door did not latch when pulled shut and that a gap over 1/8 inch existed.

Based on observation and staff interview, the facility failed to maintain a gap less than 1/8 inch at the meeting edges of 1 of 4 sets of smoke doors to resist the passage of smoke. This failure would allow smoke to migrate into another smoke compartment and would affect all visitors and staff. Facility census was 1.

Findings are:
Observation during the facility tour on 2/22/10, at 11:07 am, revealed a gap that exceeded 1/8 inch at the meeting edges of the Emergency Room Double Doors when the doors were in the closed position and would allow smoke to seep through the doors into another smoke compartment.
In an interview conducted at the time of observation (2/22/10 at 11:07 am), Administration A confirmed the gap between the doors exceeded 1/8 inch.

Based on observation, record review and staff interview, the facility failed to 1 hour separate non-sprinkled hazardous areas from use areas for 3 of 3 smoke compartments. This failure would allow smoke and fire to move through the hospital more rapidly due to combustible materials stored in hazardous rooms 56 and would affect the patient. Facility census was 1.

Findings are:
Observations during the facility tour on 2/22/10, from 11:03 am to 1:36 pm revealed:
1. The New CT Area was under construction during the survey. The doors that separated the New CT Area from the Hospital did not have a tag that specified the fire resistance rating of the doors.
2. The Hospital sprinkler protected store room near the laundry and pop machines revealed the wall that separated the store room from the non-sprinkled corridor did not extend to the roof deck.
3. The non-sprinkled Hospital Vending Corridor revealed the wall that separated the non-sprinkled laundry from the corridor did not extend to the roof deck.
4. The Hospital South Wall that separated the non-sprinkled laundry from the non-sprinkled corridor revealed the wall did not extend to the roof deck.
5. The non-sprinkled Hospital X-Ray Record Room revealed the room measured over 50 square feet with x-rays stored inside. The door did not have a tag that specified the fire resistance rating of the door.
6. The non-sprinkled Hospital Maintenance/Bio Med room revealed the room measured over 50 square feet with tools and storage inside. The door did not have a tag that specified the fire resistance rating of the door.
7. The non-sprinkled Hospital Decontamination Water/Storage area for pandemic supplies inside of the Conference Room revealed the storage area not separated from the Conference Room on the east side. The door on the west side of the storage area did not have a tag that stated the fire resistance rating of the door.
8. The non-sprinkled Hospital Central Sterile Storage Room revealed the room measured over 50 square feet with sterile medical shelf storage inside. Both doors did not have a tag that specified the fire resistance rating of the doors.
9. The non-sprinkled Hospital Soiled Linen Room Door near the Nursery revealed the door did not have a tag that specified the fire resistance rating of the door.
10. The non-sprinkled Clean Utility Room in the Acute Corridor revealed the room measured over 50 square feet with clean linen and medical supplies stored inside. The door did not have a tag that specified the fire resistance rating of the door.
11. The non-sprinkled Pharmacy Drug Storage Room revealed the room measured over 50 square feet with shelf storage for drugs inside. The door did not have a tag that specified the fire resistance rating of the door.

Record review revealed a waiver granted by CMS until 12/31/2011 for deficiencies 2-11.

In an interview conducted at the time of observations (2/22/10, from 11:03 am to 1:36 pm), Administration A confirmed the hazardous areas were not 1 hour separated from use areas.

Based on observation, record review and staff interview, the facility failed to install the automatic sprinkler system in accordance with NFPA 13. This failure had the potential for fire to damage the fire sprinkler water main and cut water off to other areas of the facility, which would affect the patient. Facility census was 1.

Findings are:
Observation during the facility tour on 2/22/10, at 11:18 am, in the Hospital Clean Linen Room in the Maintenance Corridor, revealed an unprotected sprinkler main. The Hospital is partially sprinkled and sprinkler mains run through both sprinkled and non-sprinkled areas.

Record review revealed a waiver granted by CMS until 12/31/2011 for this deficiency.

During an interview at the time of observation (2/22/10 at 11:18 am) Administration A confirmed the findings.

NFPA 101, 2000 Edition, 19.3.5: Where required by 19.1.61 health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.

NFPA 13, 8.15.3.3.1 Private service main aboveground piping shall not pass through hazardous areas and shall be located so that it is protected from mechanical and fire damage.

Based on observation and staff interview, the facility failed to use electrical wiring in accordance with the National Fire Protection Association 70 for 2 of 3 smoke compartments in the facility. This failure had the potential to cause an electrical fire and would affect all visitors and staff. Facility census was 1.
Findings are:

Observation during the facility tour on 2/22/10, from 10:54 am to 1:28 pm, revealed:
1. A power strip not tested in accordance with UL-60601-1 for a TV, video camera and a flashlight in the Emergency Room.
2. A mini-refrigerator plugged into a power strip in the Doctor's Lounge. The mini-refrigerator had the potential to overload the power strip and cause a fire.
3. A mini-refrigerator plugged into a power strip in X-Ray. The mini-refrigerator had the potential to overload the power strip and cause a fire.
4. A mini-refrigerator plugged into a power strip in CJ's Office. The mini-refrigerator had the potential to overload the power strip and cause a fire.

In an interview conducted at the times of observation (on 2/22/10 from 10:54 am to 1:28 pm), Administration A confirmed the findings and asked for clarification of correct use of the equipment.