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Based on observation and interview, the facility is not providing a firewall with a two-hour rating between the hospital and business occupancy (clinic). The wall is penetrated above the lay-in ceiling tile with building services. This deficient practice would affect all occupant including staff, visitors and patients. This facility has 99 certified beds and at the time of the survey the census was 38.

Findings include:

Observations and interview on 2/27/13, revealed a gap (approximately 1/2 inch in size) around a penetration containing two cables above the fire doors. Maintenance Staff A verified this observation
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Based on observation and interview, it was determined the facility is a three-story building and consisted of Type II construction. The facility failed to assure minimum building construction requirements were maintained. This facility has a capacity of 99 patients and at the time of the survey the census was 38.

Findings include:

Observation and interview on 2/27/13, revealed a hole (approximately 2 inches in size) behind the door in Break Room 2602. Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to provide an interior finish of corridor walls with a flame spread rating of class A, B, or C. This facility has 99 certified beds and at the time of the survey the census was 38.

Findings include:

Observation and interview on 2/27/13, revealed the facility was not able to provide the flame spread rating for the decorative wood on the corridor wall going into the Women's Center. Maintenance Staff A verified this observation.

Based on observation and interview, the facility is not ensuring that doors to resident rooms, offices and other ancillary areas are free of impediments that would prevent the doors from being closed or that the doors are provided with suitable hardware that keep the doors shut tightly in their frames. This facility has 99 certified beds and at the time of the survey the census was 38.

Findings include:

1. Observation and interview on 2/27/13, revealed the corridor door to Room 2815 contained two holes (approximately 1/4 inch in size) above the door handle.
2. Observation and interview on 2/27/13, revealed the door to Room 2625 failed to latch properly when tested.
3. Observation and interview on 2/27/13, revealed the closet door in the Dietician's Office (Room 1811) obstructed the closing of the corridor door.
4. Observation and interview on 2/27/13, revealed a door wedge being used to prop open the door to Room 1642.
5. Observation and interview on 2/27/13, revealed a door wedge being used to prop open the door to Room 1340 located in the Abben.

Maintenance Staff A verified these observations.

Based on observation and interview, this facility is not assuring that smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone. This facility has 99 certified beds and 38 patients.

Findings include:

Observation and interview on 2/27/13, revealed the following penetrations above the smoke doors outside of RT: 1/2 inch penetration surrounding two 1" copper pipes, 1/4 inch penetration surrounding a 2" conduit sleeve, and a 5 inch by 5 inch hole surrounding a 1/2 inch metal conduit. Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to maintain the fire doors to close and resist the passage of smoke. This facility has 99 certified beds and at the time of the survey the census was 38.

Findings include:

1. Observations and interview on 2/27/13, reveled the fire door next to Room 2625 did not latch properly when tested.
2. Observations and interview on 2/27/13, revealed the fire door in the 1st Floor South Hallway did not latch properly when tested.
3. Observations and interview on 2/27/13, revealed the fire doors going into the Women's Center (by Room 1702) did not latch properly when tested.
4. Observations and interview on 2/27/13, revealed the fire doors by Room 1645 did not latch properly when tested.
5. Observations and interview on 2/27/13, revealed the fire door to the Elevator B Stairwell #6 did not latch properly when tested.
6. Observations and interview on 2/27/13, revealed the fire door to Stairwell #10 did not latch properly when tested.
7. Observations and interview on 2/27/13, revealed L725 Fire Door did not latch properly when tested.
8. Observations and interview on 2/27/13, revealed a one inch hole surrounding a five inch sprinkler pipe in the West Wall of Stairwell 5, Main Level.


Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. This facility has 99 certified beds and at the time of the survey the census was 38.

Findings include:

1. Observation and interview on 2/27/13, revealed the absence of a self-closing device on the door to OR Storage (1st Floor).
2. Observation and interview on 2/27/13, revealed door wedges propping open the two doors to the Kitchen which opens into the corridor.
3. Observation and interview on 2/27/13, revealed a hole (approximately 1/2 inch in size) next to a conduit in the HR Storage Room located in the Basement.
4. Observation and interview on 2/27/13, revealed multiple penetrations in Electrical Equipment Room L407.
5. Observation and interview on 2/27/13, revealed a gap (approximately 1 inch in size) around penetration above the door in Mechanical Equipment Room L402.


Maintenance Staff A verified these observations.

(A)
Based on observation and interview, the facility is not assuring that a prompt and safe exit from all locked rooms can be achieved. This facility has 99 certified beds and a census of 38.

Findings include:

1. Observation and interview on 2/27/13, revealed padlocks on doors in the following areas: '64 Building File Storage, Basement Phone Room and Door going to Phone Room area.
2. Observation and interview on 2/27/13, revealed that many office doors and storage room doors located throughout the building were equipped with deadbolt locks on the corridor doors which required more than a single action to open the door if the deadbolt lock was in the locked position.

Maintenace Staff A and B verified these observations.

(B)
Based on observation and interview, the facility failed to maintain a clear path from an exit to a public way. This facility has 99 certified beds and at the time of the survey the census was 38.

Findings include:

1. Observation and interview on 2/27/13, revealed the path from the Dining Room exit door leading into the Courtyard and to a public way was obstructed with snow. This area has not been maintained free of snow and ice. According to the facility layout, this is a required exit.
2. Observation and interview on 2/27/13, revealed three oxygen tanks being stored in the path of egress from the Cardiac Rehab Room in the Athletic Enhancement Area.

Maintenance Staff A verified these observations.

Based on observation and interview, the facility is not ensuring that patient room doors are arranged such that the patients can open the door from inside without the use of a key or special knowledge. This facility has 99 certified beds and at the time of the survey, the census was 38.

Findings include:

1. Observation and interview on 2/27/13, revealed that many patient room doors were equipped with a deadbolt lock that did not release with a single action turn of the door handle. This type of hardware was located throughout the building.
2. Observation and interview on 2/27/13, revealed the Seclusion Room located in the Mental Health Wing was equipped with a deadbolt lock instead of the required hardware that requires a staff member to hold the door handle in the locked position to prevent a patient from accidentally being left in seclusion room unattended.

Maintenance Staff A and B verified these observations.

Based on observation, record review and interview, the facility failed to maintain the emergency egress lighting as required. This deficient practice affects all occupants of the building. This facility has a capacity of 99 patients and a census of 38.

Findings include:

1. Observation, interview and record review on 2/27/13, revealed the absence of documentation to verify that 30 second monthly tests are being performed on all emergency lights located throughout the entire building.
2. Observation, interview and record review on 2/27/13, revealed the absence of documentation to verify that a 90 minute annual test has been performed within the last 12 months on all emergency lights located throughout the entire building.
3. Observation and interview on 2/27/13, revealed the emergency lights in OR Storage Room 2 (1st Floor) did not illuminate properly when tested.
4. Observation and interview on 2/27/13, revealed the emergency lights in OR Storage Room 3 (1st Floor) did not illuminate properly when tested.
5. Observation and interview on 2/27/13, revealed the emergency lights in OR Storage Room 4 (1st Floor) did not illuminate properly when tested.
6. Observation and interview on 2/27/13, revealed all the emergency lights located in the Abben Link were not being tested. During the survey process, we were not able to test these lights to test for functionality due to the height of the ceiling.
7. Observation and interview on 2/27/13, revealed the emergency light located in Mechanical Room 1338 (Abben) did not operate properly when tested.
8. Observation and interview on 2/27/13, revealed the two sets of emergency lights located in the Vault (Abben) did not operate properly when tested.
9. Observation and interview on 2/27/13, revealed the emergency light located in the Athletic Enhancement Area did not operate properly when tested.
10. Observation and interview on 2/27/13, revealed two emergency lights located in HIMS did not operate properly when tested.

Administrative Staff A and Maintenance Staff A verified these observations.

Based on observation and interview, the facility is not providing a directional exit sign at both ends of a hall. This facility has 99 certified beds and at the time of the survey the census was 38.

Findings include:

Observation and interview on 2/27/13, revealed a missing exit sign above the fire doors located by Room 2625. Maintenance Staff A verified this observation.

Based on record review and staff interview, the facility is not conducting fire drills at least quarterly on each shift as required. This 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 99 patients and a census of 38.

Findings include:

Record review and staff interview on 2/27/13, revealed the facility failed to perform a fire drill in the 4th quarter on the third shift. Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to provide and maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code 1999 edition. This deficient practice affects all occupants of the building. This facility has 99 certified beds and at the time of the survey the census was 38.

Findings include:

Observation and interview on 2/27/13, revealed numerous fire alarm pull stations located throughout the entire building were mounted above the 4 1/2 foot maximum height allowed. Maintenance Staff A and B verified these deficiencies.

(A)
Based on observation and interview, the facility failed to properly protect and label the primary power supply for the fire alarm system in accordance with National Fire Protection Association (NFPA) 72, 1999 edition, 1-5.2.5.2 . This deficiency affects all occupants of the building. This facility has 99 certified beds and at the time of the survey the census was 38.

Findings include:

Observation and interview on 2/27/13, revealed the circuit breaker for the fire alarms primary power located in the Hot Mechanical Room (Breaker #9) was not mechanically protected or properly labeled. Maintenance Staff A verified this observation.

(B)
Based on observation and interview, the facility failed to provide a properly tested and maintained fire alarm system. The entire facility is affected by this deficient practice. This facility has 99 certified beds and at the time of the survey the census was 38.

Findings include:

Observation and interview on 2/27/13, revealed the main fire alarm control panel located in the Plant Operations Office is an area that is not continuously occupied and not electronically supervised by a smoke detector. Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13, Standard for the Installation of Sprinkler Systems, 1999 edition. This facility has a capacity of 99 patients and a census of 38.

Findings include:

Observation and interview on 2/27/13, revealed the Butler Elevator Shaft does not have sprinkler coverage. Maintenance Staff B verified this observation.

Based on record review, interview, and observation, the facility failed to maintain and test a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998 edition. All smoke compartments and all occupants could be affected by this deficient practice. This facility has 99 licensed beds and at the time of the survey the census was 38.

Findings include:

1. During record review, interview and observation of the facility's fire safety components on 2/27/13, revealed the absence of documentation to indicate that quarterly inspections of the sprinkler system had been performed on the 2nd and 4th quarters. Maintenance Staff A stated that quarterly inspections are conducted by Simplex Grinnell (sprinkler inspection company) but no documentation could be provided.
2. Observations and interview on 2/27/13, revealed a missing escutcheon ring located in the OR Storage Area.
3. Observations and interview on 2/27/13, revealed a missing escutcheon ring in the corridor by Room 1430 (near the two hour fire wall).

Based on observations, record review and interview, the facility failed to provide a commercial cooking suppression system that is tested and maintained as required. This facility has 99 certified beds and at the time of the survey, the census was 38.

Findings include:

1. Observations, record review and interview on 2/27/13, revealed the facility failed to perform and document monthly visual inspections of the ansul system.
2. Observations and interview on 2/27/13, revealed a cracked glass rod in the pull station for the ansul system located in the Kitchen.

Maintenance Staff A verified these observations.

Based on observations and interview the facility failed to provide window coverings that are flame retardant. This facility has 99 certified beds and at the time of the survey the census was 38.

Findings include:

1. Observation and interview on 2/27/13, revealed vinyl mini blinds located in the Plant Operations Office and were not tagged as being flame retardant.
2. Observation and interview on 2/27/13, revealed vinyl mini blinds located in the Mental Health Med Room and were not tagged as being flame retardant.
3. Observation and interview on 2/27/13, revealed vinyl mini blinds located in the Business Manager's Office and were not tagged as being flame retardant.

Maintenance Staff A verified these observations.

Based on observation and 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. This facility has 99 certified beds and at the time of the survey the census was 38.

Findings include:

1. Observation and interview on 2/27/13, revealed a missing blank in the electrical panel located in the Soiled Work Room in Mental Health.
2. Observation and interview on 2/27/13, revealed the facility failed to maintain a three foot clearance around the electrical panel in the Utility Room located by Room 2821.
3. Observation and interview on 2/27/13, revealed two holes in a junction box on the ceiling located in the Basement HR Storage Room.
4. Observation and interview on 2/27/13, revealed an outlet within 6 feet of a water source (sink by ice machine) in the 3rd Floor Dialysis which was not equipped with a GFCI outlet.
5. Observation and interview on 2/27/13, revealed an outlet within six feet of a water source (water fountain) in the 3rd Floor Administration area which was not equipped with a GFCI outlet.


Maintenance Staff A and B verified these observations.