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Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with rated wall construction. This deficiency occurred in 3 of the 4 smoke compartments, and would affect 6 of the 10 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
Observation by surveyor #12187 at 1:00 PM on 4/6/2010 revealed in the chaplain office and Q1 Diabetes education room, located in the zones 2 ,3, & 4 smoke compartment, that the smoke barrier wall was not constructed to a 1-hour fire resistance rating because holes were in the wall, areas around pipes were not caulked, and dry wall was missing. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.3. This deficiency was confirmed at the time of discovery in an interview with Staff A (Maintenance Director) .

Based on observation and interview, the facility did not provide protection of the facility from the contents of hazardous room with rated wall construction, and door closers. This deficiency occurred in 2 of the 4 smoke compartments, and would affect 3 of the 10 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
1. Observation by surveyor #12187 at 12:30 PM on 4/5/2010 revealed in the hospital storage room by PT, located in the zone 4 smoke compartment, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall had an old nurse call electrical cabinet that was not 1 hour fire rated. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. This deficiency was confirmed at the time of discovery in an interview with Staff A (Maintenance Director) .

2. Observation by surveyor #12187 at 2:30 PM on 4/5/2010 revealed in the procedure clean-up room in the OR area, located in the zone 1 smoke compartment, that the door would not self-close because it was blocked open with a wedge. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1 and 18.3.6.3.4. This deficiency was confirmed at the time of discovery in an interview with Staff A (Maintenance Director) .

3. Observation by surveyor #12187 at 1:45 PM on 4/6/2010 revealed in the clean supply room of the OR, located in the zone 1 smoke compartment, that the door would not self-close because there was no door closer arm. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1 and 18.3.6.3.4. This deficiency was confirmed at the time of discovery in an interview with Staff A (Maintenance Director) .

Based on observation and interview, the facility did not maintain a written evacuation plan that contained all the elements with Staff trained in life safety procedures. This deficiency occurred in 1 of the 4 smoke compartments, and would affect 2 of the 10 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
Observation by surveyor #12187 at 4:10 PM on 4/5/2010 revealed in the kitchen, located in the zone 2 smoke compartment, that staff were not familiar with their responsibilities in the event of a fire, including that staff C (Director of Nutrition Service) and staff H, (cook) did not know what type of fires that the K fire extinguisher is used for. This observed situation was not compliant with NFPA 101 (2000 edition), 18.7.1.3. This deficiency was confirmed at the time of discovery in an interview with Staff A (Maintenance Director) .

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, including sprinklers with the proper separation distance. This deficiency occurred in 1 of the 4 smoke compartments, and would affect 4 of the 10 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
Observation by surveyor #12187 at 1:30 PM on 4/6/2010 revealed in the OR room by the sterilizer , located in the zone 1 smoke compartment, that a sprinkler was located about 2 1/2 inches from the wall. Sprinklers cannot be closer to each other than the minimum required separation distance of 60" or closer to a wall than 4". This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.3. This deficiency was confirmed at the time of discovery in an interview with Staff A (Maintenance Director) .

Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25, verification of all quarterly sprinkler tests. This deficiency occurred in 4 of the 4 smoke compartments, and would affect 10 of the 10 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
Observation by surveyor #12187 at 9:00 AM on 4/6/2010 revealed through out the building, located in the all smoke compartments, that the quarterly sprinkler inspection was not conducted within 3 months of the previous quarterly inspection. Quarterly tests were not conducted between August 2009 and the present. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2. and Table 2-1. This deficiency was confirmed at the time of discovery in an interview with Staff A (Maintenance Director) .

Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacture specifications and NFPA 90A with proper damper maintenance. This deficiency occurred in 4 of the 4 smoke compartments, and would affect 10 of the 10 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
Observation and documentation review by surveyor #12187 at 2:10PM on 4/6/2010 revealed that periodic testing of the fire damper was not done throughout the building. There is no record of the fire dampers being tested within the last 6 years. This observed situation was not compliant with NFPA 101 (2000 edition), 18.5.2.1 9.2 and NFPA 90A. This deficiency was confirmed at the time of discovery in an interview with Staff A (Maintenance Director) .

Based on observation and interview, the facility did not maintain corridors free of materials that obstruct egress. This deficiency occurred in 2 of the 4 smoke compartments, and would affect 7 of the 10 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
1. Observation by surveyor #12187 at 11:00 AM on 4/5/2010 revealed in the corridor by the maintenance room, located in the 4th smoke compartment, that materials were stored in the exit access pathway, including ladder, cart with garbage, 2 hand trucks, 10 boxes of ceiling titles and a vacuum The materials were stored in this location for greater than 30 minutes and were not attended by a staff person that was responsible for their use. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.1 and 18.7.5.5. This deficiency was confirmed at the time of discovery in an interview with Staff A (Maintenance Director) .

2. Observation by surveyor #12187 at 1:50 PM on 4/5/2010 revealed in the corridor by the clinic area, located in the zone 1 smoke compartment, that materials were stored in the exit access pathway, including linen cart and weight scale The materials were stored in this location for greater than 30 minutes and were not attended by a staff person that was responsible for their use. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.1 and 18.7.5.5. This deficiency was confirmed at the time of discovery in an interview with Staff A (Maintenance Director) .

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with proper use of extension cords. This deficiency occurred in 2 of the 4 smoke compartments, and would affect 4 of the 10 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
1. Observation by surveyor #12187 at 11:30 AM on 4/5/2010 revealed in the Director of PT, located in the zone 4 smoke compartment, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to electrical equipment This observed situation was not compliant with NFPA 70 (1999 edition), 400-8 and 517-18. This deficiency was confirmed at the time of discovery in an interview with Staff A (Maintenance Director) .

2. Observation by surveyor #12187 at 2:00 PM on 4/5/2010 revealed in the IV storage room, located in the zone 1 smoke compartment, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to electrical equipment This observed situation was not compliant with NFPA 70 (1999 edition), 400-8 and 517-18. This deficiency was confirmed at the time of discovery in an interview with Staff A (Maintenance Director) .

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with rated wall construction. This deficiency occurred in 3 of the 4 smoke compartments, and would affect 6 of the 10 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
Observation by surveyor #12187 at 1:00 PM on 4/6/2010 revealed in the chaplain office and Q1 Diabetes education room, located in the zones 2 ,3, & 4 smoke compartment, that the smoke barrier wall was not constructed to a 1-hour fire resistance rating because holes were in the wall, areas around pipes were not caulked, and dry wall was missing. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.3. This deficiency was confirmed at the time of discovery in an interview with Staff A (Maintenance Director) .

Based on observation and interview, the facility did not provide protection of the facility from the contents of hazardous room with rated wall construction, and door closers. This deficiency occurred in 2 of the 4 smoke compartments, and would affect 3 of the 10 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
1. Observation by surveyor #12187 at 12:30 PM on 4/5/2010 revealed in the hospital storage room by PT, located in the zone 4 smoke compartment, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall had an old nurse call electrical cabinet that was not 1 hour fire rated. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. This deficiency was confirmed at the time of discovery in an interview with Staff A (Maintenance Director) .

2. Observation by surveyor #12187 at 2:30 PM on 4/5/2010 revealed in the procedure clean-up room in the OR area, located in the zone 1 smoke compartment, that the door would not self-close because it was blocked open with a wedge. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1 and 18.3.6.3.4. This deficiency was confirmed at the time of discovery in an interview with Staff A (Maintenance Director) .

3. Observation by surveyor #12187 at 1:45 PM on 4/6/2010 revealed in the clean supply room of the OR, located in the zone 1 smoke compartment, that the door would not self-close because there was no door closer arm. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1 and 18.3.6.3.4. This deficiency was confirmed at the time of discovery in an interview with Staff A (Maintenance Director) .

Based on observation and interview, the facility did not maintain a written evacuation plan that contained all the elements with Staff trained in life safety procedures. This deficiency occurred in 1 of the 4 smoke compartments, and would affect 2 of the 10 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
Observation by surveyor #12187 at 4:10 PM on 4/5/2010 revealed in the kitchen, located in the zone 2 smoke compartment, that staff were not familiar with their responsibilities in the event of a fire, including that staff C (Director of Nutrition Service) and staff H, (cook) did not know what type of fires that the K fire extinguisher is used for. This observed situation was not compliant with NFPA 101 (2000 edition), 18.7.1.3. This deficiency was confirmed at the time of discovery in an interview with Staff A (Maintenance Director) .

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, including sprinklers with the proper separation distance. This deficiency occurred in 1 of the 4 smoke compartments, and would affect 4 of the 10 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
Observation by surveyor #12187 at 1:30 PM on 4/6/2010 revealed in the OR room by the sterilizer , located in the zone 1 smoke compartment, that a sprinkler was located about 2 1/2 inches from the wall. Sprinklers cannot be closer to each other than the minimum required separation distance of 60" or closer to a wall than 4". This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.3. This deficiency was confirmed at the time of discovery in an interview with Staff A (Maintenance Director) .

Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25, verification of all quarterly sprinkler tests. This deficiency occurred in 4 of the 4 smoke compartments, and would affect 10 of the 10 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
Observation by surveyor #12187 at 9:00 AM on 4/6/2010 revealed through out the building, located in the all smoke compartments, that the quarterly sprinkler inspection was not conducted within 3 months of the previous quarterly inspection. Quarterly tests were not conducted between August 2009 and the present. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2. and Table 2-1. This deficiency was confirmed at the time of discovery in an interview with Staff A (Maintenance Director) .

Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacture specifications and NFPA 90A with proper damper maintenance. This deficiency occurred in 4 of the 4 smoke compartments, and would affect 10 of the 10 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
Observation and documentation review by surveyor #12187 at 2:10PM on 4/6/2010 revealed that periodic testing of the fire damper was not done throughout the building. There is no record of the fire dampers being tested within the last 6 years. This observed situation was not compliant with NFPA 101 (2000 edition), 18.5.2.1 9.2 and NFPA 90A. This deficiency was confirmed at the time of discovery in an interview with Staff A (Maintenance Director) .

Based on observation and interview, the facility did not maintain corridors free of materials that obstruct egress. This deficiency occurred in 2 of the 4 smoke compartments, and would affect 7 of the 10 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
1. Observation by surveyor #12187 at 11:00 AM on 4/5/2010 revealed in the corridor by the maintenance room, located in the 4th smoke compartment, that materials were stored in the exit access pathway, including ladder, cart with garbage, 2 hand trucks, 10 boxes of ceiling titles and a vacuum The materials were stored in this location for greater than 30 minutes and were not attended by a staff person that was responsible for their use. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.1 and 18.7.5.5. This deficiency was confirmed at the time of discovery in an interview with Staff A (Maintenance Director) .

2. Observation by surveyor #12187 at 1:50 PM on 4/5/2010 revealed in the corridor by the clinic area, located in the zone 1 smoke compartment, that materials were stored in the exit access pathway, including linen cart and weight scale The materials were stored in this location for greater than 30 minutes and were not attended by a staff person that was responsible for their use. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.1 and 18.7.5.5. This deficiency was confirmed at the time of discovery in an interview with Staff A (Maintenance Director) .

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with proper use of extension cords. This deficiency occurred in 2 of the 4 smoke compartments, and would affect 4 of the 10 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
1. Observation by surveyor #12187 at 11:30 AM on 4/5/2010 revealed in the Director of PT, located in the zone 4 smoke compartment, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to electrical equipment This observed situation was not compliant with NFPA 70 (1999 edition), 400-8 and 517-18. This deficiency was confirmed at the time of discovery in an interview with Staff A (Maintenance Director) .

2. Observation by surveyor #12187 at 2:00 PM on 4/5/2010 revealed in the IV storage room, located in the zone 1 smoke compartment, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to electrical equipment This observed situation was not compliant with NFPA 70 (1999 edition), 400-8 and 517-18. This deficiency was confirmed at the time of discovery in an interview with Staff A (Maintenance Director) .