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Based on observations and staff interview, this facility is not properly maintaining the fire rated construction of all two hour walls. This deficient practice affects all occupants including staff, visitors and patients. The facility has a capacity of 217 with a census of 43 patients.

Findings include:

Observations and staff interview on 1/31/13, revealed the following deficiencies:

1. There was an open pipe penetration, (approximately 1/4 inch), extending through the 3 - West Two Hour Wall by the Multipurpose Room.
2. There was an open pipe penetration, (approximately 1/4 inch), extending thorough the 3 - West Two Hour Wall by the Multipurpose Room.
3. There was a penetration, (approximately 3/16 inch), around a flexible conduit extending through the 3 - West Two Hour Wall by the Multipurpose Room.
4. There was a penetration, (approximately 1/4 inch), around an insulated pipe extending through the 3 - West Two Hour Wall by Room 301.
5. There was a penetration, (approximately 3/16 inch), around a flexible line extending through the Two Hour Wall to the Clinic.
6. There was an open pipe penetration, (approximately 2 inches), extending through the Two Hour Wall to the Clinic.
7. There was an open pipe penetration, (approximately 4 inches), extending through the Two Hour Wall to the Clinic.
8. The Fire Doors located in the Two Hour Wall to the Clinic did not close and latch properly.

Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, it was determined the facility was a four story building consisting of protected non-combustible construction equipped with an automatic sprinkler system. The facility failed to assure minimum building construction requirements were maintained by ensuring that holes and gaps around penetrations are sealed with fire rated materials. The facility has a capacity of 217 with a census of 43 patients.

Findings include:

Observations and staff interview on 1/31/13, revealed the following deficiencies:

1. There was a hole, (approximately 2-1/2 inches), in the ceiling tile in the bathroom of Room 411.
2. There was a penetration, (approximately 1/4 inch), around a sprinkler head extending through the ceiling tile assembly in Room 315.
3. There was a hole, (approximately 2-1/2 inches), in a ceiling tile in the 3 - West Supply Room by Room 314.
4. There was a penetration, (approximately 1 inch), around communications lines extending through the ceiling of the 3 - East SA Closet.

Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, this facility failed to maintain smoke barriers in accordance with National Fire Protection Association (NFPA) Standard 101, 2000 edition, 19.3.7.3. Smoke barriers shall be continuous from outside wall to outside wall and from floor to a roof extending through all concealed spaces. Smoke barriers shall have a fire resistance rating of not less than 1/2 hour. The facility has a capacity of 217 with a census of 43 patients.

Findings include:

Observations and staff interview on 1/31/13, revealed the following deficiencies:

1. There was an open pipe penetration, (approximately 1 inch), extending through the 4th Floor Smoke Barrier Wall separating the Elevator Lobby from the OB Department.
2. There was an open pipe penetration, (approximately 2 inches), extending through the 4th Floor Smoke Barrier Wall separating the Elevator Lobby from the OB Department.
3. There was a penetration, (approximately 3 inches), around communications lines extending through the 4th Floor Smoke Barrier Wall separating the Elevator Lobby from the Wound Center.
4. There was a penetration, (approximately 1/4 inch), around a conduit extending through the 4th Floor Smoke Barrier Wall separating the Elevator Lobby from the Wound Center.
5. There was an open pipe penetration, (approximately 4 inches), extending through the 3rd Floor Smoke Barrier Wall by Room 378.

Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, the facility failed to provide separation of hazardous areas from other compartments in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition, 19.3.2.1. The facility is composed of protected non-combustible construction and equipped with a sprinkler system. Where a sprinkler system option is used to provide separation, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. The facility has a capacity of 217 with a census of 43 patients.

Findings include:

Observations and staff interview on 1/31/13, revealed the following deficiencies:

1. The door to the OB Soiled Utility Room did not close and latch properly.
2. The door to the OB Storage Room by Room 416 did not close and latch properly.
3. The ER Storage Room by Secure Exam Room 5 did not close and latch properly.

Maintenance Staff A verified observations during the survey process.

Based upon record review and staff interview, the facility failed to hold fire drills under varied conditions at different times of the day for four of four quarters reviewed. Fire drills shall be held at unexpected times under varying conditions, at least quarterly on each shift. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all patients in the event of a fire. This facility has a capacity of 217 with a census of 43 patients.

Findings include:

Record review and staff interview on 1/31/13, revealed no documentation of a fire drill for the 2nd Shift in the 4th Quarter of 2012. Available documentation also indicated that the facility conducted two fire drills for the 3rd Shift at 6:30 a.m. on 7/10/12 and 10/12/12. The facility also conducted two fire drills for the 1st shift at 9:31 a.m. on 2/14/12 and 6/13/12. Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, the facility failed to properly protect the primary power supply for the fire alarm system in accordance with the National Fire Protection Association (NFPA), Standard 72, 1999 edition, 1-5.2.5.2. This deficient practice affects all occupants of the building. The facility has a capacity of 217 with a census of 43 residents.

Findings include:

Observation and staff interview on 1/31/13, revealed that the facility failed to mechanically protect the circuit breaker supplying power to the fire alarm system. Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, this facility is not assuring that the fire alarm system is installed and maintained in accordance with National Fire Protection Association (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 diffuser can impede the operation of the smoke detector. The facility has a capacity of 217 with a census of 43 patients.

Findings include:

Observations and staff interview on 1/31/13, revealed that smoke detectors were installed within three feet of an air supply or return in the following areas:

1. In the Main Entrance Lobby Area.
2. In the OB Corridor by Room 413.
3. In the Med/Surg Corridor by Room 380.
4. In the 3 - South Supply Room.
5. In the 3 - South Corridor by Room 370.
6. In the 3 - East Corridor by the Shower Room.
7. In the 3 - East Corridor by the Nurses Station.
8. In the 2nd Floor Corridor by the Entrance to the Cancer Center.
9. In the 2nd Floor Corridor in the Infusion Center.
10. In the Radiology Corridor by the Dark Room.
11. In the 2nd Floor Oncology Corridor by the Dressing Rooms.

Maintenance Staff A verified observations during the survey process.

Based on observation, record review and staff interview, the facility failed to maintain a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998 edition. All smoke compartments and all residents and staff could be affected by the deficient practice. The facility has a capacity of 217 with a census of 43 patients.

Findings include:

Observation, record review and staff interview on 1/31/13, revealed the following sprinkler system deficiencies:

1. There was a sprinkler head with a missing escutcheon located in the 4th Floor Corridor by Room 402.
2. There was no documentation of run time during weekly testing of the fire pump from 1/1/12 to 10/1/12. During this time the dates of testing for the fire pump were only listed.

Maintenance Staff A verified observations and record review during the survey process.

Based on record review and staff interview, the facility failed to maintain the wet chemical extinguishing system in accordance with National Fire Protection Association (NFPA) Standard 17A, the standard for Wet Chemical Extinguishing Systems, 5-2.1. A monthly inspection of the system shall be conducted. The facility has a capacity of 217 with a census of 43 patients.

Findings include:

Record review and staff interview on 1/31/13, revealed no documentation of monthly inspections for the Kitchen hood and duct extinguishing system. Maintenance Staff A verified observations during the survey process.

Based on record review and staff interview, the facility failed to maintain and test the emergency generator power supply as required. Emergency generators are required to be inspected weekly and exercised under load for 30 minutes per month and shall be in accordance with National Fire Protection Association (NFPA), Standard 99, 3.4.4.1, and NFPA 110, 8.4.2. The emergency generator would effect all smoke compartments and all facility staff and residents. The facility has a capacity of 217 with a census of 43 patients.

Findings include:

Record review and staff interview on 1/31/13, revealed no documentation of weekly inspections for the facility's two generators. Maintenance Staff A verified record review during the survey process.

Based on observations and staff 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. The facility has a capacity of 217 with a census of 43 patients.

Findings include:

Observations and staff interview on 1/31/13, revealed open gaps, (both approximately 1-1/2 inches), at the bottom of the two electrical panels located in the 3 - East SA Closet. Maintenance Staff A verified observations during the survey process.

Based on record review and staff interview, this facility is not assuring that 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 217 with a census of 43 patients.

Findings include:

Record review and staff interview on 1/31/13, revealed that the facility did not have a policy in place for the event that the sprinkler system is out of service for more than four hours in a twenty-four hour period. The facility's fire watch policy did not contain language in reference to the actions to be taken and notifications to be made to the proper authorities having jurisdiction. Maintenance Staff A verified record review during the survey process.

Based on record review and staff interview, this facility is not assuring that 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 217 with a census of 43 patients.

Findings include:

Record review and staff interview on 1/31/13, revealed that the facility did not have a policy in place for the event that the fire alarm system is out of service for more than four hours in a twenty-four hour period. The facility's fire watch policy did not contain language in reference to the actions to be taken and notifications to be made to the proper authorities having jurisdiction. Maintenance Staff A verified record review during the survey process.