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Based on observations, the facility failed to maintain a smoke tight ceiling. The building is composed of Type II protected construction and is required by the Life Safety Code 19.1.6.2, to maintain smoke tight ceilings if used for healthcare occupancy. This deficient practice affects one (1) of seven (7) smoke zones, This facility has a capacity of 18 and a census of 7 patients.
Findings include:
Observations on 10/27/10, at 10:38 a.m., revealed the following construction deficiencies:
1.) Observations found the Recycling Storage Room had a sprinkler head with a 1/4 inch gap in the ceiling.
2.) Observations found the Loading Dock Housekeeping room had a sprinkler head with a 1/4 inch to 1/2 inch gap at the ceiling.

Maintenance Staff A & B verified these findings.

Based on observation, the facility failed to provide smoke barriers that were free of penetrations that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone. This deficient practice affects two (2) of seven (7) smoke zones. This could affect 14 patients and 5-10 staff and visitors to the facility. This facility has a capacity of 18 and a census of 7 residents.

Findings include:

Observations on 10/27/10 at 11:58 a.m., revealed the smoke barrier above the East Wing Smoke Doors had a 1/4 inch to 1/2 inch hole in the rated wall that penetrated the smoke barrier.

Maintenance Staff A & B verified this observation.

Based on observations, the facility failed to maintain smoke doors to close and resist the passage of smoke. The smoke doors affected two (2) of the seven (7) smoke compartments in the building. This could affect 10-15 staff, patients and visitors to the facility. The facility has 18 certified beds and a census was 7.

Findings include:

Observation's on 10/27/10 at 11:28 a.m., revealed the double smoke doors separating the Laboratory corridor from X-ray had a 1/2 inch to 3/4 inch gap between the doors when in the fully closed position.

Maintenance Staff A & B verified this observation.

Based on observations, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected two (2) of seven (7) smoke compartments. This could affect 4-5 staff members in one smoke compartment and 4-5 staff and 5-10 patients in the other smoke compartment. This facility has a capacity of 18 and a census of 7 residents.

Findings include:

1.) Observation's on 10/27/10 at 10:38 a.m., revealed the Recycling Storage Room had a 2 inch x 4 inch hole of the ceiling in the Northwest corner. This had communication wires running through the penetration.
2.) Observation's on 10/27/10 at 10:38 a.m., revealed the Recycling Storage Room had a 1 inch hole of the ceiling in the Northeast corner.
3.) Observation's on 10/27/10 at 12:37 p.m., revealed the Clinic Network Closet had a 3 inch conduit (with communication wires) penetrating both the North and South wall had a 1/4 inch to 1/2 inch gap around them. The walls were separating the Room from the restrooms.
4.) Observation's on 10/27/10 at 12:37 p.m., revealed the Clinic Network Closet had a 1/2 inch conduit penetrating the West Wall. This penetration had a 1/4 inch to 1/2 inch gap at the wall.

Maintenance Staff A & B verified these observations.

Based on observations, the facility failed to provide functioning emergency egress lighting in the facility. This deficient practice affects one (1) of seven (7) smoke compartments and could affect 5-10 patients and staff to the facility. This facility has a capacity of 18 and a census of 7 residents.

Findings include:

1.) Observations on 10/27/10 at 11:37 a.m., revealed the Battery back-up emergency light in the Imaging Room failed when tested.
2.) Record review of the facility's maintenance records on 10/27/10, revealed that there was no documentation regarding the testing of the emergency battery lighting system.
Maintenance Staff A & B verified this finding

Based on record review and staff interview, the facility is not conducting fire drills at varied times during the year on one (1) of three (3) shift. This deficient practice effects all occupants including staff, visitors and residents, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. This facility has a capacity of 18 and a census of 7 residents.

Findings include:

Review of the facility's fire drill records and interview with the Maintenance Director on 10/27/10, revealed that fire drills were conducted with in an hour of each other on the day shift for the year reviewed. The Day shift (7a-3p) were completed during the following times: 01/27/10 at 2:05 p.m., 05/17/10 at 1:00 p.m., 07/29/10 at 1:15 p.m. and 10/20/10 at 9:50 a.m.

Maintenance Staff A verified these observations.

(A)
Based on observation 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 corrosion, paint or other 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 occupants including staff, visitors and residents in two (2) of seven (7) smoke zones. The facility had a capacity of 18 and a census of 7 at the time of survey.

Findings include:

1.) Observations on 10/27/10 at 10:33 a.m., revealed six (6) of six (6) sprinkler heads located in the Laundry Hall were covered with dirt and lint. This was on the diffuser, arms and glass bulb.
2.) Observations on 10/27/10 at 10:33 a.m., revealed six (6) of sixteen (16) sprinkler heads located in the Kitchen were covered with dirt and lint. This was on the diffuser, arms and glass bulb.

(B)
Based on record review and interview the facility failed to maintain and test a complete automatic sprinkler system. This could affect all patients, staff and visitors to the facility. The facility has 18 certified beds and at the time of the survey the census was 7.

Findings include:

During the record review of the facilities fire safety components and interview on 10/27/10, revealed that the 1st and 2nd quarter testing of 2010 had not been conducted. The facility was unaware of the need for this test prior to September 2010. At this time a policy was put in place and Quarterly testing was started and documented.


Maintenance Staff A & B verified these observations.

Based on observations, the facility failed to provide draperies, curtains and window blinds that were flame resistant in accordance with provisions of NFPA National Fire Protection Association 101, Life Safety Code 2000 edition, possibly placing 5-10 staff and patiens at risk in the event of a fire. The facility is licensed for 18 and a census of 7.

Findings include:

Observations on 10/27/10 at 11:46 a.m., revealed that the privacy curtains in ER exam rooms #8, 9, 10, 11 and 12 not have the 1/2 inch mesh at the top 18 inches of the curtain.
Maintenance Staff A & B verified these observations.

Based on observation, the facility failed to provide emergency task illumination at the emergency generator and transfer switch locations. The emergency generator would affect all smoke compartments and all of the facility residents and staff. The facility has 18 beds and a census of 7 at the time of the survey.

Findings include:

Observation's on 10/27/10 from 9:15 a.m. to 1:30 p.m., revealed that a battery emergency light was not provided at the emergency generator transfer switch locations in the facility to provide task illumination. These locations were located both in the old portion and Clinic portion of the facility.

Maintenance Staff A & B confirmed these observations.

(A)
Based on observation, the facility failed to prohibit the use of extension cords as a substitute for permanent wiring, the proper use power strips. The location of deficient practice was located in numerous location throughout the hospital. These were located in all seven (7) of the zones in the facility. This could affect all of the residents, staff and visitors in the facility. The facility has a capacity of 18 and a census of 7 at the time of the survey.

Findings include:

Observations on 10/27/10 from 9:15 a.m.- 1:30 p.m., reveled the following locations had inappropriate use of extension cords or surge protectors.
1.) Observations at 10:36 a.m., revealed a surge protector was plugged into a surge protector in the Central Supply next to the Desk.
2.) Observations at 11:31 a.m., revealed a white extension cord being used under the South Cubicle Desk.
3.) Observations at 11:43 a.m., revealed a refrigerator plugged into a surge protector in the Quality Services Office.
4.) Observations at 12:46 p.m., revealed a refrigerator plugged into a surge protector in the Physical Therapy Storage Area.
5.) Observations at 1:06 p.m., revealed a gray extension cord was being used to supply power to the printers in the Administrative Assistance Office.

(B)
Based on observation, 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 up to 18 residents and 5 Staff at risk in the event of a fire. The facility had a capacity of 18 and a census of 7 at the time of the survey.

Findings Include:

1.) Observations on 10/27/10 at 11:58 a.m., revealed the facility failed to maintain the electrical system above the ceiling at the East wing smoke doors. Above the lay-in-tile there was an open junction box with exposed wires.
Maintenance Staff A & B verified these findings.

Based on staff interview and record review, failed to provide a policy is in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than four hours in any twenty-four hour period. The lack of procedures could effect the actions taken by staff in the event of an emergency. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 18 with a census of 7.

Findings include:

According to Maintenance Staff A interview and record review on 10/27/10, revealed the facility did not have a policy regarding the procedures to be taken in the event that the sprinkler system was out of service for more than four hours in a twenty-four hour period.
Maintenance Staff A and B verified this observation.

Based on staff interview and record review, failed to provide a policy is in place regarding the procedures to be taken in the event that the Fire Alarm system is out of service for more than four hours in any twenty-four hour period. The lack of procedures could effect the actions taken by staff in the event of an emergency. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 18 with a census of 7.

Findings include:

According to Maintenance Staff A interview and record review on 10/27/10, revealed the facility did not have a policy regarding the procedures to be taken in the event that the Fire Alarm System was out of service for more than four hours in a twenty-four hour period.
Maintenance Staff A and B verified this observation.