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Based upon observation, records review and staff interview the facility failed to maintain proper separation between the Hospital proper and other attached, non-hospital use buildings. This condition affects 1 of 9 smoke zones provided. Facility has a capacity of 107 and a census of 18 at the time of the inspection.

During the tour on December 21, 2010 between 8 AM and 4 PM the following condition was identified:

Findings Include:

A.] 2 hour fire wall between building D [MOB] and building A [Hospital] had unsealed penetrations in the wall and improper installation and maintenance of a small [8 by 8 inch] fire damper.

Facility staff M and M1 were also present and are aware of the finding.

Based on observation and staff interview, the facility is not providing appropriate construction standards as required by life safety code. A rated ceiling assembly is not provided as required by the building's construction type, which would not prevent the spread of smoke and/or fire, affecting 2 of 9 smoke zones. The facility has a capacity of 107 and a census of 1 at the time of this survey.

Findings Include:

During the facility tour on December 20 and 21, 2010, between the hours of 8 am and 4 pm on both days, the following conditions were observed:

A.] Missing ceiling tile in IT/Server room;

B.] Ceiling tile missing in the Emergency Room mop closet.

Facility staff M and M1 were both present at the time of these findings and are aware of these issues.

Based upon observation and staff interview, the facility failed to maintain the integrity of a required corridor smoke barrier as prescribed. Specific doors observed were found wedged open. This deficient practice fails to prevent the spread of smoke and/or fire, affecting 2 of 9 smoke zones. The facility has a capacity of 107 and a census of 18 at the time of this inspection.

FINDINGS INCLUDE:

During the facility tour on 12/21/2010, between 8 am and 4 PM, the following conditions were observed:

1. 20 minute rated door to infusion room was found in wedged open position.

The described conditions were also observed and acknowledged by Facility Staff M and M1.

Based upon records review and staff interview the facility failed to properly test portions of the required fire alarm system. This deficiency does not ensure the reliability of the alarm system in the event of an emergency, affecting one of nine smoke zones. The facility has a capacity of 107 and a census of 18 at the time of this survey.

Findings include:

During records review conducted on 12/20/2010 between 8 am and 4 PM, the following condition was identified:

1.] Manual pull station M1-97 was identified on latest annual test report as not having been tested, due to being inaccessible.

2.] Additionally, several smoke detectors were identified as not being tested due to being inaccessible.

Facility staff M and M1 have been made aware of this finding. Staff indicated that these conditions are the result of recently completed construction/remodel efforts. The smoke detectors were temporary for construction and will be or have been removed. The pull station still exists and needs testing.

Based upon observation and staff interview the facility failed to properly install and maintain automatic fire sprinkler systems and components as required by NFPA 13 and NFPA 25. These conditions identified fail to ensure that the suppression system will operate properly in the event of fire, affecting 9 of 9 smoke zones. The facility has a capacity of 107 and a census of 18 at the time of this survey.

Findings include:

During the facility tour on December 20 and 21, 2010, between the hours of 8 am and 4 PM on both days, the following conditions were identified:

A.] future chiller room in building C - no sprinkler head under obstructive HVAC at NE entrance;

B.] Housekeeping area in building C had lint on sprinkler head above domestic dryer;

C.] Mechanical room north of clean linen room - no sprinkler head provided;

D.] Pathology lab office, no sprinkler head in small closet;

E.] Stair "D" on ground floor missing sprinkler head in north side of stair enclosure area, evaluate all stairs for proper coverage;

F.] No hydraulic data plate for MRI pre-action sprinkler system;

G.] two heads found obstructed by materials in the south dry goods storage room of the kitchen support area;

H.] No sprinkler at upper level of south stair on level 3;

I.] upright sprinkler head in Stair B did not provide proper area coverage inside stair.

Facility staff M and M1 were both present at the time of these findings and are aware of these issues. Facility staff M contacted sprinkler service contractor and reported many of these issues to the service provider and obtained commitment for rapid response and corrective action on most issues identified. Facility demonstrated excellent working relationship with sprinkler service contractor.

Based upon observation, records review and staff interview; the facility failed to provide required water supply for fire sprinkler systems. This deficiency will not ensure that the sprinkler system will function properly in the event of a fire, affecting 9 of 9 smoke zones. Facility has a capacity of 107 and a census of 18 at the time of this survey.

Findings include:

During the facility tour on December 21, 2010, between 8 am and 4 PM the following condition was identified:

A.] Hydraulic data plate on supply main at north end of building A indicates requirement for 229.24 GPM ad 49.47 PSI at base of riser; quarterly sprinkler test reports indicate average of 40 PSI residual pressure available with lesser flows being established. Facility needs to resolve any pressure issues.

Facility staff M and M1 were present at the time of the discovery of this issue and are aware of inspector's concerns.

Based upon observation and staff interview the facility failed to properly install a fire extinguisher as required by NFPA 10. This deficiency may prevent the portable fire extinguisher from being readily accessible due to difficulty retrieving it from the mounting bracket. The condition observed affects only one of nine smoke zones. The facility has a capacity of 107 and a census of 18 at the time of the survey.

Findings include:

During the facility tour on 12/21/2010, between 8 AM and 4 PM the following condition was identified:

1.] The Carbon Dioxide fire extinguisher located inside of the IT/Server room is mounted higher than allowed by NFPA 10.

Facility staff M and M1 were present and are aware of the finding.

Based upon observation and staff interview the facility failed to maintain proper storage practices for portable oxygen cylinders. This deficient practice does not ensure that medical gas storage is protected in accordance with NFPA 99. The condition observed affects one of nine smoke zones. The facility has a capacity of 107 and a census of 18 at the time of this survey.

Findings include:

During the facility tour on 12/21/2010, between 8 am and 4 PM the following condition was identified:

1. ] two small oxygen cylinders were found to be unsecured in the north foyer area of the emergency room.

Facility staff M and M1 were also present and are aware of this finding.

Based upon observation and staff interview the facility failed to maintain electrical installations as
prescribed by NFPA 70. These conditions observed could cause an electrical fire or equipment failure, affecting only 1 of 9 smoke zones. The facility has a capacity of 107 and a census of 18 at the time of the survey.

Findings include:

During the facility tour on 12/20-21/2010, between 8 AM and 4 PM the following conditions were identified:

A.] Ceiling mounted, J-box cover missing between boilers;

B.] temporary cord use and series use of power strips observed in phone/FACP room;

C.] Mechanical room between dry goods storage rooms in kitchen support area has missing J-box cover on south wall of room.

Facility staff M and M1 were present and are aware of these findings.

Based upon observation, records review and staff interview the facility failed to maintain proper separation between the Hospital proper and other attached, non-hospital use buildings. This condition affects 1 of 9 smoke zones provided. Facility has a capacity of 107 and a census of 18 at the time of the inspection.

During the tour on December 21, 2010 between 8 AM and 4 PM the following condition was identified:

Findings Include:

A.] 2 hour fire wall between building D [MOB] and building A [Hospital] had unsealed penetrations in the wall and improper installation and maintenance of a small [8 by 8 inch] fire damper.

Facility staff M and M1 were also present and are aware of the finding.

Based on observation and staff interview, the facility is not providing appropriate construction standards as required by life safety code. A rated ceiling assembly is not provided as required by the building's construction type, which would not prevent the spread of smoke and/or fire, affecting 2 of 9 smoke zones. The facility has a capacity of 107 and a census of 1 at the time of this survey.

Findings Include:

During the facility tour on December 20 and 21, 2010, between the hours of 8 am and 4 pm on both days, the following conditions were observed:

A.] Missing ceiling tile in IT/Server room;

B.] Ceiling tile missing in the Emergency Room mop closet.

Facility staff M and M1 were both present at the time of these findings and are aware of these issues.

Based upon observation and staff interview, the facility failed to maintain the integrity of a required corridor smoke barrier as prescribed. Specific doors observed were found wedged open. This deficient practice fails to prevent the spread of smoke and/or fire, affecting 2 of 9 smoke zones. The facility has a capacity of 107 and a census of 18 at the time of this inspection.

FINDINGS INCLUDE:

During the facility tour on 12/21/2010, between 8 am and 4 PM, the following conditions were observed:

1. 20 minute rated door to infusion room was found in wedged open position.

The described conditions were also observed and acknowledged by Facility Staff M and M1.

Based upon records review and staff interview the facility failed to properly test portions of the required fire alarm system. This deficiency does not ensure the reliability of the alarm system in the event of an emergency, affecting one of nine smoke zones. The facility has a capacity of 107 and a census of 18 at the time of this survey.

Findings include:

During records review conducted on 12/20/2010 between 8 am and 4 PM, the following condition was identified:

1.] Manual pull station M1-97 was identified on latest annual test report as not having been tested, due to being inaccessible.

2.] Additionally, several smoke detectors were identified as not being tested due to being inaccessible.

Facility staff M and M1 have been made aware of this finding. Staff indicated that these conditions are the result of recently completed construction/remodel efforts. The smoke detectors were temporary for construction and will be or have been removed. The pull station still exists and needs testing.

Based upon observation and staff interview the facility failed to properly install and maintain automatic fire sprinkler systems and components as required by NFPA 13 and NFPA 25. These conditions identified fail to ensure that the suppression system will operate properly in the event of fire, affecting 9 of 9 smoke zones. The facility has a capacity of 107 and a census of 18 at the time of this survey.

Findings include:

During the facility tour on December 20 and 21, 2010, between the hours of 8 am and 4 PM on both days, the following conditions were identified:

A.] future chiller room in building C - no sprinkler head under obstructive HVAC at NE entrance;

B.] Housekeeping area in building C had lint on sprinkler head above domestic dryer;

C.] Mechanical room north of clean linen room - no sprinkler head provided;

D.] Pathology lab office, no sprinkler head in small closet;

E.] Stair "D" on ground floor missing sprinkler head in north side of stair enclosure area, evaluate all stairs for proper coverage;

F.] No hydraulic data plate for MRI pre-action sprinkler system;

G.] two heads found obstructed by materials in the south dry goods storage room of the kitchen support area;

H.] No sprinkler at upper level of south stair on level 3;

I.] upright sprinkler head in Stair B did not provide proper area coverage inside stair.

Facility staff M and M1 were both present at the time of these findings and are aware of these issues. Facility staff M contacted sprinkler service contractor and reported many of these issues to the service provider and obtained commitment for rapid response and corrective action on most issues identified. Facility demonstrated excellent working relationship with sprinkler service contractor.

Based upon observation, records review and staff interview; the facility failed to provide required water supply for fire sprinkler systems. This deficiency will not ensure that the sprinkler system will function properly in the event of a fire, affecting 9 of 9 smoke zones. Facility has a capacity of 107 and a census of 18 at the time of this survey.

Findings include:

During the facility tour on December 21, 2010, between 8 am and 4 PM the following condition was identified:

A.] Hydraulic data plate on supply main at north end of building A indicates requirement for 229.24 GPM ad 49.47 PSI at base of riser; quarterly sprinkler test reports indicate average of 40 PSI residual pressure available with lesser flows being established. Facility needs to resolve any pressure issues.

Facility staff M and M1 were present at the time of the discovery of this issue and are aware of inspector's concerns.

Based upon observation and staff interview the facility failed to properly install a fire extinguisher as required by NFPA 10. This deficiency may prevent the portable fire extinguisher from being readily accessible due to difficulty retrieving it from the mounting bracket. The condition observed affects only one of nine smoke zones. The facility has a capacity of 107 and a census of 18 at the time of the survey.

Findings include:

During the facility tour on 12/21/2010, between 8 AM and 4 PM the following condition was identified:

1.] The Carbon Dioxide fire extinguisher located inside of the IT/Server room is mounted higher than allowed by NFPA 10.

Facility staff M and M1 were present and are aware of the finding.

Based upon observation and staff interview the facility failed to maintain proper storage practices for portable oxygen cylinders. This deficient practice does not ensure that medical gas storage is protected in accordance with NFPA 99. The condition observed affects one of nine smoke zones. The facility has a capacity of 107 and a census of 18 at the time of this survey.

Findings include:

During the facility tour on 12/21/2010, between 8 am and 4 PM the following condition was identified:

1. ] two small oxygen cylinders were found to be unsecured in the north foyer area of the emergency room.

Facility staff M and M1 were also present and are aware of this finding.

Based upon observation and staff interview the facility failed to maintain electrical installations as
prescribed by NFPA 70. These conditions observed could cause an electrical fire or equipment failure, affecting only 1 of 9 smoke zones. The facility has a capacity of 107 and a census of 18 at the time of the survey.

Findings include:

During the facility tour on 12/20-21/2010, between 8 AM and 4 PM the following conditions were identified:

A.] Ceiling mounted, J-box cover missing between boilers;

B.] temporary cord use and series use of power strips observed in phone/FACP room;

C.] Mechanical room between dry goods storage rooms in kitchen support area has missing J-box cover on south wall of room.

Facility staff M and M1 were present and are aware of these findings.