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Based on observation, this facility is not assuring that five of ten 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. It was determined the facility failed to maintain the 30 minute fire resistive rating of the smoke barrier. This deficient practice affects all occupants of the building, including staff, visitors and patients. The facility has a capacity of 25 with a census of 12.

Findings include:

1. Observations on 06/22/10 at 11:35 a.m., revealed the smoke barrier in the corridor near the Pharmacy contained a fourth inch conduit with an open center above the lay in tile. According to the facility layout, this was a required barrier.

2. Observations on 06/22/10 at 10:32 a.m., revealed the smoke barrier in the corridor near the Cardio Pulmonary Suite contained two 3/4 inch conduits with open centers above the lay in tile. According to the facility layout, this was a required barrier.

3. Observations on 06/22/10 at 11:38 a.m., revealed the smoke barrier in the corridor near the Pharmacy contained a fourth inch conduit with a 1/2 inch gap above the lay in tile. According to the facility layout, this was a required barrier.

4. Observations on 06/22/10 at 11:39 a.m., revealed the smoke barrier in the corridor near the Pharmacy contained two oxygen pipes with a 1/2 inch gap above the lay in tile. According to the facility layout, this was a required barrier.

5. Observations on 06/22/10 at 11:50 a.m., revealed the smoke barrier in the corridor near the Patients wing contained a fourth inch conduit with an open center above the lay in tile. According to the facility layout, this was a required barrier. The Maintenance Director verified these observations.

Based on observation, the facility failed to provide separation of hazardous areas from other compartments. This deficient practice affects one of ten smoke compartments in the building. This deficient practice would effect all visitors and staff in the Lower level. The facility has a capacity of 25 and a census of 12.

Findings include:

Observations on 06/22/10 at 2:00 p.m., revealed the facility failed to separate the Materials Management Room from other compartments. This storage room contained combustible storage and was over one thousand square feet. This door contained a self closing device and failed to close and positively latch. The Maintenance Director verified this observation.

Based on observation, the facility failed to provide a directional exit sign at the end of the corridor for one of six exits. This deficient practice effects approximately 10 patients, staff and visitors using the corridor near the Obstetrics Entrance. The facility has a capacity of 25 and a census of 12.

Findings include:

Observations on 06/22/10 at 10:35 a.m., revealed the facility failed to provide a directional exit sign in the corridor above the Obstetrics Entrance. According to the facility layout, which is used in conjunction with the emergency procedures, this designated exit is a required exit. The Maintenance Director verified this observation and corrected this deficiency at the time of inspection.

Based on record review, the facility is not conducting fire drills at least quarterly on each shift. This deficient practice effects all occupants including staff, visitors and patients, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. The facility has a capacity of 25 and a census of 12.

Findings include:

Review of the facility's fire drill records on 6/22/10 at 4:02 p.m., revealed the facility failed to conduct at least one fire drill per shift per quarter of 2009 and 2010. The facility failed to provide documentation of any fire drills being conducted on the third shift, fourth quarter of 2009 and first quarter 2010. The Maintenance Director verified this observation.

Based on observation, the facility did not assure that the fire alarm system is in accordance with NFPA 72, and chapter 9.6.4 of NFPA 101 by ensuring that the fire alarm breaker is mechanically protected. This deficient practice affects all occupants of the building, including staff, visitors and patients. The facility has a capacity of 25 with a census of 12.

Findings include:

Observations on 06/22/10 at 1:45 p.m., revealed the facility failed to provide a properly maintained fire alarm system. Fire alarm breaker #7 located in Mechanical Room electrical panel L8-2 was not secured with a mechanical lock to assure that the breaker is not inadvertently shut off. The Maintenance Director verified this observation.

Based on observation, the facility failed to provide a properly tested and maintained fire alarm system. One of five sets of smoke barrier doors in the lower level failed to release upon the activation of the buildings fire alarm system. This deficient practice affects all staff and visitors on the lower level. The facility has a capacity of 25 and a census of 12.

Findings include:

Observations on 6/22/10 at 4:00 p.m., revealed the facility failed to maintain the fire alarm system in the lower level near the Dietary Services Room. One of the interface/control functions tested on the fire alarm system failed to operate properly. The south double smoke door in the the corridor near the Dietary Services Room was being held open by an electromagnetic device that failed to release and allow the door to close upon the activation of the fire alarm system. The Maintenance Director verified this observation.

Based on observation and, the facility is not assuring that the fire alarm system is installed and maintained in accordance with NFPA 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer than three feet to an air supply or air return. Installation of a smoke detector close to an air diffuser can impede the operation of the smoke detector and can affect all staff, visitors and patients in the facility. The facility has a capacity of 25 and a census of 12.

Findings include:

1. Observations on 06/22/2010 at 10:26 a.m., revealed the facility failed to maintain the Fire Alarm System in the Safety Directors Office. This office contained a smoke detector with in three feet of an air diffuser.

2. Observations on 06/22/2010 at 10:36 a.m., revealed the facility failed to maintain the Fire Alarm System in the Obstetrics Change Room #2063. This room contained a smoke detector with in three feet of an air diffuser.

3. Observations on 06/22/2010 at 11:20 a.m., revealed the facility failed to maintain the Fire Alarm System in the Equipment Storage Room #2060. This room contained a smoke detector with in three feet of an air diffuser.

4. Observations on 06/22/2010 at 11:40 a.m., revealed the facility failed to maintain the Fire Alarm System in the Corridor near Patient Room #140. This corridor contained a smoke detector with in three feet of an air diffuser.

5. Observations on 06/22/2010 at 11:41 a.m., revealed the facility failed to maintain the Fire Alarm System in the Equipment Storage Room #2109. This room contained a smoke detector with in three feet of an air diffuser.

6. Observations on 06/22/2010 at 12:50 p.m., revealed the facility failed to maintain the Fire Alarm System in the Activity Storage Room #2169. This room contained a smoke detector with in three feet of an air diffuser.

7. Observations on 06/22/2010 at 12:55 p.m., revealed the facility failed to maintain the Fire Alarm System in the Corridor near the Health Information Management Room #2005. This corridor contained a smoke detector with in three feet of an air diffuser.

8. Observations on 06/22/2010 at 1:30 p.m., revealed the facility failed to maintain the Fire Alarm System in the Dining Room. This room contained a smoke detector with in three feet of an air diffuser.

9. Observations on 06/22/2010 at 2:15 p.m., revealed the facility failed to maintain the Fire Alarm System in Storage Room #1178. This room contained a smoke detector with in three feet of an air diffuser.

10. Observations on 06/22/2010 at 2:40 p.m., revealed the facility failed to maintain the Fire Alarm System in the Out-patient Janitors Closet. This room contained a smoke detector with in three feet of an air diffuser.

11. Observations on 06/22/2010 at 2:45 p.m., revealed the facility failed to maintain the Fire Alarm System in the Physical Therapy Storage Room #1101. This room contained a smoke detector with in three feet of an air diffuser. The Maintenance Director verified these observations.

Based on Observation and record review, the facility failed to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25, by ensuring the sprinkler system is inspected quarterly. The facility also failed to maintain the system with an acceptable clearance around sprinkler heads to prevent obstructions to spray patterns. This deficient practice affects all visitors, staff and patients. The facility has a capacity of 25 and a census of 12.

Findings include:

1. Observations on 6/22/10 at 10:28 a.m., revealed the facility failed to maintain the sprinkler system in Storage Room #2030. This room contained a metal rack and a full plastic bag stored directly under one of one sprinkler heads.

2. Observations on 6/22/10 at 2:18 p.m., revealed the facility failed to maintain the sprinkler system in the Radiology Storage Room. One of one sprinkler heads contained a 1/4 inch gap in the ceiling and missing the escutcheon ring.

3. Observations on 6/22/10 at 4:01 p.m., revealed the facility failed to provide a sprinkler head in the Elevator Equipment Room.

The Maintenance Director verified these observations.

Based on observation and record review, the facility could not provide documentation that the window blinds were flame resistant in accordance with provisions of NFPA 101, 10.3. This has the potential of affecting all staff in this office. This facility has a capacity of 25 and a census of 12.

Findings include:

Observations and record review of the mini blinds in the Safety Directors Office on 06/22/10 at 10:27 a.m., revealed they were not metal and were not tagged as being flame retardant. The facility could not provide documentation that the vinyl mini blinds were flame retardant. The Maintenance Director verified this observation.

Based on observations, the facility failed to provide emergency task illumination at the emergency generator and transfer switch location. The emergency generator would affect all smoke comparments and all of the staff, visitors and patients. The facility has a capacity of 25 and a census of 12.

Findings include:

Observation on 6/22/10 at 3:50 p.m., revealed that a battery back-up emergency light was not provided at the emergency generator or the emergency generator transfer switch location to provide task illumination. The Maintenance Director verified this observation.

Based on observation, 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, placing the Staff, visitors and Patients of the facility at risk in the event of a fire. The facility had a capacity of 25 and a census of 12.

Findings Include:

1. Observations on 06/22/10 at 11:30 a.m., revealed the facility failed to maintain the electrical system in the Corridor near the Obstetrics entrance. Electrical breakers #3, #5, #7, #9, #11, #13, #15, #17, #21, #23, #25, #27, #29, #31 and #34 in Electrical Panel L-1 were not identified or labeled in the Electrical Panel Directory.

2. Observations on 06/22/10 at 11:45 a.m., revealed the facility failed to maintain the electrical system in the Soiled Utility Room #2077. This room contained four standard outlets not Ground Fault Circuit Interrupted outlets next to the sink.

3. Observations on 06/22/10 at 1:48 p.m., revealed the facility failed to maintain the electrical system in the Pump Room. This room contained an open knock-out with exposed electrical wiring in the side of the Electrical Panel.

4. Observations on 06/22/10 at 1:50 p.m., revealed the facility failed to maintain the electrical system in Air Handler Room #3. This room contained an open junction box with exposed electrical wiring along the ceiling.

5. Observations on 06/22/10 at 2:20 p.m., revealed the facility failed to maintain the electrical system in the Boiler Room. This room contained an open ended conduit with exposed electrical wiring along the north wall.

6. Observations on 06/22/10 at 10:30 a.m., revealed the facility failed to maintain the electrical system in the Sleep Study corridor. This corridor contained a scale, portable tables and wheel chair being stored in front of the electrical panels. The Maintenance Director verified these observations.

Based on observation, this facility is not assuring that five of ten 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. It was determined the facility failed to maintain the 30 minute fire resistive rating of the smoke barrier. This deficient practice affects all occupants of the building, including staff, visitors and patients. The facility has a capacity of 25 with a census of 12.

Findings include:

1. Observations on 06/22/10 at 11:35 a.m., revealed the smoke barrier in the corridor near the Pharmacy contained a fourth inch conduit with an open center above the lay in tile. According to the facility layout, this was a required barrier.

2. Observations on 06/22/10 at 10:32 a.m., revealed the smoke barrier in the corridor near the Cardio Pulmonary Suite contained two 3/4 inch conduits with open centers above the lay in tile. According to the facility layout, this was a required barrier.

3. Observations on 06/22/10 at 11:38 a.m., revealed the smoke barrier in the corridor near the Pharmacy contained a fourth inch conduit with a 1/2 inch gap above the lay in tile. According to the facility layout, this was a required barrier.

4. Observations on 06/22/10 at 11:39 a.m., revealed the smoke barrier in the corridor near the Pharmacy contained two oxygen pipes with a 1/2 inch gap above the lay in tile. According to the facility layout, this was a required barrier.

5. Observations on 06/22/10 at 11:50 a.m., revealed the smoke barrier in the corridor near the Patients wing contained a fourth inch conduit with an open center above the lay in tile. According to the facility layout, this was a required barrier. The Maintenance Director verified these observations.

Based on observation, the facility failed to provide separation of hazardous areas from other compartments. This deficient practice affects one of ten smoke compartments in the building. This deficient practice would effect all visitors and staff in the Lower level. The facility has a capacity of 25 and a census of 12.

Findings include:

Observations on 06/22/10 at 2:00 p.m., revealed the facility failed to separate the Materials Management Room from other compartments. This storage room contained combustible storage and was over one thousand square feet. This door contained a self closing device and failed to close and positively latch. The Maintenance Director verified this observation.

Based on observation, the facility failed to provide a directional exit sign at the end of the corridor for one of six exits. This deficient practice effects approximately 10 patients, staff and visitors using the corridor near the Obstetrics Entrance. The facility has a capacity of 25 and a census of 12.

Findings include:

Observations on 06/22/10 at 10:35 a.m., revealed the facility failed to provide a directional exit sign in the corridor above the Obstetrics Entrance. According to the facility layout, which is used in conjunction with the emergency procedures, this designated exit is a required exit. The Maintenance Director verified this observation and corrected this deficiency at the time of inspection.

Based on record review, the facility is not conducting fire drills at least quarterly on each shift. This deficient practice effects all occupants including staff, visitors and patients, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. The facility has a capacity of 25 and a census of 12.

Findings include:

Review of the facility's fire drill records on 6/22/10 at 4:02 p.m., revealed the facility failed to conduct at least one fire drill per shift per quarter of 2009 and 2010. The facility failed to provide documentation of any fire drills being conducted on the third shift, fourth quarter of 2009 and first quarter 2010. The Maintenance Director verified this observation.

Based on observation, the facility did not assure that the fire alarm system is in accordance with NFPA 72, and chapter 9.6.4 of NFPA 101 by ensuring that the fire alarm breaker is mechanically protected. This deficient practice affects all occupants of the building, including staff, visitors and patients. The facility has a capacity of 25 with a census of 12.

Findings include:

Observations on 06/22/10 at 1:45 p.m., revealed the facility failed to provide a properly maintained fire alarm system. Fire alarm breaker #7 located in Mechanical Room electrical panel L8-2 was not secured with a mechanical lock to assure that the breaker is not inadvertently shut off. The Maintenance Director verified this observation.

Based on observation, the facility failed to provide a properly tested and maintained fire alarm system. One of five sets of smoke barrier doors in the lower level failed to release upon the activation of the buildings fire alarm system. This deficient practice affects all staff and visitors on the lower level. The facility has a capacity of 25 and a census of 12.

Findings include:

Observations on 6/22/10 at 4:00 p.m., revealed the facility failed to maintain the fire alarm system in the lower level near the Dietary Services Room. One of the interface/control functions tested on the fire alarm system failed to operate properly. The south double smoke door in the the corridor near the Dietary Services Room was being held open by an electromagnetic device that failed to release and allow the door to close upon the activation of the fire alarm system. The Maintenance Director verified this observation.

Based on observation and, the facility is not assuring that the fire alarm system is installed and maintained in accordance with NFPA 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer than three feet to an air supply or air return. Installation of a smoke detector close to an air diffuser can impede the operation of the smoke detector and can affect all staff, visitors and patients in the facility. The facility has a capacity of 25 and a census of 12.

Findings include:

1. Observations on 06/22/2010 at 10:26 a.m., revealed the facility failed to maintain the Fire Alarm System in the Safety Directors Office. This office contained a smoke detector with in three feet of an air diffuser.

2. Observations on 06/22/2010 at 10:36 a.m., revealed the facility failed to maintain the Fire Alarm System in the Obstetrics Change Room #2063. This room contained a smoke detector with in three feet of an air diffuser.

3. Observations on 06/22/2010 at 11:20 a.m., revealed the facility failed to maintain the Fire Alarm System in the Equipment Storage Room #2060. This room contained a smoke detector with in three feet of an air diffuser.

4. Observations on 06/22/2010 at 11:40 a.m., revealed the facility failed to maintain the Fire Alarm System in the Corridor near Patient Room #140. This corridor contained a smoke detector with in three feet of an air diffuser.

5. Observations on 06/22/2010 at 11:41 a.m., revealed the facility failed to maintain the Fire Alarm System in the Equipment Storage Room #2109. This room contained a smoke detector with in three feet of an air diffuser.

6. Observations on 06/22/2010 at 12:50 p.m., revealed the facility failed to maintain the Fire Alarm System in the Activity Storage Room #2169. This room contained a smoke detector with in three feet of an air diffuser.

7. Observations on 06/22/2010 at 12:55 p.m., revealed the facility failed to maintain the Fire Alarm System in the Corridor near the Health Information Management Room #2005. This corridor contained a smoke detector with in three feet of an air diffuser.

8. Observations on 06/22/2010 at 1:30 p.m., revealed the facility failed to maintain the Fire Alarm System in the Dining Room. This room contained a smoke detector with in three feet of an air diffuser.

9. Observations on 06/22/2010 at 2:15 p.m., revealed the facility failed to maintain the Fire Alarm System in Storage Room #1178. This room contained a smoke detector with in three feet of an air diffuser.

10. Observations on 06/22/2010 at 2:40 p.m., revealed the facility failed to maintain the Fire Alarm System in the Out-patient Janitors Closet. This room contained a smoke detector with in three feet of an air diffuser.

11. Observations on 06/22/2010 at 2:45 p.m., revealed the facility failed to maintain the Fire Alarm System in the Physical Therapy Storage Room #1101. This room contained a smoke detector with in three feet of an air diffuser. The Maintenance Director verified these observations.

Based on Observation and record review, the facility failed to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25, by ensuring the sprinkler system is inspected quarterly. The facility also failed to maintain the system with an acceptable clearance around sprinkler heads to prevent obstructions to spray patterns. This deficient practice affects all visitors, staff and patients. The facility has a capacity of 25 and a census of 12.

Findings include:

1. Observations on 6/22/10 at 10:28 a.m., revealed the facility failed to maintain the sprinkler system in Storage Room #2030. This room contained a metal rack and a full plastic bag stored directly under one of one sprinkler heads.

2. Observations on 6/22/10 at 2:18 p.m., revealed the facility failed to maintain the sprinkler system in the Radiology Storage Room. One of one sprinkler heads contained a 1/4 inch gap in the ceiling and missing the escutcheon ring.

3. Observations on 6/22/10 at 4:01 p.m., revealed the facility failed to provide a sprinkler head in the Elevator Equipment Room.

The Maintenance Director verified these observations.

Based on observation and record review, the facility could not provide documentation that the window blinds were flame resistant in accordance with provisions of NFPA 101, 10.3. This has the potential of affecting all staff in this office. This facility has a capacity of 25 and a census of 12.

Findings include:

Observations and record review of the mini blinds in the Safety Directors Office on 06/22/10 at 10:27 a.m., revealed they were not metal and were not tagged as being flame retardant. The facility could not provide documentation that the vinyl mini blinds were flame retardant. The Maintenance Director verified this observation.

Based on observations, the facility failed to provide emergency task illumination at the emergency generator and transfer switch location. The emergency generator would affect all smoke comparments and all of the staff, visitors and patients. The facility has a capacity of 25 and a census of 12.

Findings include:

Observation on 6/22/10 at 3:50 p.m., revealed that a battery back-up emergency light was not provided at the emergency generator or the emergency generator transfer switch location to provide task illumination. The Maintenance Director verified this observation.

Based on observation, 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, placing the Staff, visitors and Patients of the facility at risk in the event of a fire. The facility had a capacity of 25 and a census of 12.

Findings Include:

1. Observations on 06/22/10 at 11:30 a.m., revealed the facility failed to maintain the electrical system in the Corridor near the Obstetrics entrance. Electrical breakers #3, #5, #7, #9, #11, #13, #15, #17, #21, #23, #25, #27, #29, #31 and #34 in Electrical Panel L-1 were not identified or labeled in the Electrical Panel Directory.

2. Observations on 06/22/10 at 11:45 a.m., revealed the facility failed to maintain the electrical system in the Soiled Utility Room #2077. This room contained four standard outlets not Ground Fault Circuit Interrupted outlets next to the sink.

3. Observations on 06/22/10 at 1:48 p.m., revealed the facility failed to maintain the electrical system in the Pump Room. This room contained an open knock-out with exposed electrical wiring in the side of the Electrical Panel.

4. Observations on 06/22/10 at 1:50 p.m., revealed the facility failed to maintain the electrical system in Air Handler Room #3. This room contained an open junction box with exposed electrical wiring along the ceiling.

5. Observations on 06/22/10 at 2:20 p.m., revealed the facility failed to maintain the electrical system in the Boiler Room. This room contained an open ended conduit with exposed electrical wiring along the north wall.

6. Observations on 06/22/10 at 10:30 a.m., revealed the facility failed to maintain the electrical system in the Sleep Study corridor. This corridor contained a scale, portable tables and wheel chair being stored in front of the electrical panels. The Maintenance Director verified these observations.