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Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affects one of eight smoke zones in the building. These areas could affect approximately 10 residents and staff members. The facility has 200 certified beds and at the time of the survey the census was 40.

Findings include:

1. Observation and interview of the 4th story O.B. Soiled Utility room on 10/30/12 at approximately 8:25 a.m., revealed that the north wall above the ceiling tiles there was pipe penetrations with approximately 2 inches gaps in the wall around the pipes.
2. Observation and interview of the 4th story O.B. Electrical room on 10/30/12 at approximately 8:32 a.m., revealed that walls contained one inch gaps around the ceiling beams.

Maintenance Staff (A) verified these observations.

(A)
Based on observation and interview, the facility is not providing an exit door in accordance with 7.2.1.4.5 which requires that a door will not require more than 15 pounds of force to release the latch, 30 pounds of force to set the door in motion and 15 pounds of force to open the door to the minimum required width. This deficient practice affects all residents, staff and visitors that may need to evacuate from one of eight smoke zones: the Radiology Hall. This facility has a capacity of 200 with a census of 40.

Findings include:

Observation and interview on 10/30/12 at approximately 12:01 p.m. revealed, the north exit door located at the east end of the Radiology Hall would not open with-out excessive force. Maintenance Staff (B) was not able to open the door with-out kicking the bottom of the door.

According to the facility layout, this was a required exit.

(B)
Based on observation, staff interview and record review this facility is not providing unobstructed corridors that provides a clear path of egress for eight of eight smoke zones. The facility is also not providing sufficient egress corridors due to projections on the walls in the corridor. This facility has a capacity of 200 with a census of 40.

Findings include:

Observation and interview on 10/30/12 at approximately 9:30 a.m., reveled that the Patent Wing next to room #369 had hinged charting stations in the corridor. Some of these stations were in the down position and did not automatically retract with upward force on the tray.

Maintenance Staff (A) verified the observation. According to the facility layout, this was a required exit.

Based upon record review and interview, the facility failed to hold fire drills under varied times of the day for four of four quarters reviewed. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This facility has a capacity of 200 with a census of 40.

Findings include:

Record review and interview on 10/30/12, the facility fire drill documentation showed that four of the third shift drills were conducted at approximately the same time of the day. The third shifts were conducted as follows: on 1-9-12 at 6:17 a.m., on 6-1-12 at 6:19 a.m., on 8-10-12 at 6:25 a.m. and on 11-10-11 at 6:12 a.m.
The facility also failed to activate the fire alarm system the next day to verify the system is in proper operation and document.

Maintenance Staff (A) verified the documentation.

Based on observation and interview, the facility failed to provide a properly installed fire alarm system. The deficient practice would affect one of eight smoke compartments in the facility. The facility has 200 certified beds and at the time of the survey the census was 40.

Findings include:

Observation and interview on 10/30/12 at 11:30 a.m. revealed, the Cath Lab Hall CVOR was provided with one smoke detector located at the west doors. There were no other smoke detection located in the corridor. The CVOR Unit was provided with a fully automatic sprinkler protection.

Maintenance Staff (A) verified this observation.

Based on observation and interview, this facility is not assuring that the fire alarm system is installed in accordance with NFPA 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer that three feet to air supply or air return. Installation of a smoke detector close to a ceiling fan or air diffusers can impede the operation of the smoke detector and can affect all occupants of the building. This facility has a capacity of 200 and a census of 40 residents.

Findings include:

Observation and interview on 10/30/12 at approximately 10:30 a.m. revealed, the smoke detector in the Pediatric Kitchen was located within three feet of the air diffuser.

Maintenance Staff (A) verified this observation.

(A)
Based on observation and interview the facility failed to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25. The facility failed to maintain the same type of sprinkler heads within a compartment. This item could effect the operation of the heads by delaying the response time, and causing the heads or the entire sprinkler system to be inoperable. This deficient practice affects all occupants in one of eight smoke zones with a capacity of 200 and a census of 40.

Findings include:

Observation and interview of the facility on 10/30/12 at approximately 11:42 a.m., revealed the facility failed to maintain the sprinkler system sprinkler heads in a compartment to be of one temperature rating, which could severely affect system performance. The INDO Kitchenette contained a quick response head and open to the corridor that contained standard response heads.

(B)
Observation and interview revealed the facility failed to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25, by ensuring that the facility failed to maintain the system with an acceptable clearance around sprinkler heads to prevent obstructions to spray patterns. This item could effect the operation of the heads by obstructing spray patterns. This facility with a capacity of 200 and a census of 40.

Findings include:

1. Observation and interview on 10/30/12 at approximately 11:55 a.m., revealed that in the Ambulance Garage the sprinkler heads where located above the four over head garage doors. When the doors are in the open position they would obstruct the spray patterns.

2. Observation and interview on 10/30/12 at approximately 11:20 a.m., revealed that in the Cath Lab between rooms 1 and 2 the sprinkler head was located approximately 8 inches above a storage shelf.

Maintenance Staff (A) verified these observations.

(A)
Based on observation and interview, the facility is not maintaining the sprinkler system in accordance with the 1998 edition of NFPA 25, 2-2.1.1, by ensuring that sprinkler heads are free of foreign material. This can effect the operation of the heads by obstructing spray patterns, delay the response time or even cause the heads to be inoperable which can compromise the effectiveness of the fire suppression system and place occupants at risk of injury in the event of a fire. This deficient practice affects all staff in one of eight smoke zones. The facility had a capacity of 200 and a census of 40 at the time of survey.

Findings include:

Observation and interview on 10/30/12 at approximately 12:15 p.m., revealed that in the Washer room along the south wall was coated with white paint that covered nearly all of the deflector and fusible link.

Maintenance Staff (A) verified this observation.

(B)
Based on observation and interview, the facility is not maintaining the sprinkler system in accordance with the 1998 edition of NFPA 25, 2-2.1.1, by ensuring that the Class 1 Standpipe OS&Y valves are free of foreign material. This can effect the operation of the OS&Y valve to be inoperable which can compromise the effectiveness of the fire suppression system and place occupants at risk of injury in the event of a fire. This deficient practice affects all staff, visitors and residents. The facility had a capacity of 200 and a census of 40 at the time of survey.

Findings include:

Observation and interview on 10/30/12 at approximately 10:05 a.m., revealed that in the 2nd floor north stairway the Class 1 standpipe connection contained corrosion which could prevent the valve from being opened.

Maintenance Staff (A) verified this observation.

Based on observation and interview, 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, placing the Staff and Residents of the facility at risk in the event of a fire. The facility had a capacity of 200 and a census of 40 at the time of the survey.

Findings Include:

1. Observations on 10/30/12 at approximately 9:07 a.m., revealed the facility failed to provide a Ground Fault Circuit Interrupter electrical outlet in the Physical Therapy Kitchenette next to the sink.

2. Observations on 10/30/12 at approximately 10:15 a.m., revealed the facility failed to provide a Ground Fault Circuit Interrupter electrical outlet in the 2nd floor Elevator Lobby Restroom next to the sink.

3. Observations on 10/30/12 at approximately 11:00 a.m., revealed the facility failed to provide a Ground Fault Circuit Interrupter electrical outlet in the I.C.U. House Keeping closet next to the wash basin.

4. Observation on 10/30/12 at approximately 9:48 a.m., revealed above the ceiling tiles next to the smoke doors by room N292 there was an open electrical junction box. At this location there also was an electrical conduit that separated from the junction box exposing electrical wires.

5. Observation on 10/30/12 at approximately 10:00 a.m., revealed that the electrical panel in the 2 North Panel 2B contained an open blank at breaker location #31 exposing internal wiring.

Maintenance Staff (A) verified theses observations.

Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affects one of eight smoke zones in the building. These areas could affect approximately 10 residents and staff members. The facility has 200 certified beds and at the time of the survey the census was 40.

Findings include:

1. Observation and interview of the 4th story O.B. Soiled Utility room on 10/30/12 at approximately 8:25 a.m., revealed that the north wall above the ceiling tiles there was pipe penetrations with approximately 2 inches gaps in the wall around the pipes.
2. Observation and interview of the 4th story O.B. Electrical room on 10/30/12 at approximately 8:32 a.m., revealed that walls contained one inch gaps around the ceiling beams.

Maintenance Staff (A) verified these observations.

(A)
Based on observation and interview, the facility is not providing an exit door in accordance with 7.2.1.4.5 which requires that a door will not require more than 15 pounds of force to release the latch, 30 pounds of force to set the door in motion and 15 pounds of force to open the door to the minimum required width. This deficient practice affects all residents, staff and visitors that may need to evacuate from one of eight smoke zones: the Radiology Hall. This facility has a capacity of 200 with a census of 40.

Findings include:

Observation and interview on 10/30/12 at approximately 12:01 p.m. revealed, the north exit door located at the east end of the Radiology Hall would not open with-out excessive force. Maintenance Staff (B) was not able to open the door with-out kicking the bottom of the door.

According to the facility layout, this was a required exit.

(B)
Based on observation, staff interview and record review this facility is not providing unobstructed corridors that provides a clear path of egress for eight of eight smoke zones. The facility is also not providing sufficient egress corridors due to projections on the walls in the corridor. This facility has a capacity of 200 with a census of 40.

Findings include:

Observation and interview on 10/30/12 at approximately 9:30 a.m., reveled that the Patent Wing next to room #369 had hinged charting stations in the corridor. Some of these stations were in the down position and did not automatically retract with upward force on the tray.

Maintenance Staff (A) verified the observation. According to the facility layout, this was a required exit.

Based upon record review and interview, the facility failed to hold fire drills under varied times of the day for four of four quarters reviewed. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This facility has a capacity of 200 with a census of 40.

Findings include:

Record review and interview on 10/30/12, the facility fire drill documentation showed that four of the third shift drills were conducted at approximately the same time of the day. The third shifts were conducted as follows: on 1-9-12 at 6:17 a.m., on 6-1-12 at 6:19 a.m., on 8-10-12 at 6:25 a.m. and on 11-10-11 at 6:12 a.m.
The facility also failed to activate the fire alarm system the next day to verify the system is in proper operation and document.

Maintenance Staff (A) verified the documentation.

Based on observation and interview, the facility failed to provide a properly installed fire alarm system. The deficient practice would affect one of eight smoke compartments in the facility. The facility has 200 certified beds and at the time of the survey the census was 40.

Findings include:

Observation and interview on 10/30/12 at 11:30 a.m. revealed, the Cath Lab Hall CVOR was provided with one smoke detector located at the west doors. There were no other smoke detection located in the corridor. The CVOR Unit was provided with a fully automatic sprinkler protection.

Maintenance Staff (A) verified this observation.

Based on observation and interview, this facility is not assuring that the fire alarm system is installed in accordance with NFPA 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer that three feet to air supply or air return. Installation of a smoke detector close to a ceiling fan or air diffusers can impede the operation of the smoke detector and can affect all occupants of the building. This facility has a capacity of 200 and a census of 40 residents.

Findings include:

Observation and interview on 10/30/12 at approximately 10:30 a.m. revealed, the smoke detector in the Pediatric Kitchen was located within three feet of the air diffuser.

Maintenance Staff (A) verified this observation.

(A)
Based on observation and interview the facility failed to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25. The facility failed to maintain the same type of sprinkler heads within a compartment. This item could effect the operation of the heads by delaying the response time, and causing the heads or the entire sprinkler system to be inoperable. This deficient practice affects all occupants in one of eight smoke zones with a capacity of 200 and a census of 40.

Findings include:

Observation and interview of the facility on 10/30/12 at approximately 11:42 a.m., revealed the facility failed to maintain the sprinkler system sprinkler heads in a compartment to be of one temperature rating, which could severely affect system performance. The INDO Kitchenette contained a quick response head and open to the corridor that contained standard response heads.

(B)
Observation and interview revealed the facility failed to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25, by ensuring that the facility failed to maintain the system with an acceptable clearance around sprinkler heads to prevent obstructions to spray patterns. This item could effect the operation of the heads by obstructing spray patterns. This facility with a capacity of 200 and a census of 40.

Findings include:

1. Observation and interview on 10/30/12 at approximately 11:55 a.m., revealed that in the Ambulance Garage the sprinkler heads where located above the four over head garage doors. When the doors are in the open position they would obstruct the spray patterns.

2. Observation and interview on 10/30/12 at approximately 11:20 a.m., revealed that in the Cath Lab between rooms 1 and 2 the sprinkler head was located approximately 8 inches above a storage shelf.

Maintenance Staff (A) verified these observations.

(A)
Based on observation and interview, the facility is not maintaining the sprinkler system in accordance with the 1998 edition of NFPA 25, 2-2.1.1, by ensuring that sprinkler heads are free of foreign material. This can effect the operation of the heads by obstructing spray patterns, delay the response time or even cause the heads to be inoperable which can compromise the effectiveness of the fire suppression system and place occupants at risk of injury in the event of a fire. This deficient practice affects all staff in one of eight smoke zones. The facility had a capacity of 200 and a census of 40 at the time of survey.

Findings include:

Observation and interview on 10/30/12 at approximately 12:15 p.m., revealed that in the Washer room along the south wall was coated with white paint that covered nearly all of the deflector and fusible link.

Maintenance Staff (A) verified this observation.

(B)
Based on observation and interview, the facility is not maintaining the sprinkler system in accordance with the 1998 edition of NFPA 25, 2-2.1.1, by ensuring that the Class 1 Standpipe OS&Y valves are free of foreign material. This can effect the operation of the OS&Y valve to be inoperable which can compromise the effectiveness of the fire suppression system and place occupants at risk of injury in the event of a fire. This deficient practice affects all staff, visitors and residents. The facility had a capacity of 200 and a census of 40 at the time of survey.

Findings include:

Observation and interview on 10/30/12 at approximately 10:05 a.m., revealed that in the 2nd floor north stairway the Class 1 standpipe connection contained corrosion which could prevent the valve from being opened.

Maintenance Staff (A) verified this observation.

Based on observation and interview, 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, placing the Staff and Residents of the facility at risk in the event of a fire. The facility had a capacity of 200 and a census of 40 at the time of the survey.

Findings Include:

1. Observations on 10/30/12 at approximately 9:07 a.m., revealed the facility failed to provide a Ground Fault Circuit Interrupter electrical outlet in the Physical Therapy Kitchenette next to the sink.

2. Observations on 10/30/12 at approximately 10:15 a.m., revealed the facility failed to provide a Ground Fault Circuit Interrupter electrical outlet in the 2nd floor Elevator Lobby Restroom next to the sink.

3. Observations on 10/30/12 at approximately 11:00 a.m., revealed the facility failed to provide a Ground Fault Circuit Interrupter electrical outlet in the I.C.U. House Keeping closet next to the wash basin.

4. Observation on 10/30/12 at approximately 9:48 a.m., revealed above the ceiling tiles next to the smoke doors by room N292 there was an open electrical junction box. At this location there also was an electrical conduit that separated from the junction box exposing electrical wires.

5. Observation on 10/30/12 at approximately 10:00 a.m., revealed that the electrical panel in the 2 North Panel 2B contained an open blank at breaker location #31 exposing internal wiring.

Maintenance Staff (A) verified theses observations.