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Through observation during the survey, August 29, 2013, it was determined that the facility failed to construct smoke barriers to provide at least a smoke resistance rating.

During the walk through of the facility, with the Maintenance Director, the smoke barrier wall, located at the "Therapy room" contained one (1) unsealed wire penetration without fire caulking or other approved method of maintaining the fire rating of the wall.

Through record review and discussions with the staff during the survey, August 29, 2013, it was determined that the facility failed to conduct fire drills at varying times.

During the review of the facility records, with the Maintenance Director;
1) The facility conducted drills on a quarterly basis, however the drills on the "overnight shifts" were conducted at the same time every month. The drills all occured between 5:10am and 5:30am on all overnight fire drills.
2) The facility utilized an actual fire alarm on April 24, 2013 for a fire drill.
Per NFPA 101, Chapter 18, section 18.7.1.2 which states in part "with the signals and emergency action required under varied conditions"

Through observation during the survey,August 29, 2013, it was determined that the facility failed to maintain the fire alarm per NFPA 72.

During the walk through of the facility, with the Maintenance Director, the manual pull station, located at the Emergency Department exit, was blocked by a plastic backboard and was not visible.
Note: The backboard was moved during the survey.

Through observation during the survey, August 29, 2013, it was determined that the facility failed to continuously maintain the means of egress free of all obstructions or impediments to full instant use in case of fire or other emergency.

During the walkthrough of the facility, with the Maintenance Director, items were being stored in the corridor.
1) One (1) BP Cuff machine located outside room #1
2) Two (2) soield linen carts stored outside room #1
3) One (1) wheelchair stored outside room #1
4) Two (2) LV carts stored outside of the "Private room"
5) Two (2) OR machines and one (1) table stored in the OR corridor
6) One (1) Nurse Medication cart outside room #111
7) One (1) Nurse medication cart outside room #105
8) One (1) Nurse Medication cart outside room #101
Chapter 7, section 7.1.10 " Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use. "

Through record review during the survey, August 29, 2013, it was determined that the facility failed to review laboratory procedures on an annual basis.

During staff interviews and records review, with The Laboratory Director, documentation was not available to indicate that the facilities Laboratory personnel reviewed the emergency procedures for the Laboratory on an annual basis as required.

Through record review during the survey, August 29, 2013, it was determined that the facility failed to document the generator testing properly.

During the review of the facility records, with the Maintenance Director, the monthly testing documents did not indicate the amperage put on the generator during the monthly load test, therefore it could not be determined if the generator was actually run under a load on a monthly basis.
Per the 1999 Edition of NFPA 110 section 6-4.2 and 6-4.2.2. 2
"Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
a. Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
b. Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer."

Through observation during the survey, August 29, 2013, it was determined that the facility failed to install and maintain the electrical system in accordance with NFPA 70.

During the walk through of the facility with the Maintenance Director, one (1) four by four (4"x4") electrical box was missing the cover plate at the smoke barrier wall adjacent to the "RT clean up room". This electrical box was located above the drop ceiling in the interstitial space.

Through observation during the survey, August 29, 2013, it was determined that the facility failed to construct smoke barriers to provide at least a smoke resistance rating.

During the walk through of the facility, with the Maintenance Director, the smoke barrier wall, located at the "Therapy room" contained one (1) unsealed wire penetration without fire caulking or other approved method of maintaining the fire rating of the wall.

Through record review and discussions with the staff during the survey, August 29, 2013, it was determined that the facility failed to conduct fire drills at varying times.

During the review of the facility records, with the Maintenance Director;
1) The facility conducted drills on a quarterly basis, however the drills on the "overnight shifts" were conducted at the same time every month. The drills all occured between 5:10am and 5:30am on all overnight fire drills.
2) The facility utilized an actual fire alarm on April 24, 2013 for a fire drill.
Per NFPA 101, Chapter 18, section 18.7.1.2 which states in part "with the signals and emergency action required under varied conditions"

Through observation during the survey,August 29, 2013, it was determined that the facility failed to maintain the fire alarm per NFPA 72.

During the walk through of the facility, with the Maintenance Director, the manual pull station, located at the Emergency Department exit, was blocked by a plastic backboard and was not visible.
Note: The backboard was moved during the survey.

Through observation during the survey, August 29, 2013, it was determined that the facility failed to continuously maintain the means of egress free of all obstructions or impediments to full instant use in case of fire or other emergency.

During the walkthrough of the facility, with the Maintenance Director, items were being stored in the corridor.
1) One (1) BP Cuff machine located outside room #1
2) Two (2) soield linen carts stored outside room #1
3) One (1) wheelchair stored outside room #1
4) Two (2) LV carts stored outside of the "Private room"
5) Two (2) OR machines and one (1) table stored in the OR corridor
6) One (1) Nurse Medication cart outside room #111
7) One (1) Nurse medication cart outside room #105
8) One (1) Nurse Medication cart outside room #101
Chapter 7, section 7.1.10 " Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use. "

Through record review during the survey, August 29, 2013, it was determined that the facility failed to document the generator testing properly.

During the review of the facility records, with the Maintenance Director, the monthly testing documents did not indicate the amperage put on the generator during the monthly load test, therefore it could not be determined if the generator was actually run under a load on a monthly basis.
Per the 1999 Edition of NFPA 110 section 6-4.2 and 6-4.2.2. 2
"Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
a. Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
b. Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer."

Through observation during the survey, August 29, 2013, it was determined that the facility failed to install and maintain the electrical system in accordance with NFPA 70.

During the walk through of the facility with the Maintenance Director, one (1) four by four (4"x4") electrical box was missing the cover plate at the smoke barrier wall adjacent to the "RT clean up room". This electrical box was located above the drop ceiling in the interstitial space.