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Based on observations, the facility is not ensuring that doors to rooms are provided with suitable hardware that keep the doors shut tightly into their frames. This deficient practice affects occupants in 1 of 13 smoke zones as the doors would not prevent the spread of fire and smoke. The facility has a capacity for 38 and at the time of the survey the census was 9.

Findings include:

Observations on 3/22/11, revealed the corridor door to the Old Morgue did not latch properly when tested.

Based on observations, the facility is not providing unobstructed corridors that provides a clear path of egress for one of thirteen smoke zones. This facility has a capacity of 38 with a census of 9.

Findings include:

Observations on 3/22/11, revealed 2 carts and 2 tables had been stored in the corridor of OB by Room 104.

Based on observations, the facility failed to install exit signs in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition. Exits shall be marked by an approved sign readily visible from any direction of exit access. This deficient practice effects residents, staff, and visitors in 2 of 13 zones. The facility has a capacity of 38 and at the time of the survey the census was 9.

Findings include:

1. Observations on 3/22/11, revealed the exit sign at the end of the corridor above the smoke barrier within the patient room smoke zone of the Behavioral Unit was facing the Nurses Station and the back of the exit sign was displayed within the zone.

2. Observations on 3/22/11, revealed an exit sign had not been not been installed above the door leading to the Nurses Station from the 30 Wing.

Based on observations and record review, the facility failed to inspect and test the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, 1999 edition. This deficient practice affects all occupants of the building. The facility has a capacity of 38 and at the time of the survey had a census of 9.

Findings include:

1. Record review of the fire alarm test records on 3/22/11, revealed the fire alarm system was inspected and tested by Honeywell on 12/22/10 and 6/29/10. The Initiating and Supervisory Device Tests and Inspection sections of the reports were left blank. A quantity of devices tested was listed in the Alarm-Initiating Devices and Circuit Information. Additional sheets were provided with the inspection report showing the date of the tested devices but did not document the inspection of the remaining devices and failed to give the result of the test. On 12/22/10, 26 of 28 manual pull stations, 125 of 228 of the ion smoke detectors, 0 of 10 duct detectors, 7 of 7 heat detectors, 5 of 5 waterflow switches, and 30 of 30 supervisory switches were documented as being tested. No documentation was provided to show the remaining devices had been inspected. On 6/29/10, 21 of 28 manual pull stations, 119 of 228 of the ion smoke detectors, 5 of 10 duct detectors, 5 of 7 heat detectors, 5 of 5 waterflow switches, and 30 of 30 switches were documented as being tested. No documentation was provided to show the remaining devices had been inspected.

2. Observations and record review on 3/22/11, revealed the connection of the fire alarm system with hood and duct system in the Kitchen had not been documented as being tested or inspected. Observations of the hood and duct system and the fire alarm system in the Kitchen showed the interconnection between the two systems.

3. Observations on 3/22/11, revealed the circuit breaker in Panel O was labeled as fire panel/computer room and the breaker was not mechanically protected.

Based on observations, the facility failed to maintain a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998 edition. The facility has 38 certified beds and at the time of the survey the census was 9.

Findings include:

Observations on 3/22/11, revealed an electrical cord had been attached to the sprinkler piping in the Biohazard Room. Observations also showed cables attached to the sprinkler piping in the Soiled Linen Room, Clean Laundry Room, and Purchasing.

Based on observations the facility failed to provide window coverings that were flame resistant in accordance with provisions of National Fire Protection Association (NFPA) 101, 10.3. The facility has 38 certified beds and at the time of the survey had a census of 9.

Findings include:

Observations on 3/22/11, revealed the curtain hung on the window in Room 221 was not tagged as being flame resistant, and at the time of the survey the facility was unable to to provide documentation to show the curtain was flame resistant.

(A)
Based on observations and record review the facility failed to maintain the enclosure of the clean agent fire extinguishing system in accordance with National Fire Protection Association (NFPA) Standard 2001, Standard on Clean Agent Fire Extinguishing Systems. To prevent loss of agent through openings to adjacent hazards or work areas, openings shall be permanently sealed or equipped with automatic closures. The protected enclosure shall have the structural strength and integrity necessary to contain the agent discharge. The facility has a capacity of 38 and at the time of the survey had a census of 9.

Findings include:

1. Record review on 3/22/11, revealed the clean agent fire extinguishing systems were inspected and tested by Ahern. The following deficiencies had been noted on the inspection reports: first floor telecom closet- "Door should have a sweep and weather stripping and closure." 1/28/11; X-ray File Storage - "Should have a door sweep on the door." 1/28/11; and basement Phone Room - "The Mr. Slim AC unit does not shut down on agent discharge. Signs say FM 200 and the system is Halon 1301. Halon signs no longer available and must be custom made." 1/28/11 and "No door closures or weather stripping. Some open conduits and wall penetrations. Signs read FM 200 and system is Halon. There are 2 air conditioners in the room. The Mr. Slim does not shutdown." 7/28/10.

2. Observations on 3/22/11, revealed the gauge on the tank for the clean agent extinguishing system in the Telecom Closet on the first floor showed overcharged.

(B)
Based on observations, the facility failed to provide building construction in accordance with the plans developed by an architect. This deficient practice could affect all occupants in all zones on the first floor of the facility. The facility has a capacity of 38 and at the time of the survey had a census of 9.

Findings include:

Review of the architectural plans during the survey of the hospital for the new hospice wing on 7/14/10, revealed a plan developed for an addition and remodel of the existing hospital dated 7/21/95 revealed the facility failed to provide a "2 hour horizontal exit in existing space". A separation had been shown on the plan in the corridor outside of the Emergency Room. Observations at the time of the survey revealed no 2 hour separation wall or doors in this space.

Also the facility was unable to verify the existing section of the wall was a 2 hour rated separation. The doors to the Emergency Room bathrooms were within the labeled 2 hour horizontal exit in the existing space and were not labeled as being 90 minutes, and the wall surrounding the corridor door and separating the corridor from Same Day Surgery was constructed of one layer of 5/8 inch sheetrock on either side of a stud.

A letter and waiver was submitted with the plan of correction from the survey on 7/14/10 and reported the plan "unnecessarily" labeled this a 2 hour fire wall and should have been a smoke barrier with 20 minute openings (doors). The submitted waiver reported this will be corrected during the upcoming remodeling project.

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. This deficient practice affects occupants in 1 of 13 zones. This facility has a capacity of 38 and a census of 9.

Findings include:

Observations on 3/22/11, revealed a coffee pot had been plugged into a surge protector in the second floor Educational Services Office.

Based on observations, the facility is not ensuring that doors to rooms are provided with suitable hardware that keep the doors shut tightly into their frames. This deficient practice affects occupants in 1 of 13 smoke zones as the doors would not prevent the spread of fire and smoke. The facility has a capacity for 38 and at the time of the survey the census was 9.

Findings include:

Observations on 3/22/11, revealed the corridor door to the Old Morgue did not latch properly when tested.

Based on observations, the facility is not providing unobstructed corridors that provides a clear path of egress for one of thirteen smoke zones. This facility has a capacity of 38 with a census of 9.

Findings include:

Observations on 3/22/11, revealed 2 carts and 2 tables had been stored in the corridor of OB by Room 104.

Based on observations, the facility failed to install exit signs in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition. Exits shall be marked by an approved sign readily visible from any direction of exit access. This deficient practice effects residents, staff, and visitors in 2 of 13 zones. The facility has a capacity of 38 and at the time of the survey the census was 9.

Findings include:

1. Observations on 3/22/11, revealed the exit sign at the end of the corridor above the smoke barrier within the patient room smoke zone of the Behavioral Unit was facing the Nurses Station and the back of the exit sign was displayed within the zone.

2. Observations on 3/22/11, revealed an exit sign had not been not been installed above the door leading to the Nurses Station from the 30 Wing.

Based on observations and record review, the facility failed to inspect and test the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, 1999 edition. This deficient practice affects all occupants of the building. The facility has a capacity of 38 and at the time of the survey had a census of 9.

Findings include:

1. Record review of the fire alarm test records on 3/22/11, revealed the fire alarm system was inspected and tested by Honeywell on 12/22/10 and 6/29/10. The Initiating and Supervisory Device Tests and Inspection sections of the reports were left blank. A quantity of devices tested was listed in the Alarm-Initiating Devices and Circuit Information. Additional sheets were provided with the inspection report showing the date of the tested devices but did not document the inspection of the remaining devices and failed to give the result of the test. On 12/22/10, 26 of 28 manual pull stations, 125 of 228 of the ion smoke detectors, 0 of 10 duct detectors, 7 of 7 heat detectors, 5 of 5 waterflow switches, and 30 of 30 supervisory switches were documented as being tested. No documentation was provided to show the remaining devices had been inspected. On 6/29/10, 21 of 28 manual pull stations, 119 of 228 of the ion smoke detectors, 5 of 10 duct detectors, 5 of 7 heat detectors, 5 of 5 waterflow switches, and 30 of 30 switches were documented as being tested. No documentation was provided to show the remaining devices had been inspected.

2. Observations and record review on 3/22/11, revealed the connection of the fire alarm system with hood and duct system in the Kitchen had not been documented as being tested or inspected. Observations of the hood and duct system and the fire alarm system in the Kitchen showed the interconnection between the two systems.

3. Observations on 3/22/11, revealed the circuit breaker in Panel O was labeled as fire panel/computer room and the breaker was not mechanically protected.

Based on observations, the facility failed to maintain a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998 edition. The facility has 38 certified beds and at the time of the survey the census was 9.

Findings include:

Observations on 3/22/11, revealed an electrical cord had been attached to the sprinkler piping in the Biohazard Room. Observations also showed cables attached to the sprinkler piping in the Soiled Linen Room, Clean Laundry Room, and Purchasing.

Based on observations the facility failed to provide window coverings that were flame resistant in accordance with provisions of National Fire Protection Association (NFPA) 101, 10.3. The facility has 38 certified beds and at the time of the survey had a census of 9.

Findings include:

Observations on 3/22/11, revealed the curtain hung on the window in Room 221 was not tagged as being flame resistant, and at the time of the survey the facility was unable to to provide documentation to show the curtain was flame resistant.

(A)
Based on observations and record review the facility failed to maintain the enclosure of the clean agent fire extinguishing system in accordance with National Fire Protection Association (NFPA) Standard 2001, Standard on Clean Agent Fire Extinguishing Systems. To prevent loss of agent through openings to adjacent hazards or work areas, openings shall be permanently sealed or equipped with automatic closures. The protected enclosure shall have the structural strength and integrity necessary to contain the agent discharge. The facility has a capacity of 38 and at the time of the survey had a census of 9.

Findings include:

1. Record review on 3/22/11, revealed the clean agent fire extinguishing systems were inspected and tested by Ahern. The following deficiencies had been noted on the inspection reports: first floor telecom closet- "Door should have a sweep and weather stripping and closure." 1/28/11; X-ray File Storage - "Should have a door sweep on the door." 1/28/11; and basement Phone Room - "The Mr. Slim AC unit does not shut down on agent discharge. Signs say FM 200 and the system is Halon 1301. Halon signs no longer available and must be custom made." 1/28/11 and "No door closures or weather stripping. Some open conduits and wall penetrations. Signs read FM 200 and system is Halon. There are 2 air conditioners in the room. The Mr. Slim does not shutdown." 7/28/10.

2. Observations on 3/22/11, revealed the gauge on the tank for the clean agent extinguishing system in the Telecom Closet on the first floor showed overcharged.

(B)
Based on observations, the facility failed to provide building construction in accordance with the plans developed by an architect. This deficient practice could affect all occupants in all zones on the first floor of the facility. The facility has a capacity of 38 and at the time of the survey had a census of 9.

Findings include:

Review of the architectural plans during the survey of the hospital for the new hospice wing on 7/14/10, revealed a plan developed for an addition and remodel of the existing hospital dated 7/21/95 revealed the facility failed to provide a "2 hour horizontal exit in existing space". A separation had been shown on the plan in the corridor outside of the Emergency Room. Observations at the time of the survey revealed no 2 hour separation wall or doors in this space.

Also the facility was unable to verify the existing section of the wall was a 2 hour rated separation. The doors to the Emergency Room bathrooms were within the labeled 2 hour horizontal exit in the existing space and were not labeled as being 90 minutes, and the wall surrounding the corridor door and separating the corridor from Same Day Surgery was constructed of one layer of 5/8 inch sheetrock on either side of a stud.

A letter and waiver was submitted with the plan of correction from the survey on 7/14/10 and reported the plan "unnecessarily" labeled this a 2 hour fire wall and should have been a smoke barrier with 20 minute openings (doors). The submitted waiver reported this will be corrected during the upcoming remodeling project.

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. This deficient practice affects occupants in 1 of 13 zones. This facility has a capacity of 38 and a census of 9.

Findings include:

Observations on 3/22/11, revealed a coffee pot had been plugged into a surge protector in the second floor Educational Services Office.