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Based on observation and staff interview, the facility failed to maintain corridor walls free of penetrations by not patching holes above ceiling in the corridor walls in 3 of 6 smoke compartments in the Hospital. This failure would allow smoke to seep through the hole into the patient rooms or the exit corridor. Facility census was 3.

Findings are:
Observation during the facility tour on 4/28/10 from 1:09 pm to 1:16 pm above ceiling revealed:
1. Multiple holes around ductwork and pipes between Patient Rooms 103 and 105.
2. Multiple holes around cable and pipes above Patient Room 330.
3. Multiple holes around cable and pipes above the Doctor Sleep Room.
4. Hole around sprinkler pipe in the East Stairwell wall.
5. Penetrations were observed throughout the corridors of the Hospital.

In an interview conducted at the time of observation (4/28/10 from 1:09 pm to 1:16 pm), Maintenance A stated the penetrations had to be from projects years ago.

Based on observation and staff interview, the facility failed to mark exits, so that the exit signs clearly directed occupants out of the facility for 4 of 6 smoke compartments in the Hospital. This failure had the potential to not direct occupants out of the facility during a fire or other emergency, which would affect visitors, and staff evacuating patients. Facility census was 3.

Findings are:
Observations during the facility tour on 4/28/10, from 11:07 am to 12:43 am revealed:
1. Exit signs were not visible in two separate directions in the East Basement Hallway. The facility failed to install an exit sign above the smoke doors looking west on the east side of the doors.
2. An exit from the East Stairwell failed to be visible. The facility failed to install an exit sign above the stair well door that led to the Clinic, which also led to the exit outside from the stairwell.
3. The exit sign above the South and East Clinic Exits directed occupants left, to a dead end. The facility failed to install a blank cover over the chevron so the exit sign directed occupants through the exit door.
4. Exit signs were not visible in two separate directions in the Ground Level East Corridor and the Center Corridor. The facility failed install exit signs on both sides of the East Hospital Smoke Doors.
5. Exit signs were not visible in two separate directions in the Ground Level West Corridor. The facility failed to install an exit sign on the west side of West Hospital Smoke Doors.
In an interview conducted at the time of observation (4/28/10, from 11:07 am to 12:43 am), Maintenance A confirmed exit signs were not visible in two separate directions.

Based on observation and staff interview, the facility failed to construct at least ? hour smoke barrier walls that resisted the passage of smoke for 1 of 4 smoke barriers in the Hospital. This failure would not contain a fire to one smoke compartment and allow smoke and fire to migrate to other smoke compartments in the facility. Facility census was 3.

Findings are:
During the facility tour on 4/28/10 at 1:18 pm, observation above ceiling at the Ground Floor East Smoke Doors revealed a 1 ft by 1 ft square hole and holes around cables and a sprinkler pipe in the barrier wall. Penetrations in smoke barrier walls were observed throughout the facility.
In an interview conducted at the time of observations (4/28/10 at 1:18 pm), Maintenance A confirmed the penetrations in the barrier walls.

Based on observation and staff interview, the facility failed to maintain a gap less than 1/8 inch at the meeting edges of 1 of 4 sets of smoke doors to resist the passage of smoke in the Hospital. This failure would allow smoke to migrate into another smoke compartment. Facility census was 3.

Findings are:
Observation during the facility tour on 4/28/10, at 12:42 pm revealed a gap that exceeded 1/8 inch at the meeting edges of the Ground Level West Smoke Doors.
In an interview conducted at the time of observation (4/28/10, at 12:42 pm), Maintenance A confirmed the gap between the doors exceeded 1/8 inch.

Based on observation and staff interview, the facility failed to separate hazardous areas from other spaces by smoke resisting partitions and doors in 1 of 6 smoke compartments in the Hospital. This failure would allow smoke and fire to migrate from hazardous areas with high intensity due to the combustible items inside the rooms. Facility census was 3.

Findings are:
During the facility tour on 4/28/10, from 10:44 am to 10:47 am revealed:
1. The Mechanical Room Door did not latch when swung shut by the automatic closure.
2. The Lower Level Medical Records Room revealed the room measured over 50 square feet with multiple boxes of files stored on shelves inside. The facility failed to install an automatic closure on the room door.
In an interview conducted at the time of observations (4/28/10, from 10:44 am to 10:47 am), Maintenance A confirmed the hazardous areas did not provide smoke resisting partitions.

Based on observation, record review and staff interview, the facility failed to provide documentation that an exit corridor was illuminated in accordance with NFPA 101, 7.8.1.3 in 3 of 6 smoke compartments in the Hospital. This failure had the potential to hinder patient and occupant evacuation during an emergency. Facility census was 3.

Findings are:
During the facility tour on 4/28/10, from 10:35 am to 10:51 am revealed:
1. Only 3 lights stayed on in the Basement Hallway when the light switch was turned off.
2. The light switch in the West Stairwell turned off the light and left the stairwell in darkness.
Record review revealed the facility failed to provide documentation that the illumination configuration equaled 1 ft-candle in the hallway.
In an interview conducted at the time of observation 4/28/10, from 10:35 am to 10:51 am, Maintenance A confirmed the amount of lighting and that no documentation was not made available for review.

Based on record review and staff interview, the facility failed to maintain the fire alarm system in accordance with NFPA 72. This failure increased the potential of system failure. Facility census was 3.

Findings are:
Record review of the 1/25/10 fire alarm inspection report revealed a calibration test noted to have been completed 1/26/09. A report to verify the calibration report had been completed failed to be available for review.
In an interview conducted at the time of record review (4/28/10, at 11:50 am), Maintenance A confirmed the findings.

Based on record review and staff interview, the facility failed to continuously maintain the automatic sprinkler system. This failure would increase the probability of system failure. Facility census was 3.

Findings are:
Record review of sprinkler system inspection reports revealed:
1. The last annual sprinkler inspection report was dated 10/20/08. The facility failed to conduct an annual inspection within 12 months of the last annual inspection.
2. The facility failed to provide documentation of quarterly sprinkler system testing.
In an interview conducted at the time of record review (4/28/10, from 11:45 am to 1:13 pm), Maintenance A and Administration A confirmed the missing documentation.

NFPA 25, 2-2.6 Alarm Devices.
Alarm devices shall be inspected quarterly to verify that they are free of physical damage.

Based on record review and staff interview, the facility failed to provide documentation to verify fire extinguishers were inspected monthly in accordance with NFPA 10 for 4 of 4 fire extinguishers sampled. This failure would increase the probability of fire extinguisher failure. Facility census was 3.

Findings are:
Record review of fire extinguisher inspection tags revealed none of the tags were initialed and dated to verify monthly inspection of fire extinguishers.
In an interview conducted at the time of record review, (4/28/10, from 11:03 am to 11:46 am) Maintenance A stated that he performed the monthly inspections but did not fill out the inspection tags throughout the facility.

Based on record review and staff interview, the facility failed to install the range hood suppression system in accordance with NFPA 96. This failure would not alert the facility of range fire in the event of automatic actuation of the suppression system. Facility census was 3.

Findings are:
Record review of range hood suppression system inspections revealed the portion of the report titled " Electronic Devices " had a " no " filled in the line to indicate if a micro switch (a device that ties the range hood suppression system into the fire alarm) was tested. The facility failed to provide documentation that the range hood suppression system was tied to the fire alarm system.
In an interview conducted at the time of record review, (4/28/10, 11:01 am) Maintenance A stated that he did not ever recall a fire alarm activation during range hood suppression system testing.

Based on record review and staff interview, the facility failed to inspect and test the facility generator in accordance with NFPA 110. This failure would increase the probability of generator failure. Facility census was 3.

Findings are:

Record review revealed weekly generator inspections were being conducted monthly.
In an interview conducted at the time of record review (4/28/10, at 10:42 am), Maintenance A confirmed that weekly generator inspections were performed monthly. Maintenance A stated that the generator was run under load weekly, but documentation failed to be provided to verify the testing.

NFPA 110, 6-3 Maintenance and Operational Testing.
6-3.1*
The EPSS shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class.
6-3.2
A routine maintenance and operational testing program shall be initiated immediately after the EPSS has passed acceptance tests or after completion of repairs that impact the operational reliability of the system.
6-3.3
A written schedule for routine maintenance and operational testing of the EPSS shall be established.
6-3.4
A written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises. The written record shall include the following:
(a) The date of the maintenance report
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer
6-3.5*
Transfer switches shall be subjected to a maintenance program including connections, inspection or testing for evidence of overheating and excessive contact erosion, removal of dust and dirt, and replacement of contacts when required.
6-3.6*
Storage batteries, including electrolyte levels, used in connection with Level 1 and Level 2 systems shall be inspected at intervals of not more than 7 days and shall be maintained in full compliance with manufacturer ' s specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects.
6-4 Operational Inspection and Testing.
6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.
6-4.2*
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
The date and time of day for required testing shall be decided by the owner, based on facility operations.

Based on observation and staff interview, the facility failed to use electrical wiring and equipment in accordance with the National Fire Protection Association 70 in the Laundry, Cardiac Rehab and Medical Records. This failure had the potential to start an electrical fire. Facility census was 3.

Findings are:
During the facility tour on 4/28/10, from 10:54 am to 11:38 am, observations revealed:
1. An extension cord used for a soap dispenser in the dirty side of the Laundry. Extension cords are not designed to take the place of permanent wiring.
2. Two power strips plugged into a batter backup power strip for the computer. Power strips are not designed to be ganged together.
3. An extension cord used for a radio in the Clinic Medical Records Room.
In an interview conducted at the times of observation (4/28/10, from 10:54 am to 11:38 am), Maintenance A confirmed the findings.

Based on observation and staff interview, the facility failed to maintain corridor walls free of penetrations by not patching holes above ceiling in the corridor walls in 3 of 6 smoke compartments in the Hospital. This failure would allow smoke to seep through the hole into the patient rooms or the exit corridor. Facility census was 3.

Findings are:
Observation during the facility tour on 4/28/10 from 1:09 pm to 1:16 pm above ceiling revealed:
1. Multiple holes around ductwork and pipes between Patient Rooms 103 and 105.
2. Multiple holes around cable and pipes above Patient Room 330.
3. Multiple holes around cable and pipes above the Doctor Sleep Room.
4. Hole around sprinkler pipe in the East Stairwell wall.
5. Penetrations were observed throughout the corridors of the Hospital.

In an interview conducted at the time of observation (4/28/10 from 1:09 pm to 1:16 pm), Maintenance A stated the penetrations had to be from projects years ago.

Based on observation and staff interview, the facility failed to mark exits, so that the exit signs clearly directed occupants out of the facility for 4 of 6 smoke compartments in the Hospital. This failure had the potential to not direct occupants out of the facility during a fire or other emergency, which would affect visitors, and staff evacuating patients. Facility census was 3.

Findings are:
Observations during the facility tour on 4/28/10, from 11:07 am to 12:43 am revealed:
1. Exit signs were not visible in two separate directions in the East Basement Hallway. The facility failed to install an exit sign above the smoke doors looking west on the east side of the doors.
2. An exit from the East Stairwell failed to be visible. The facility failed to install an exit sign above the stair well door that led to the Clinic, which also led to the exit outside from the stairwell.
3. The exit sign above the South and East Clinic Exits directed occupants left, to a dead end. The facility failed to install a blank cover over the chevron so the exit sign directed occupants through the exit door.
4. Exit signs were not visible in two separate directions in the Ground Level East Corridor and the Center Corridor. The facility failed install exit signs on both sides of the East Hospital Smoke Doors.
5. Exit signs were not visible in two separate directions in the Ground Level West Corridor. The facility failed to install an exit sign on the west side of West Hospital Smoke Doors.
In an interview conducted at the time of observation (4/28/10, from 11:07 am to 12:43 am), Maintenance A confirmed exit signs were not visible in two separate directions.

Based on observation and staff interview, the facility failed to construct at least ? hour smoke barrier walls that resisted the passage of smoke for 1 of 4 smoke barriers in the Hospital. This failure would not contain a fire to one smoke compartment and allow smoke and fire to migrate to other smoke compartments in the facility. Facility census was 3.

Findings are:
During the facility tour on 4/28/10 at 1:18 pm, observation above ceiling at the Ground Floor East Smoke Doors revealed a 1 ft by 1 ft square hole and holes around cables and a sprinkler pipe in the barrier wall. Penetrations in smoke barrier walls were observed throughout the facility.
In an interview conducted at the time of observations (4/28/10 at 1:18 pm), Maintenance A confirmed the penetrations in the barrier walls.

Based on observation and staff interview, the facility failed to maintain a gap less than 1/8 inch at the meeting edges of 1 of 4 sets of smoke doors to resist the passage of smoke in the Hospital. This failure would allow smoke to migrate into another smoke compartment. Facility census was 3.

Findings are:
Observation during the facility tour on 4/28/10, at 12:42 pm revealed a gap that exceeded 1/8 inch at the meeting edges of the Ground Level West Smoke Doors.
In an interview conducted at the time of observation (4/28/10, at 12:42 pm), Maintenance A confirmed the gap between the doors exceeded 1/8 inch.

Based on observation and staff interview, the facility failed to separate hazardous areas from other spaces by smoke resisting partitions and doors in 1 of 6 smoke compartments in the Hospital. This failure would allow smoke and fire to migrate from hazardous areas with high intensity due to the combustible items inside the rooms. Facility census was 3.

Findings are:
During the facility tour on 4/28/10, from 10:44 am to 10:47 am revealed:
1. The Mechanical Room Door did not latch when swung shut by the automatic closure.
2. The Lower Level Medical Records Room revealed the room measured over 50 square feet with multiple boxes of files stored on shelves inside. The facility failed to install an automatic closure on the room door.
In an interview conducted at the time of observations (4/28/10, from 10:44 am to 10:47 am), Maintenance A confirmed the hazardous areas did not provide smoke resisting partitions.

Based on observation, record review and staff interview, the facility failed to provide documentation that an exit corridor was illuminated in accordance with NFPA 101, 7.8.1.3 in 3 of 6 smoke compartments in the Hospital. This failure had the potential to hinder patient and occupant evacuation during an emergency. Facility census was 3.

Findings are:
During the facility tour on 4/28/10, from 10:35 am to 10:51 am revealed:
1. Only 3 lights stayed on in the Basement Hallway when the light switch was turned off.
2. The light switch in the West Stairwell turned off the light and left the stairwell in darkness.
Record review revealed the facility failed to provide documentation that the illumination configuration equaled 1 ft-candle in the hallway.
In an interview conducted at the time of observation 4/28/10, from 10:35 am to 10:51 am, Maintenance A confirmed the amount of lighting and that no documentation was not made available for review.

Based on record review and staff interview, the facility failed to maintain the fire alarm system in accordance with NFPA 72. This failure increased the potential of system failure. Facility census was 3.

Findings are:
Record review of the 1/25/10 fire alarm inspection report revealed a calibration test noted to have been completed 1/26/09. A report to verify the calibration report had been completed failed to be available for review.
In an interview conducted at the time of record review (4/28/10, at 11:50 am), Maintenance A confirmed the findings.

Based on record review and staff interview, the facility failed to continuously maintain the automatic sprinkler system. This failure would increase the probability of system failure. Facility census was 3.

Findings are:
Record review of sprinkler system inspection reports revealed:
1. The last annual sprinkler inspection report was dated 10/20/08. The facility failed to conduct an annual inspection within 12 months of the last annual inspection.
2. The facility failed to provide documentation of quarterly sprinkler system testing.
In an interview conducted at the time of record review (4/28/10, from 11:45 am to 1:13 pm), Maintenance A and Administration A confirmed the missing documentation.

NFPA 25, 2-2.6 Alarm Devices.
Alarm devices shall be inspected quarterly to verify that they are free of physical damage.

Based on record review and staff interview, the facility failed to provide documentation to verify fire extinguishers were inspected monthly in accordance with NFPA 10 for 4 of 4 fire extinguishers sampled. This failure would increase the probability of fire extinguisher failure. Facility census was 3.

Findings are:
Record review of fire extinguisher inspection tags revealed none of the tags were initialed and dated to verify monthly inspection of fire extinguishers.
In an interview conducted at the time of record review, (4/28/10, from 11:03 am to 11:46 am) Maintenance A stated that he performed the monthly inspections but did not fill out the inspection tags throughout the facility.

Based on record review and staff interview, the facility failed to install the range hood suppression system in accordance with NFPA 96. This failure would not alert the facility of range fire in the event of automatic actuation of the suppression system. Facility census was 3.

Findings are:
Record review of range hood suppression system inspections revealed the portion of the report titled " Electronic Devices " had a " no " filled in the line to indicate if a micro switch (a device that ties the range hood suppression system into the fire alarm) was tested. The facility failed to provide documentation that the range hood suppression system was tied to the fire alarm system.
In an interview conducted at the time of record review, (4/28/10, 11:01 am) Maintenance A stated that he did not ever recall a fire alarm activation during range hood suppression system testing.

Based on record review and staff interview, the facility failed to inspect and test the facility generator in accordance with NFPA 110. This failure would increase the probability of generator failure. Facility census was 3.

Findings are:

Record review revealed weekly generator inspections were being conducted monthly.
In an interview conducted at the time of record review (4/28/10, at 10:42 am), Maintenance A confirmed that weekly generator inspections were performed monthly. Maintenance A stated that the generator was run under load weekly, but documentation failed to be provided to verify the testing.

NFPA 110, 6-3 Maintenance and Operational Testing.
6-3.1*
The EPSS shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class.
6-3.2
A routine maintenance and operational testing program shall be initiated immediately after the EPSS has passed acceptance tests or after completion of repairs that impact the operational reliability of the system.
6-3.3
A written schedule for routine maintenance and operational testing of the EPSS shall be established.
6-3.4
A written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises. The written record shall include the following:
(a) The date of the maintenance report
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer
6-3.5*
Transfer switches shall be subjected to a maintenance program including connections, inspection or testing for evidence of overheating and excessive contact erosion, removal of dust and dirt, and replacement of contacts when required.
6-3.6*
Storage batteries, including electrolyte levels, used in connection with Level 1 and Level 2 systems shall be inspected at intervals of not more than 7 days and shall be maintained in full compliance with manufacturer ' s specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects.
6-4 Operational Inspection and Testing.
6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.
6-4.2*
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
The date and time of day for required testing shall be decided by the owner, based on facility operations.

Based on observation and staff interview, the facility failed to use electrical wiring and equipment in accordance with the National Fire Protection Association 70 in the Laundry, Cardiac Rehab and Medical Records. This failure had the potential to start an electrical fire. Facility census was 3.

Findings are:
During the facility tour on 4/28/10, from 10:54 am to 11:38 am, observations revealed:
1. An extension cord used for a soap dispenser in the dirty side of the Laundry. Extension cords are not designed to take the place of permanent wiring.
2. Two power strips plugged into a batter backup power strip for the computer. Power strips are not designed to be ganged together.
3. An extension cord used for a radio in the Clinic Medical Records Room.
In an interview conducted at the times of observation (4/28/10, from 10:54 am to 11:38 am), Maintenance A confirmed the findings.