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Based on observation and interview, the facility failed to provide or maintain the 2-hour fire rated construction separation of occupancies that are located immediately next to the Health Care Occupancy. This practice would allow fire and smoke to spread beween areas of the facility affected all patients, visitors and staff that use the facility. The facility census was 3 and a capacity of 25.

Finding are:

Observations on March 2, 2017 between 9:30 A.M. to 2:30 P.M. am revealed:
1. In the Hallway outside of Board room, there was unsealed conduit and sprinkler pipe penetrations in the 2 hour fire wall.
2. There was unsealed conduit penetrations in the 2 hour fire wall in Payroll Office.
3. There was an unsealed 4 inch conduit penetration in the 2 hour fire wall In the corridor wall outside of the IT room opening.
4. The North wall of the doctors sleeping room was identified as a two hour fire separation and the truss webbing along the top of the wall was not sealed to complete the fire separation.
5. There was an unsealed 3 inch hole above the ceiling in the 2 hour fire wall In the southwest storage room in the ER area .
6. There were penetrations sealed with spray foam in the two hour fire wall in the A-wing corridor above the east set of fire rated doors on the east side. There were also numerous unsealed electrical conduit penetrations in this area. The facility failed to provide documentation of the rating of the material used to seal these penetrations.
7. There was unsealed conduit and duct penetrations above the drop ceiling in the C-wing above the double doors.
8. There was unsealed air duct penetrations in the east and west walls in the C-wing Linen closet.
9. There wa an unsealed data wire penetration above the double 1 hour smoke doors near the X-ray area.

Observations were acknowledged by and verified by Maintenance Staff at the time of the observations and/or at the exit interview conducted 3/2/17 at 2:30 P.M.

Based on observation and interviews, the facility failed to maintain the egress stairways free of all obstruction to full use in case of emergency. This practice would delay evacuation from the lower level and affected all visitors and staff that use the facility. The facility census was 3 and a capacity of 25.

Finding are:

Observation of the North stairway from the lower level on 3/1/17 at 11:15 A.M. revealed the facility was using the space for storage of old doors, lab coats, locker and boxes of supplies.

Observations were acknowledged by and verified by Maintenance Staff at the time of the observations and/or at the exit interview conducted 3/2/17 at 2:30 P.M.


NFPA Standard: 7.1.3.2.3* An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge.

Based on observation and interviews, the facility failed to provide smoke proof enclosures for the facility's stairways. This practice would allow smoke to enter the stairway rendering it useless for evacuation and affected all patients, visitors and staff that use the facility. The facility census was 3 and a capacity of 25.

Finding are:

Observation on 3/2/17 at 10:40 A.M. of the facility's C-wing revealed an unsealed flex conduit penetration above the exit door leading into the exiting stairway.

Observations were acknowledged by and verified by Maintenance Staff at the time of the observations and/or at the exit interview conducted 3/2/17 at 2:30 P.M

Based on interview and record review, the facility failed to conduct the required annual test of all emergency lighting to provide a reliable source of emergency lighting in the event normal power failure or loss. This practice could leave areas in darknes delaying eacuation from the facility and affected all patients, visitors and staff that use the facility. The facility census was 3 and a capacity of 25.

Finding are:

Record review on 3/1/17 at 11:00 A.M. revealed the facility failed to provide documentation that the facility had performed annuall functional testing of the battery powered emergency lighting system in the facility for the required duration of 1 ½ hours.

Observations were acknowledged by and verified by Maintenance Staff at the time of the observations and/or at the exit interview conducted 3/2/17 at 2:30 P.M.



NFPA Standard: 7.9.3.1.1 (3) Required emergency lighting systems shall be tested annually for a duration of 1 ½ hour if the emergency lighting system is battery powered.

Based on Observation and interviews, the facility failed to provide and/or maintain hazardous areas with a one hour fire resistance rating with ¾-hour fire rated self-closing or automatic closing doors, or, if sprinkler protected failed to provide a smoke resistant enclosure toe separate the hazardous area form the rest of the facility. This practice would allow smoke and fire to extend beyond the hazardous areas and affected all patients, visitors and staff that use the facility. The facility census was 3 and a capacity of 25.

Finding are:

Observations on March 1, 2017 between 9:30 A.M. to 3:30 P.M. am revealed:
1. There were numerous holes and/or unsealed electrical conduits and plumbing or PVC pipe penetrations in the ceiling throughout the Plant Basement mechanical area.
2. The south paper recycle bin storage room in the basement did not have a self-closing device installed on the door.
3. The south elevator control room had unsealed conduit penetrations in the ceiling along east and west wall.
4. The unfinished space used for storage north of the Physical Therapy suite did not have doors with self-closing devices and did not have a means to keep the doors closed in the frames.
5. The door opening that opened from the corridor into the unfinished space for the future kitchenette was covered with plastic and did not have a door installed. The area is under construction and was being used for storage.
6. The north 2-hour fire wall in the unfinished space being used for storage across the Administration hallway had unsealed web trust penetrations and did not have the space between the drywall and steel deck roof sealed or fire caulked.
7. The storage room across from the Payroll office had unsealed conduit penetrations in the East wall and unsealed holes in the one hour fire wall.
8. The east wall in the Soiled Linen room in the C-wing, had an unsealed duct penetration and there were numerous hole in the drywall in both the east and west one hour fire rated walls.


Observations were acknowledged by and verified by Maintenance Staff at the time of the observations and/or at the exit interview conducted 3/2/17 at 2:30 P.M.

Based on observation and interviews, the facility failed to install an audible / visual fire alarm notification device to provide occupant notification in the event of an fire alarm activation to any occupants of the internal courtyard areas. This practice would not alert occupats in the event of a fire in the facility and affected all patients, visitors and staff that use the facility. The facility census was 3 and a capacity of 25.

Finding are:

Observation on 3/1/17 at 1:00 P.M. of the facility's internal courtyard areas revealed there was no fire alarm notification devices present in these areas to notify occupants that the fire alarms system has been activated.

Observation was acknowledged by and verified by Maintenance Staff at the time of the observations and/or at the exit interview conducted 3/2/17 at 2:30 P.M.

Based on record review and interviews, the facility failed to provide a written procedure or document to address how staff would provide patient, staff or visitor safety in the event the facility's fire alarm system was out of service for more than 4 hours in a 24 hour periods. This practice did not ensure the faciity would taken would apply interim safety measures and affected all patients, visitors and staff that use the facility. The facility census was 3 and a capacity of 25.

Finding are:

Record review on 3/2/17 at 1:15 P.M. revealed the facility did not have a written Fire Watch policy describing procedures the facility would take if the buildings fire alarm system was out of service for more than 4 hours in a 24 hour period.

Observation was acknowledged by and verified by Maintenance Staff at the time of the observations and/or at the exit interview conducted 3/2/17 at 2:30 P.M.

Based on observation and interviews, the facility failed to conduct the 5 year internal pipe inspection, failed to maintain all required appurtenaces for the automatic fire sprinkler system, and failed to maintain ceilings so the fire sprinkler system woul operate as designed. These deficient practices did not ensure the sprinkler system would operate as designed and would affect all patients, visitors and staff that use the facility. The facility census was 3 and a capacity of 25.

Finding are:

Observation in the IT area in the basement on 3/1/17 at 1:55 P.M. revealed near the ceiling tile around the sprinkler head by the west stairway door was missing.

Observation of the facility's front entrance lobby area on 3/2/17 at 11:30 A.M. , revealed the escutcheon ring around the sprinkler head along the east wall near the construction door was missing.

Document review on 3/1/17 at 11:05 A.M. of the facility's automatic fire sprinkler system inspection records revealed the facility did not have documentation available verifying when the latest 5 year internal inspection of the sprinkler system was performed.

Findings were acknowledged by and verified by Maintenance Staff at the time of the observations and/or at the exit interview conducted 3/2/17 at 2:30 P.M.

Based on record review and interviews, the facility failed to provide a written procedure or document addressing how staff would provide patient, staff or visitor safety in the event the facility's Automatic Fire Sprinkler Protection system was impaired or out of service for more than 10 hours in a 24 hour periods. This practice did not ensure the facility would implement interim safety measures and affected all patients, visitors and staff that use the facility. The facility census was 3 and a capacity of 25.

Finding are:

Record review on 3/2/17 at 1:15 P.M. revealed the facility did not have a written Fire Watch policy describing procedures to be taken in the event the faciliy's Automatic Fire Sprinkler system was be out of service for more than 10 hours in a 24 hour period.

The findings were acknowledged by and verified by Maintenance Staff at the time of the observations and/or at the exit interview conducted 3/2/17 at 2:30 P.M.

Based on observation and interviews, the facility did not ensure that areas being renovated were separated from the rest of the facility by 1 hour fire resistive construction. This practice increased the potential for a fire starting in the area under construction to extend into the rest of the facility and affected all patients, visitors and staff that use the facility. The facility census was 3 and a capacity of 25.

Finding are:

Observation on 3/1/17 at 1:45 P.M. of the renovation project of the facility's B-wing revealed the temporary construction walls separating the construction area and the occupied area were not constructed to provide a 1-hour fire resistance rating.

Observation on 3/1/17 at 2:15 P.M. of the renovation project of the South Central portion of the facility revealed the temporary construction walls separating the construction area and the occupied area were not constructed to provide a 1-hour fire resistance rating.

Findings were acknowledged by and verified by Maintenance Staff at the time of the observations and/or at the exit interview conducted 3/2/17 at 2:30 P.M.


NFPA Standard: NFPA 241 8.6.2.1 Protection shall be provided to separate an occupied portion of the structure from a portion of the structure undergoing alteration, construction, or demolition operations when such operations are considered as having a higher level of hazard than the occupied portion of the building. 8.6.2.2 Walls shall have at least a 1-hour fire resistance rating. 8.6.2.3 Opening protectives shall have at least a 45-minute fire protection rating.

Based on observation and interview the facility failed to maintain the Type I essential electrical system of the facility by having loads intermixed between the Life Safety Branch, The Critical Branch, and the Equipment System and by not having the required loads connected to proper branch of the Essential Electrical System. This deficient practice increased the potential that a failure in a non-life safety code circuit could damage a life safety code circuit and had the potential to affect all residents, staff and visitors of the facility by affecting the egress lighting and emergency systems of the facility. The facility capacity is 25 and the census is 3.

Findings are:

Observation on 3/1/17 at 10:45 A.M. revealed the facility's Essential Electrical System had loads intermixed between the Life Safety Branch, The Critical Branch and Equipment Branch. Panels and circuits were not identified or labeled.

During interview on 3-2-17 at 10:45 A.M. Maintenance A indicated the facility was in the process of installing a new generator system and emergency electrical system. At the time of the survey the project was half way completed.