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Based on observation and interview, the facility failed to ensure 3 of 14 open use areas were separated from the corridors or met an Exception. Exception # 1, Spaces shall be permitted to be unlimited in area and open to the corridor, provided the following criteria are met: (a) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas. (b) The corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the smoke compartment in which the space is located is protected throughout by quick response sprinklers. (c) The open space is protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the entire space is arranged and located to allow direct supervision by the facility staff from a nurses' station or similar space. (d) The space does not obstruct access to required exits. This deficient practice could affect all patients in the facility.

Findings include:

Based on observations on 02/02/10 during a tour of the facility from 9:00 a.m. to 2:45 p.m. with the maintenance director, the therapy receptionist office, the laboratory waiting room receptionist office, and the cat scan technician office each had a four foot by four foot sliding glass window. The sliding glass windows left a one half inch to a one inch gap between the panes of glass with the windows in the closed position. Furthermore, Exception # 1, requirement (c ) of the Life Safety Code, Chapter 19.3.6.1 was not met as follows: the open areas were not protected by an automatic smoke detection system or arranged to allow direct supervision by facility staff from a continuously staffed area such as a nurses' station.

Based on observation and interview, the facility failed to ensure smoke barriers were maintained to provide a one half hour fire resistance rating to protect 9 of 9 patients. LSC 8.3.2 requires smoke barriers shall be continuous from an outside wall to an outside wall. This deficient practice affects all patients in the facility.

Findings include:

Based on observations with the maintenance director on 02/02/10 during a tour of the facility from 9:00 a.m. to 2:45 p.m., the following ceiling and wall smoke barriers had penetrations with no fire stopping material;
a. The basement mechanical workshop had four water pipe penetrations in the west wall with two inch to four inch gaps which were not fire stopped.
b. The basement maintenance workshop north wall had a four inch sewer pipe penetration with a six inch gap not fire stopped, and the south wall had a six inch by six inch opening around four hot water piping penetrations which were not fire stopped.
c. The second floor Medical Surgery Wing East/West Hall corridor had a four inch by five inch penetration, and a two inch by three inch penetration in the south wall at the medical surgery nurses' station where electrical conduit passed between the wall with no fire stopping material.
d. The second floor Medical Surgery Wing corridor had a two inch penetration in the ceiling next to the elevator with no fire stopping material.
e. The second floor elevator shaft air handler room south wall had an electrical conduit penetration with a one inch gap not fire stopped and two penetrations above the drop ceiling south wall where the air handler duct penetrated the wall with a five inch by two inch gap and a seven inch by twelve inch gap which were not fire stopped.
f. The second floor corridor ceiling outside the elevator had two, two inch by two inch penetrations above the drop ceiling where communication lines penetrated the ceiling with no fire stopping material.
g. The second floor corridor across from respiratory therapy had a two inch ceiling penetration above the drop ceiling from a fire alarm system wire penetration with no fire stopping material.
h. The second floor Surgery Wing lobby elevator corridor ceiling had a one inch by two inch penetration from electrical conduit with no fire stopping material.
The ceiling and wall penetrations not fire stopped were verified by the maintenance director at the time of observations.

1. Based on observation and interview, the facility failed to ensure the corridor doors to 5 of 34 nonsprinklered hazardous areas such as combustible storage areas over 50 square feet in size were provided with 45 minute rated fire doors and equipped with self closing devices which would cause the doors to automatically close and latch into the door frame. This deficient practice affects all patients in the facility.

Findings include:

Based on observations on 02/02/10 during a tour of the facility from 9:00 a.m. to 2:45 p.m. with the maintenance director, the following rooms which measured from one hundred twelve square feet to two hundred sixteen square feet in size and stored shelves of combustible paper, combustible cardboard boxes, linen, and plastic office supplies lacked forty five minute rated fire doors and self closing devices: the first floor housekeeping storage room, the maintenance workshop storage room, the kitchen food storage room, the main boiler room, and the shipping storage room. This was verified by the maintenance director at the time of observations.

2. Based on observation and interview, the facility failed to ensure the corridor doors to 1 of 34 nonsprinklered hazardous areas such as a natural gas equipment room was provided with one hour construction. This deficient practice affects all patients in the facility.

Based on observations on 02/02/10 at 1:15 p.m. with the maintenance director, the sleep apnia computer room had an enclosed natural gas furnace room in the back of the room. Furthermore, three walls in furnace room lacked drywall leaving the metal metal studs exposed, which did not provide one hour fire resistant construction. Based on an interview with the maintenance director on 02/02/10 at 1:30 p.m., a furnace was added in the sleep apnia room about a year ago and the walls were not finished with drywall.

Based on observation and interview, the facility failed to ensure 6 of 6 stairway battery backup lights were tested annually for a 90 minute duration to ensure the lights would provide lighting during periods of power outages to protect 9 of 9 patients. LSC 19.2.9.1 requires emergency lighting shall be provided in accordance with Section 7.9. Section 7.9.3 requires 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. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all patients in the facility.

Findings include:

Based on observations on 02/02/10 during a tour of the facility from 9:00 a.m. to 2:45 p.m. with the maintenance director, the six stairways each had a battery backup light mounted on the stairway wall. Based on an interview with the maintenance director on 02/02/10 at 1:30 p.m., the maintenance director stated the battery powered backup lights are not tested annually for a ninety minute duration, but tested monthly by depressing the test button to ensure the lights come on and this was recorded on the monthly Preventive Maintenance Log, which was reviewed at the time of interview.

Based on record review and interview, the facility failed to ensure fire drills for 2 of 3 shifts were held at unexpected times over the past year to protect 9 of 9 patients. This deficient practice affects all patients in the facility.

Findings include:

Based on a review of the Fire Drill Book with the maintenance director on 02/02/10 at 9:00 a.m., the Fire Drill Reports for the following shifts were held at the following similar times:
a. Second shift drills; 02/26/09 at 3:15 p.m., 05/20/09 at 3:05 p.m., 08/31/09 at 3:18 p.m., and 11/24/09 at 3:00 p.m.
b. Third shift drills; 03/06/09 at 6:45 a.m., 06/12/09 at 6:42 a.m., 09/15/09 at 5;40 a.m., and 12/02/09 at 6:45 a.m.
Based on an interview with the maintenance director on 02/02/10 at 9:45 a.m., the second shift runs from 3:00 p.m. to 11: 00 p.m. and the third shift runs from 11:00 p.m. to 7:00 a.m. The maintenance director further stated, it was not known fire drills are required to be held at unexpected times on each shift.

Based on observation and interview, the facility failed to properly install and maintain 1 of 1 fire alarm systems in accordance with NFPA 72. NFPA 72, 3-8.1 allows fire alarm system components to share control equipment or operate as stand alone systems, but in any case, they shall be arranged to function as a single system. NFPA 72, 1-5.4.6 requires trouble signals to be located in an area where it is likely to be heard. NFPA 72, 1-5.4.4 requires fire alarms, supervisory signals, and trouble signals to be distinctive and descriptively annunciated. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observation and test of the fire alarm system with the maintenance director on 02/02/10 at 2:20 p.m., when the telephone line to the automatic dialer component of the fire alarm system was disconnected, a local trouble signal was not initiated by the main fire alarm system panel in the corridor by the first floor foyer. Furthermore, the fire alarm system panel showed a green light after the telephone line was disconnected, showing the system was normal and the monitoring company who is alerted to a fire alarm in the facility was contacted and they did not receive notification the fire alarm system telephone line had been disconnected, which verified the fire alarm system did not function as a single system with a trouble signal verifying the telephone line was disconnected. This was verified by the maintenance director at the time of fire alarm system testing.

1. Based on record review and interview, the facility failed to ensure the load testing for the past 12 months was conducted under operating conditions or not less than 30 percent of the nameplate rating for the emergency generator set to protect 9 of 9 patients. Chapter 3-4.4.1.1 of NFPA 99 requires monthly testing of the generator serving the emergency electrical system to be in accordance with NFPA 110, the Standard for Emergency and Standby Powers Systems, chapter 6-4.2. Chapter 6-4.2 of NFPA 110 requires generator sets in Level 1 and Level 2 service to be exercised under operating conditions or not less than 30 percent of the EPS nameplate rating at least monthly, for a minimum of 30 minutes. Chapter 3-5.4.2 of NFPA 99 requires a written record of inspection, performance, exercising period, and repairs for the generator to be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice affects all patients in the facility.

Findings include:

Based on a review of the Generator Testing Book on 02/02/10 at 9:30 a.m. with the maintenance director, the Generator Testing Book showed a monthly load test for the past twelve months for between a twenty minute and thirty minute duration. Based on an interview with the maintenance supervisor on 02/02/10 at 9:40 a.m., the maintenance director indicated it was not known if the generator set ran under full load conditions or a thirty percent nameplate rating load test was conducted during the monthly load tests.

2. Based on record review and interview, the facility failed to ensure the generator was load tested for at least 30 minutes for 4 of the past 12 months. Chapter 3-4.4.1.1 of NFPA 99 requires monthly testing of the generator serving the emergency electrical system to be in accordance with NFPA 110, the Standard for Emergency and Standby Powers Systems, chapter 6-4.2. Chapter 6-4.2 of NFPA 110 requires generator sets in Level 1 and Level 2 service to be exercised under operating conditions or not less than 30 percent of the EPS nameplate rating at least monthly, for a minimum of 30 minutes. Chapter 3-5.4.2 of NFPA 99 requires a written record of inspection, performance, exercising period, and repairs for the generator to be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice affect all patients in the facility.

Findings include:

Based on a review of the Generator Testing Book on 02/02/10 at 9:30 a.m. with the maintenance director, the monthly load tests conducted on 02/09/09, 04/10/09, 05/11/09, and 07/19/09 were conducted for a twenty minute duration instead of the required thirty minute duration. This was verified by the maintenance director at the time of record review..

Based on observation and interview, the facility failed to ensure 3 of 14 open use areas were separated from the corridors or met an Exception. Exception # 1, Spaces shall be permitted to be unlimited in area and open to the corridor, provided the following criteria are met: (a) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas. (b) The corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the smoke compartment in which the space is located is protected throughout by quick response sprinklers. (c) The open space is protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the entire space is arranged and located to allow direct supervision by the facility staff from a nurses' station or similar space. (d) The space does not obstruct access to required exits. This deficient practice could affect all patients in the facility.

Findings include:

Based on observations on 02/02/10 during a tour of the facility from 9:00 a.m. to 2:45 p.m. with the maintenance director, the therapy receptionist office, the laboratory waiting room receptionist office, and the cat scan technician office each had a four foot by four foot sliding glass window. The sliding glass windows left a one half inch to a one inch gap between the panes of glass with the windows in the closed position. Furthermore, Exception # 1, requirement (c ) of the Life Safety Code, Chapter 19.3.6.1 was not met as follows: the open areas were not protected by an automatic smoke detection system or arranged to allow direct supervision by facility staff from a continuously staffed area such as a nurses' station.

Based on observation and interview, the facility failed to ensure smoke barriers were maintained to provide a one half hour fire resistance rating to protect 9 of 9 patients. LSC 8.3.2 requires smoke barriers shall be continuous from an outside wall to an outside wall. This deficient practice affects all patients in the facility.

Findings include:

Based on observations with the maintenance director on 02/02/10 during a tour of the facility from 9:00 a.m. to 2:45 p.m., the following ceiling and wall smoke barriers had penetrations with no fire stopping material;
a. The basement mechanical workshop had four water pipe penetrations in the west wall with two inch to four inch gaps which were not fire stopped.
b. The basement maintenance workshop north wall had a four inch sewer pipe penetration with a six inch gap not fire stopped, and the south wall had a six inch by six inch opening around four hot water piping penetrations which were not fire stopped.
c. The second floor Medical Surgery Wing East/West Hall corridor had a four inch by five inch penetration, and a two inch by three inch penetration in the south wall at the medical surgery nurses' station where electrical conduit passed between the wall with no fire stopping material.
d. The second floor Medical Surgery Wing corridor had a two inch penetration in the ceiling next to the elevator with no fire stopping material.
e. The second floor elevator shaft air handler room south wall had an electrical conduit penetration with a one inch gap not fire stopped and two penetrations above the drop ceiling south wall where the air handler duct penetrated the wall with a five inch by two inch gap and a seven inch by twelve inch gap which were not fire stopped.
f. The second floor corridor ceiling outside the elevator had two, two inch by two inch penetrations above the drop ceiling where communication lines penetrated the ceiling with no fire stopping material.
g. The second floor corridor across from respiratory therapy had a two inch ceiling penetration above the drop ceiling from a fire alarm system wire penetration with no fire stopping material.
h. The second floor Surgery Wing lobby elevator corridor ceiling had a one inch by two inch penetration from electrical conduit with no fire stopping material.
The ceiling and wall penetrations not fire stopped were verified by the maintenance director at the time of observations.

1. Based on observation and interview, the facility failed to ensure the corridor doors to 5 of 34 nonsprinklered hazardous areas such as combustible storage areas over 50 square feet in size were provided with 45 minute rated fire doors and equipped with self closing devices which would cause the doors to automatically close and latch into the door frame. This deficient practice affects all patients in the facility.

Findings include:

Based on observations on 02/02/10 during a tour of the facility from 9:00 a.m. to 2:45 p.m. with the maintenance director, the following rooms which measured from one hundred twelve square feet to two hundred sixteen square feet in size and stored shelves of combustible paper, combustible cardboard boxes, linen, and plastic office supplies lacked forty five minute rated fire doors and self closing devices: the first floor housekeeping storage room, the maintenance workshop storage room, the kitchen food storage room, the main boiler room, and the shipping storage room. This was verified by the maintenance director at the time of observations.

2. Based on observation and interview, the facility failed to ensure the corridor doors to 1 of 34 nonsprinklered hazardous areas such as a natural gas equipment room was provided with one hour construction. This deficient practice affects all patients in the facility.

Based on observations on 02/02/10 at 1:15 p.m. with the maintenance director, the sleep apnia computer room had an enclosed natural gas furnace room in the back of the room. Furthermore, three walls in furnace room lacked drywall leaving the metal metal studs exposed, which did not provide one hour fire resistant construction. Based on an interview with the maintenance director on 02/02/10 at 1:30 p.m., a furnace was added in the sleep apnia room about a year ago and the walls were not finished with drywall.

Based on observation and interview, the facility failed to ensure 6 of 6 stairway battery backup lights were tested annually for a 90 minute duration to ensure the lights would provide lighting during periods of power outages to protect 9 of 9 patients. LSC 19.2.9.1 requires emergency lighting shall be provided in accordance with Section 7.9. Section 7.9.3 requires 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. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all patients in the facility.

Findings include:

Based on observations on 02/02/10 during a tour of the facility from 9:00 a.m. to 2:45 p.m. with the maintenance director, the six stairways each had a battery backup light mounted on the stairway wall. Based on an interview with the maintenance director on 02/02/10 at 1:30 p.m., the maintenance director stated the battery powered backup lights are not tested annually for a ninety minute duration, but tested monthly by depressing the test button to ensure the lights come on and this was recorded on the monthly Preventive Maintenance Log, which was reviewed at the time of interview.

Based on record review and interview, the facility failed to ensure fire drills for 2 of 3 shifts were held at unexpected times over the past year to protect 9 of 9 patients. This deficient practice affects all patients in the facility.

Findings include:

Based on a review of the Fire Drill Book with the maintenance director on 02/02/10 at 9:00 a.m., the Fire Drill Reports for the following shifts were held at the following similar times:
a. Second shift drills; 02/26/09 at 3:15 p.m., 05/20/09 at 3:05 p.m., 08/31/09 at 3:18 p.m., and 11/24/09 at 3:00 p.m.
b. Third shift drills; 03/06/09 at 6:45 a.m., 06/12/09 at 6:42 a.m., 09/15/09 at 5;40 a.m., and 12/02/09 at 6:45 a.m.
Based on an interview with the maintenance director on 02/02/10 at 9:45 a.m., the second shift runs from 3:00 p.m. to 11: 00 p.m. and the third shift runs from 11:00 p.m. to 7:00 a.m. The maintenance director further stated, it was not known fire drills are required to be held at unexpected times on each shift.

Based on observation and interview, the facility failed to properly install and maintain 1 of 1 fire alarm systems in accordance with NFPA 72. NFPA 72, 3-8.1 allows fire alarm system components to share control equipment or operate as stand alone systems, but in any case, they shall be arranged to function as a single system. NFPA 72, 1-5.4.6 requires trouble signals to be located in an area where it is likely to be heard. NFPA 72, 1-5.4.4 requires fire alarms, supervisory signals, and trouble signals to be distinctive and descriptively annunciated. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observation and test of the fire alarm system with the maintenance director on 02/02/10 at 2:20 p.m., when the telephone line to the automatic dialer component of the fire alarm system was disconnected, a local trouble signal was not initiated by the main fire alarm system panel in the corridor by the first floor foyer. Furthermore, the fire alarm system panel showed a green light after the telephone line was disconnected, showing the system was normal and the monitoring company who is alerted to a fire alarm in the facility was contacted and they did not receive notification the fire alarm system telephone line had been disconnected, which verified the fire alarm system did not function as a single system with a trouble signal verifying the telephone line was disconnected. This was verified by the maintenance director at the time of fire alarm system testing.

1. Based on record review and interview, the facility failed to ensure the load testing for the past 12 months was conducted under operating conditions or not less than 30 percent of the nameplate rating for the emergency generator set to protect 9 of 9 patients. Chapter 3-4.4.1.1 of NFPA 99 requires monthly testing of the generator serving the emergency electrical system to be in accordance with NFPA 110, the Standard for Emergency and Standby Powers Systems, chapter 6-4.2. Chapter 6-4.2 of NFPA 110 requires generator sets in Level 1 and Level 2 service to be exercised under operating conditions or not less than 30 percent of the EPS nameplate rating at least monthly, for a minimum of 30 minutes. Chapter 3-5.4.2 of NFPA 99 requires a written record of inspection, performance, exercising period, and repairs for the generator to be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice affects all patients in the facility.

Findings include:

Based on a review of the Generator Testing Book on 02/02/10 at 9:30 a.m. with the maintenance director, the Generator Testing Book showed a monthly load test for the past twelve months for between a twenty minute and thirty minute duration. Based on an interview with the maintenance supervisor on 02/02/10 at 9:40 a.m., the maintenance director indicated it was not known if the generator set ran under full load conditions or a thirty percent nameplate rating load test was conducted during the monthly load tests.

2. Based on record review and interview, the facility failed to ensure the generator was load tested for at least 30 minutes for 4 of the past 12 months. Chapter 3-4.4.1.1 of NFPA 99 requires monthly testing of the generator serving the emergency electrical system to be in accordance with NFPA 110, the Standard for Emergency and Standby Powers Systems, chapter 6-4.2. Chapter 6-4.2 of NFPA 110 requires generator sets in Level 1 and Level 2 service to be exercised under operating conditions or not less than 30 percent of the EPS nameplate rating at least monthly, for a minimum of 30 minutes. Chapter 3-5.4.2 of NFPA 99 requires a written record of inspection, performance, exercising period, and repairs for the generator to be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice affect all patients in the facility.

Findings include:

Based on a review of the Generator Testing Book on 02/02/10 at 9:30 a.m. with the maintenance director, the monthly load tests conducted on 02/09/09, 04/10/09, 05/11/09, and 07/19/09 were conducted for a twenty minute duration instead of the required thirty minute duration. This was verified by the maintenance director at the time of record review..