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Based on observation, record review and staff interviews, the facility failed to assure that penetrations in the 2 hour fire separation wall between the hospital and the Family Practice are properly sealed. This deficient practice of allowing improperly sealed penetrations in a 2 hour fire wall for occupancy separation will allow smoke and fire products to move from one occupancy to the other occupancy affecting zero patients and all occupants in one of eight smoke zones on the 1st floor. The facility has a capacity of 24 with a census of 12.

Findings Include:

During the tour on 1/8/13 between 9:30 A.M. and 4:00 P.M. the following is observed:

1.) There are penetrations around cables/wiring above the ceiling tile assembly above the CCFP hallway entry doors on the Hospital side of the 2 hour fire wall.

Adminisrative Staff A and Maintanence Staff A were present and acknowledged the finding.

NFPA Standard: Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2 hour fire resistance rating and constructed of materials as required for the addition. Communicating openings in the fire barriers shall be permitted only in corridors and protected by approved self closing fire doors. 2000 NFPA 101, 18/19.1.1.4.1 and 18/19.1.1.4.2.

Based on observation and staff interview the facility fails to maintain the integrity of the building construction by allowing gaps around sprinkler and other piping to remain open in the ceiling. This deficient practice would allow fire products to spread to the attic area, affecting 24 patients and all occupants in three of eight smoke zones. The facility has a capacity of 24 and census of 12.

Findings Include:

During the tour on 1/8/13 between 9:30 A.M. and 4:00 P.M. the following is observed:

1.) There are gaps around sprinkler piping, escutcheons and other piping passing through the ceiling into the attic area at the following locations: CCFP hallway entrance, Room 009, Radiology Check-in Office.

2.) There is an unprotected opening in the ceiling of the basement Engineering Shop leading up to the first floor around Tub plumbing.

Adminisrative Staff A and Maintanence Staff A were present and acknowledged the findings.

NFPA Standard: One story is permitted with complete sprinkler coverage and one-hour rated ceilings for all parts of a facility composed of wood frame construction, type V (111). 2000 NFPA 101, table 18/19.1.6.2

Based on observation and staff interview the facility fails to maintain smoke barriers to at least one half hour fire resistance and ensure that all penetrations are properly sealed. This deficient practice would prevent containment of fire and smoke, affecting 24 patients and all occupants in eight of eight smoke zones. This facility has a capacity of 24 and census of 12 residents.

Findings Include:

During the tour on 1/8/13 between 9:30 A.M. and 4:00 P.M. the following is observed:

1.) There are unprotected gaps and/or penetrations around cables/wiring above the data equipment room door on the South smoke barrier wall in the Engineering room.

2.) There are unprotected gaps and/or penetrations around cables/wiring on all four smoke barrier walls of Room 010.

3.) There are unprotected gaps and/or penetrations around cables/wiring above the ceiling tile assembly above the smoke barrier doors near the Laboratory, Room 300, and the O.B. Doctors' Lounge.

4.) There are unprotected gaps and/or penetrations around pipes/conduit in the basement smoke barrier wall near the IT/ Medical records office and near the old Wood shop.

Adminisrative Staff A and Maintanence Staff A were present and acknowledged the findings.

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1.

Based on observation and staff interview the facility failed to ensure proper separation of hazardous areas from other spaces. This deficient practice would allow for the spread of smoke and fire to travel into the adjacent area in one of eight smoke zones, affecting zero patients but all occupants. The facility has a capacity of 24 in patients with a census of 12.

Findings Include:

During the tour on 1/8/13 between 9:30 A.M. and 4:00 P.M. the following is observed:

1.) The basement storage room near the service elevator has a door leading to the exit corridor that has no self-closure device or door knob/latching mechanism.

2.) Room 004 is being used as general storage has no self-closure device on the door.

Adminisrative Staff A and Maintanence Staff A were present and acknowledged the findings.

NFPA Standard: Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4. 2000 NFPA 101, 39.3.2.1.

Based on observation and staff interview, the facility failed to provide means of egress that are maintained free of all obstructions or impediments to a full instant use in case of fire or other emergency. The deficient practice would prevent these exits from being arranged so that they are readily available and accessible in two of eight smoke zones, affecting zero patients but all occupants. This facility has a capacity of 24 and a census of 12.

Findings Include:

During the tour on 1/8/13 between 9:30 A.M. and 4:00 P.M. the following is observed:

1.) There is a weight scale being stored in front of the exit door in the Surgery Clinic, near Exam room #2.

2.) There are pallets, trash containers and other combustibles being stored in the exit corridor outside of the laundry/housekeeping areas in the basement.

Adminisrative Staff A and Maintanence Staff A were present and acknowledged the findings. Surgery Staff members moved the scale at the time of discovery and was verified by surveyor.

NFPA Standard: Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1

Based on records review and staff interview the facility failed to ensure that battery powered emergency lighting is tested as required and documented. This deficient practice could result in the lights not operating for the minimum required time in the event of an emergency. This deficient practice would affect 24 patients and all occupants in eight of eight smoke zones. The facility has a capacity of 24 and a census of 12.

Findings Include:

During the tour on 1/8/13 between 9:30 A.M. and 4:00 P.M. the following is observed:

1.) Facility Documentation shows that no 30 second testing was done for November or December of 2012.

2.) There is no record available of emergency lighting being tested for 90 minutes within the last year.

Adminisrative Staff A and Maintanence Staff A were present and acknowledged the findings.

NFPA Standard: A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 and 1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 2000 NFPA 101, 7.9.3 and 7.10.9

Based on record review and staff interview, the facility is not conducting fire drills as required quarterly on each shift and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency. This deficient practice would affect 24 patients and all occupants in eight of eight smoke zones. This facility has a capacity of 24 and a census of 12.

Findings Include:

During the tour on 1/8/13 between 9:30 A.M. and 4:00 P.M. the following is observed:

1.) There was no 2nd shift (7 p.m.-7 a.m.) fire drill performed during the 4th quarter of 2012.

Adminisrative Staff A and Maintanence Staff A were present and acknowledged the finding.

NFPA Standard: Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

Based on record review and staff interviews, the facility failed to assure that the sprinkler system is maintained and tested in accordance with the NFPA 13 and NFPA 25. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting 24 patients and all occupants in eight of eight smoke zones. This facility has a capacity of 24 and a census of 12.

Findings Include:

During the tour on 1/8/13 between 9:30 A.M. and 4:00 P.M. the following is observed:

1.) There is no record available of quarterly inspections being performed, available records only show an annual servicing/inspection.

2.) There are dirty sprinkler heads in the Laundry area and in room 004.

3.) The storage room 208 has a sprinkler head obstructed by items that are being stored within 18 inches of the sprinkler head.

Adminisrative Staff A and Maintanence Staff A were present and acknowledged the findings.

NFPA Standard: All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2000

Based on observation and staff interview, the facility did not ensure that electrical wiring and equipment is installed and maintained in accordance with NFPA 70, National Electrical Code. This deficient practice does not ensure prevention of an electrical fire or electric shock hazard, affecting zero patients and all occupants in three of eight smoke zones. This facility has a capacity of 24 and a census of 12.

Findings Include:

During the tour on 1/8/13 between 9:30 A.M. and 4:00 P.M. the following is observed:

1.) There is an open junction box in the ceiling area of the Engineering Shop, above the main electrical panels.

2.) There is an extension cord being used as permanent wiring in the Outpatient Clinic office and in the Southeast corner office of the Business Office.

Adminisrative Staff A and Maintanence Staff A were present and acknowledged the findings.

NFPA Standard: All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where used, metal covers shall comply with the grounding requirements of 250.110. 2000 NFPA 70, 314.28 (C).

Based on observation, record review and staff interviews, the facility failed to assure that penetrations in the 2 hour fire separation wall between the hospital and the Family Practice are properly sealed. This deficient practice of allowing improperly sealed penetrations in a 2 hour fire wall for occupancy separation will allow smoke and fire products to move from one occupancy to the other occupancy affecting zero patients and all occupants in one of eight smoke zones on the 1st floor. The facility has a capacity of 24 with a census of 12.

Findings Include:

During the tour on 1/8/13 between 9:30 A.M. and 4:00 P.M. the following is observed:

1.) There are penetrations around cables/wiring above the ceiling tile assembly above the CCFP hallway entry doors on the Hospital side of the 2 hour fire wall.

Adminisrative Staff A and Maintanence Staff A were present and acknowledged the finding.

NFPA Standard: Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2 hour fire resistance rating and constructed of materials as required for the addition. Communicating openings in the fire barriers shall be permitted only in corridors and protected by approved self closing fire doors. 2000 NFPA 101, 18/19.1.1.4.1 and 18/19.1.1.4.2.

Based on observation and staff interview the facility fails to maintain the integrity of the building construction by allowing gaps around sprinkler and other piping to remain open in the ceiling. This deficient practice would allow fire products to spread to the attic area, affecting 24 patients and all occupants in three of eight smoke zones. The facility has a capacity of 24 and census of 12.

Findings Include:

During the tour on 1/8/13 between 9:30 A.M. and 4:00 P.M. the following is observed:

1.) There are gaps around sprinkler piping, escutcheons and other piping passing through the ceiling into the attic area at the following locations: CCFP hallway entrance, Room 009, Radiology Check-in Office.

2.) There is an unprotected opening in the ceiling of the basement Engineering Shop leading up to the first floor around Tub plumbing.

Adminisrative Staff A and Maintanence Staff A were present and acknowledged the findings.

NFPA Standard: One story is permitted with complete sprinkler coverage and one-hour rated ceilings for all parts of a facility composed of wood frame construction, type V (111). 2000 NFPA 101, table 18/19.1.6.2

Based on observation and staff interview the facility fails to maintain smoke barriers to at least one half hour fire resistance and ensure that all penetrations are properly sealed. This deficient practice would prevent containment of fire and smoke, affecting 24 patients and all occupants in eight of eight smoke zones. This facility has a capacity of 24 and census of 12 residents.

Findings Include:

During the tour on 1/8/13 between 9:30 A.M. and 4:00 P.M. the following is observed:

1.) There are unprotected gaps and/or penetrations around cables/wiring above the data equipment room door on the South smoke barrier wall in the Engineering room.

2.) There are unprotected gaps and/or penetrations around cables/wiring on all four smoke barrier walls of Room 010.

3.) There are unprotected gaps and/or penetrations around cables/wiring above the ceiling tile assembly above the smoke barrier doors near the Laboratory, Room 300, and the O.B. Doctors' Lounge.

4.) There are unprotected gaps and/or penetrations around pipes/conduit in the basement smoke barrier wall near the IT/ Medical records office and near the old Wood shop.

Adminisrative Staff A and Maintanence Staff A were present and acknowledged the findings.

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1.

Based on observation and staff interview the facility failed to ensure proper separation of hazardous areas from other spaces. This deficient practice would allow for the spread of smoke and fire to travel into the adjacent area in one of eight smoke zones, affecting zero patients but all occupants. The facility has a capacity of 24 in patients with a census of 12.

Findings Include:

During the tour on 1/8/13 between 9:30 A.M. and 4:00 P.M. the following is observed:

1.) The basement storage room near the service elevator has a door leading to the exit corridor that has no self-closure device or door knob/latching mechanism.

2.) Room 004 is being used as general storage has no self-closure device on the door.

Adminisrative Staff A and Maintanence Staff A were present and acknowledged the findings.

NFPA Standard: Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4. 2000 NFPA 101, 39.3.2.1.

Based on observation and staff interview, the facility failed to provide means of egress that are maintained free of all obstructions or impediments to a full instant use in case of fire or other emergency. The deficient practice would prevent these exits from being arranged so that they are readily available and accessible in two of eight smoke zones, affecting zero patients but all occupants. This facility has a capacity of 24 and a census of 12.

Findings Include:

During the tour on 1/8/13 between 9:30 A.M. and 4:00 P.M. the following is observed:

1.) There is a weight scale being stored in front of the exit door in the Surgery Clinic, near Exam room #2.

2.) There are pallets, trash containers and other combustibles being stored in the exit corridor outside of the laundry/housekeeping areas in the basement.

Adminisrative Staff A and Maintanence Staff A were present and acknowledged the findings. Surgery Staff members moved the scale at the time of discovery and was verified by surveyor.

NFPA Standard: Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1

Based on records review and staff interview the facility failed to ensure that battery powered emergency lighting is tested as required and documented. This deficient practice could result in the lights not operating for the minimum required time in the event of an emergency. This deficient practice would affect 24 patients and all occupants in eight of eight smoke zones. The facility has a capacity of 24 and a census of 12.

Findings Include:

During the tour on 1/8/13 between 9:30 A.M. and 4:00 P.M. the following is observed:

1.) Facility Documentation shows that no 30 second testing was done for November or December of 2012.

2.) There is no record available of emergency lighting being tested for 90 minutes within the last year.

Adminisrative Staff A and Maintanence Staff A were present and acknowledged the findings.

NFPA Standard: A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 and 1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 2000 NFPA 101, 7.9.3 and 7.10.9

Based on record review and staff interview, the facility is not conducting fire drills as required quarterly on each shift and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency. This deficient practice would affect 24 patients and all occupants in eight of eight smoke zones. This facility has a capacity of 24 and a census of 12.

Findings Include:

During the tour on 1/8/13 between 9:30 A.M. and 4:00 P.M. the following is observed:

1.) There was no 2nd shift (7 p.m.-7 a.m.) fire drill performed during the 4th quarter of 2012.

Adminisrative Staff A and Maintanence Staff A were present and acknowledged the finding.

NFPA Standard: Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

Based on record review and staff interviews, the facility failed to assure that the sprinkler system is maintained and tested in accordance with the NFPA 13 and NFPA 25. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting 24 patients and all occupants in eight of eight smoke zones. This facility has a capacity of 24 and a census of 12.

Findings Include:

During the tour on 1/8/13 between 9:30 A.M. and 4:00 P.M. the following is observed:

1.) There is no record available of quarterly inspections being performed, available records only show an annual servicing/inspection.

2.) There are dirty sprinkler heads in the Laundry area and in room 004.

3.) The storage room 208 has a sprinkler head obstructed by items that are being stored within 18 inches of the sprinkler head.

Adminisrative Staff A and Maintanence Staff A were present and acknowledged the findings.

NFPA Standard: All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2000

Based on observation and staff interview, the facility did not ensure that electrical wiring and equipment is installed and maintained in accordance with NFPA 70, National Electrical Code. This deficient practice does not ensure prevention of an electrical fire or electric shock hazard, affecting zero patients and all occupants in three of eight smoke zones. This facility has a capacity of 24 and a census of 12.

Findings Include:

During the tour on 1/8/13 between 9:30 A.M. and 4:00 P.M. the following is observed:

1.) There is an open junction box in the ceiling area of the Engineering Shop, above the main electrical panels.

2.) There is an extension cord being used as permanent wiring in the Outpatient Clinic office and in the Southeast corner office of the Business Office.

Adminisrative Staff A and Maintanence Staff A were present and acknowledged the findings.

NFPA Standard: All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where used, metal covers shall comply with the grounding requirements of 250.110. 2000 NFPA 70, 314.28 (C).