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Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other spaces. The area of deficient practice would provide a path for smoke and fire to travel between the noted hazardous room and adjacent space as noted, potentially affecting 1 of 2 smoke zones. This facility has a capacity of 10 with a census of 2.

FINDINGS INCLUDE:

During the tour beginning at 1:30 PM on 05/13/2013 and ending on 05/14/2013 at 3:20 PM it is observed in the upstairs Storage Room 4, that the door to the corridor fails to positively latch when allowed to close upon drop test with the automatic door closer.

Administrative Staff A was present during the inspection tour and acknowledged the deficiency.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1.

Based on observation and staff interview the facility failed to ensure that portable oxygen cylinders are being stored in the proper location and/or are properly secured and/or stored. This deficient practice could cause an improperly stored cylinder to be damaged, possibly leak or start a fire, potentially affecting 1 of 2 smoke zones. This facility has a capacity of 10 with a census of 2.

FINDINGS INCLUDE:

During the tour beginning at 1:30 PM on 05/13/2013 and ending on 05/14/2013 at 3:20 PM it is observed in the 1st floor Oxygen Storage Room that there are 10 empty and full oxygen and 4 empty and full Nitrous containers (H tanks) that are sitting upright, loose and unsupported.

Administrative Staff A was present at time of survey, acknowledged the presence of the unsupported bottles, and immediately asked staff to chain the unsupported bottles. This was completed before the end of the survey.

NFPA Standard: Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation. 1999 NFPA 99, 4.3.1.1.2

Based on observation and staff interview, the facility failed to assure that sprinklers are properly maintained and clear of obstructions. The deficient practice fails to ensure the required sprinkler coverage in the event of a fire, creating added risk of damage and personal injury; affecting 1 of 2 smoke zones. The facility has a capacity of 10 with a census of 2.

Findings Include:

During the tour on beginning at 1:30 PM on 05/13/2013 and ending on 05/14/2013 at 3:20 PM it is observed:

1) There is lint build up on sprinkler heads in the following rooms:
a) East Sterilizer Room
b) West Sterilizer Room
c) 2nd level Storage Room, Room 4
d) OR Room 1

2) There is a missing sprinkler escutcheon in the Pre/Post Op Area, Bay 6.

Administrative Staff A and B were present during inspection and acknowledged the findings.

NFPA Standard: Corrective maintenance includes, but is not limited to, replacing loaded, corroded, or painted sprinklers; replacing missing or loose pipe hangers; cleaning clogged fire pump impellers; replacing valve seats and gaskets; restoring heat in areas subject to freezing temperatures where water-filled piping is installed; and replacing worn or missing fire hose or nozzles. 1998 NFPA 25, 1-11.3