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Based on observation, the facility failed to maintain the doors within a two-hour fire wall to close and latch properly. This facility has a capacity of 25 and a census of 19.

Findings include:

Observations on 8/31/10, revealed the fire doors in the two-hour fire wall separating the POB and Infill areas did not close and latch properly when tested.

Based on observations, it was determined the facility was a one-story building with basement composed of fire resistive construction. The facility failed to assure minimum building construction requirements were maintained by ensuring that holes and gaps around penetrations are sealed and with materials to limit the transfer of smoke and the suspended ceiling tile assembly was maintained. The facility has a capacity of 25 and that time of the survey had a census of 19.

Findings include:

1. Observations on 8/31/10, revealed a missing ceiling tile in the Conference Room Storage Room across from Oncology.

2. Observations on 8/31/10, revealed a displaced ceiling tile by the corridor door from the Oncology/Sleep Study Clinic.

3. Observations on 8/31/10, revealed a gap (approximately 1/2 inch in size) around a medical gas pipe penetration above the corridor door in the basement Mechanical Room.

4. Observations on 8/31/10, revealed a gap (approximately 1/2 in size) around a conduit penetration above the door from the Medical Gas Storage Room.

Based on observations, the facility failed to separate the corridors from other areas by partitions complying with 19.3.6.2 through 19.3.6.5 of the 2000 Life Safety Code. In fully sprinklered smoke compartments, partitions are only required to resist the passage of smoke. Charting and clerical stations, waiting ares, dining rooms, and activity spaces may be open to the corridor under certain conditions specified in the Life Safety Code. This facility has a capacity of a 25 and had a census of a 19.

Findings include:

1. Observations on 8/31/10, revealed the Vending Machine Room in the basement was open to the corridor. The room and corridor were equipped with sprinkler heads, and the corridor was provided with some some smoke detection.

2. Observations on 8/31/10, revealed the Admissions Office open to the corridor. The office and the corridor were provided with sprinkler heads and the lobby area in which the office opened on to was provided with smoke detection. Absent from the Admissions Office was smoke detection.

Based on observations, the facility is not ensuring that doors to rooms are provided with suitable hardware that keep the doors shut tightly into their frames. This deficient practice would not prevent the spread of fire and smoke. The facility has a capacity for 25 and at the time of the survey the census was 19.

Findings include:

1. Observations on 8/31/10, revealed the corridor door to Room 128 did not close and latch properly when tested.

2. Observations on 8/31/10, revealed the latch had been taped down on the corridor door to the Women's Locker Room in the PAV area and prevented it from closing and latching properly.

Based on observation and interview, the facility failed to maintain smoke doors to close and resist the passage of smoke. The smoke doors affected two of the eight smoke compartments on the first floor. The facility has 25 certified beds and at the time of the survey the census was 19.

Findings include:

Observations on 8/31/10, while testing the smoke doors, the doors by the Pharmacy did not close and latch properly.

Based on observations, the facility is not providing unobstructed corridors that provides a clear path of egress for 1 of 8 smoke zones on the first floor. This facility has a capacity of 25 with a census of 19 residents.

Findings include:

Observations on 8/31/10, revealed the hinged charting station in the corridor by Room 106 had not been provided with a self-closing device.

Based on record review and staff interview, the facility failed to properly test the emergency egress lighting in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition, 7.9.3. 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 1/2 hours. The facility also failed to maintain the battery emergency lighting system to operate properly. This deficient practice affects all occupants of the facility. This facility has a capacity of 25 and a census of 19.

Findings include:

1. Observation of the facility's maintenance records and staff interview on 8/31/10, revealed no documentation of the 30-day, 30 second test of the emergency battery lighting units had been completed. Also no documentation could be provided to show an annual test for 90 minutes. Maintenance Staff A reported it had not been completed at the time of the survey.

2. Observations on 8/31/10, revealed the emergency light unit in the Fitness Storage Room did not operate properly when tested.

Based on record review, the facility failed to inspect and test the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, 1999 edition, Chapter 7. The fire alarm system shall be inspected and tested at the frequencies established in Chapter 7. This deficient practice affects all occupants of the facility. The facility has a capacity of 25 and at the time of the survey had a census of 19.

Findings include:

Record review of the fire alarm test records on 8/31/10, revealed the following had been documented on the fire alarm inspection report: " The smoke detector mounted sideways in the skylight can not be tested as the tested has to be straight up to work when testing the smoke detector." "One fixed temp heat detector in lower level mechanical room which is non restore able type therefore not able to test it. One rate of rise heat detector in mechanical room had pipe work in the way and tester could not access it to test it." The facility did not provide documentation to show these devices had been inspected or tested.

Record review on 8/31/10, also revealed the reports failed to properly document the inspection and testing of the fire alarm components as required. Review of the 3/24/10 inspection report from Simplex Grinnell showed no documentation of the heat detectors, duct detectors, and pull stations. And, no information was included on either the 3/24/10 or 10/29/09 report on the sprinkler system components such as the waterflow switch or tamper devices. Also absent from the report were the wet chemical suppression system and the FM 200 systems.

(A)
Based on record review, the facility failed to maintain and test smoke detectors for sensitivity in accordance with NFPA 72, 7-3.2.1. This deficient practice affects 4 of 35 photoelectric smoke detectors and 68 of 68 analog smokes detectors and all occupants of the building could be affected by the deficient practice. The facility census is 19 with a capacity of 25.

Findings include:

Record review of the fire alarm test records showed 4 of 35 photoelectric smoke detectors had not been tested for sensitivity during the previous test and 68 of 68 analog detectors had also not been tested. The following was documented on the fire alarm inspection in reference to the analog detectors: "Some of the smoke detectors are analog type that do not require sensitivity testing, cleaning will be done if necessary."

(B)
Based on observation, this facility is not assuring that the fire alarm system is installed and maintained in accordance with National Fire Protection Association (NFPA) 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer that three feet to air supply or air return. This facility has a capacity of 25 and a census of 19.

Findings include:

Observations on 8/31/10, revealed the smoke detectors the following areas had been installed within 36 inches of an air supply or air return: lower level in the corridor by I.T., corridor by Oncology Reception, elevator lobby in the basement by the Conference Room, main corridor of Radiology by the Film Storage Room and POB Janitor's Closet.

Based on observation, the facility failed to install the sprinkler system in accordance with the National Fire Protection Association (NFPA) Standard 13, Standard for the Installation of Sprinkler Systems, 1999 edition. This facility has a capacity of 25 and a census of 19.

Findings include:

Observations on 8/31/10, revealed the walk-in cooler and walk-in freezer located in the Kitchen were not equipped with sprinkler heads and the facility is classified as fully sprinkled facility.

Based on observation, the facility is not providing an electrically supervised valve for the part of the sprinkler system in the Kitchen. In the event that the water supply is turned off at this valve, an alarm will not notify the occupants of the building of the trouble. This deficient practice effects all staff, visitors and residents, in this facility with a capacity of 25 and a census of 19.

Findings include:

Observations on 8/31/10, revealed the valve for the antifreeze loop for the sprinkler piping to the loading dock was not equipped with a tamper switch that was electrically supervised to sound an alarm. In the event that the water supply was turned off at this valve, an alarm would not notify the building occupants or the fire alarm monitoring company of the trouble.

Based on record review, the facility failed to inspect, test and maintain a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998 edition, Chapter 2. Inspection and periodic testing determine what, if any, maintenance action is required to maintain the operability of a water-based fire protection system. All components and systems shall be tested to verify that they function as intended. All smoke compartments in the building and all residents and staff could be affected by the deficient practice. The facility has 25 certified beds and at the time of the survey the census was 19.

Findings include:

1. During the record review of the facilities fire safety components on 8/31/10, revealed the facility was unable to produce a copy of the annual inspection report of the sprinkler system. Record review also showed all quarterly inspections had been completed as required.

2. Observations on 8/31/10, revealed a television had been mounted within 18 inches of a sprinkler head in the Oncology Clinic.

3. Observations at the time of inspection revealed a missing escutcheon ring around the sprinkler head in the Radiology Bathroom.

Based on observations, the facility failed to maintain one portable fire extinguisher in accordance with National Fire Protection Association (NFPA) Standard 10, Standard for Portable Fire Extinguishers, 1998 edition. The facility has a capacity of 25 and at the time of the survey process the census was 19 residents.

Findings include:

Observations on 8/31/10, revealed damage to the tank of the fire extinguisher in the Kitchen.

Based on observations and record review the facility failed to maintain the enclosure of the clean agent fire extinguishing system in accordance with National Fire Protection Association (NFPA) Standard 2001, Standard on Clean Agent Fire Extinguishing Systems. To prevent loss of agent through openings to adjacent hazards or work areas, openings shall be permanently sealed or equipped with automatic closures. The protected enclosure shall have the structural strength and integrity necessary to contain the agent discharge. The facility has a capacity of 25 and at the time of the survey had a census of 19.

Findings include:

Observations and record review on 8/31/10, revealed gaps around penetrations and holes in the suspended ceiling tiles of the Basement Maintenance Area, Upper I.T. Room and Admissions Upper I.T. Room. Record review of the FM 200 inspection reports revealed the following deficiency had been noted: "All opening into ceiling should be plugged to prevent FM-200 _____ in the event of discharge."

(B)
Based on observation, the facility failed to maintain and test the battery operated smoke detectors located in the ER Soiled Linen Room and first floor Women's Bathroom. This facility has a capacity of 25 and a census of 19.

Findings include:

Observations of a battery operated smoke detector in the Er Soiled Linen Room and first floor Women's Bathroom on 8/31/10, revealed they did not operate properly when tested.

(C)
Based on staff interview and record review, this facility is not assuring that policies are in place regarding the procedures to be taken in the event of laboratory emergencies. The lack of procedures could effect the actions taken by staff in the event of an emergency. This facility has a capacity of 25 with a census of 19.

Findings include:

Record review and staff interview on 8/31/10, revealed the facility was unable to produce policies regarding the procedures to be taken in the event of a laboratory emergency.

Based on observation and staff interview, the facility failed to provide a remote annunciator panel for the emergency generator in accordance with National Fire Protection Association (NFPA) Standards 99, 1999 edition. The absence of a remote annunciator for the emergency generator would affect all smoke compartments and all of the facility residents and staff. The facility has 25 certified beds and at the time of the survey the facility census was 19.

Findings include:

Observation and staff interview on 8/31/10, revealed the absence of a remote annunciator panel (storage battery powered) for the emergency generator. Maintenance Staff A reported the existing emergency generator was not equipped with a remote annunciator panel.

Based on observations, 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 a capacity of 25 and a census of 19 residents.

Findings include:

Observations on 8/31/10, revealed a refrigerator, microwave, and coffee pot had been plugged into a surge protector in the basement Materials Management Office.