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Based on observations and interview, the facility failed to maintain 3 smoke barriers free of penetrations. This affects 6 smoke zones within the hospital. The facility had a license of 80 patients and a census of 19 patients.

Findings include:

Observations and interview on 8-27-15, between the hours of 9:47 am and 11:14 am revealed the following:

1. A center of conduit penetration (approximately 1/2 inch in size) located above the suspended ceiling in the smoke barrier located near the Endoscope Room.

2. A gap around several conduits (approximately 4 inches by 5 inches in size) located above the suspended ceiling in the smoke barrier near the Radiology Waiting Room.

3. A wire penetration (approximately 1/2 inch in size) located above the suspended ceiling in the Administration Area Smoke Barrier near the Gift Shop.

Hospital Staff A, B and C verified these observations at the time of the survey process.

Based on observations and interview, the facility failed to maintain 1 hazardous room properly separated. This affects 1 smoke zone in the hospital. The facility had a license capacity of 80 patients and a census of 19 patients.

Findings include:

Observations and interview on 8-27-15 at approximately 9:42 am, revealed a hole (approximately 2 inches in size) and a conduit penetration (approximately 3/4 inches in size) located in the wall of the Short Stay Electrical Room.

Hospital Staff A, B and C verified these observations at the time of the survey process.

Based on record review and interview, the facility failed to comply with the fire drill requirements by failing to vary the times of the fire drills. This would affect all smoke zones within the hospital The facility had a capacity of 80 patients and a census of 19 patients.

Findings include:

Record review and interview on 8-24-15 at approximately 2:41 pm, revealed the facility failed to vary the times of the fire drills that were conducted on the 2nd and 3rd nursing shifts. During the previous 12 months, the 2nd shift fire drills only varied 40 minutes. Also, on the 3rd shift, the fire drills only varied 47 minutes.

Hospital Staff Members A, B and C verified these observations at the time of the survey process.

(A)
Based on record review and interview, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code, 1999 edition, by failing to manually lock the electrical breaker that is dedicated to the fire alarm system. This affects all the smoke zones in the hospital. The facility had a license of 80 patients and a census of 19 patients.

Findings include:

Record review and interview on 8-27-15 at approximately 9:42 am, revealed the absence of a locking mechanism on the electrical breaker that is dedicated to the buildings fire alarm system. This breaker shall be locked in the "On" position.

Hospital Staff A, B and C verified this observation during the survey process.


(B)
Based on observations and interview, the facility failed to provide the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code, 1999 edition, by improperly locating 9 smoke detectors. This affects 7 smoke zones within the facility. The facility had a license of 80 patients and a census of 19 patients

Findings include:

Observations and interview on 8-27-15, between the hours of 10:18 am and 11;44 am, revealed smoke detectors that were located closer than 3 feet from an air diffuser (HVAC) in the following locations:

1. The smoke detector in the 2nd Floor Kitchen.
2. The smoke detector in the Main Entrance Vestibule.
3. The smoke detector near the Information Desk.
4. The smoke detector in the Charge Nurse's Office.
5. The smoke detector in the 3rd Floor Nurse's Lounge.
6. The smoke detector in the 3rd Floor Clean Linen Room.
7. The smoke detector in the Laboratory Break Room.
8. The smoke detector in the Lab EKG area.
9. The smoke detector in the Gift Shop.

Hospital Staff A, B and C verified these observations during the survey process.

Based on observations and interview, the facility failed to provide drapery, curtains, including cubicle curtains in accordance with provisions of 10.3.1 of the Life Safety Code and NFPA 13, Standard for Installation of Sprinkler Systems, 1999 edition by allowing non-conforming mini-blinds. This affects 3 smoke zones in the hospital. The facility had a capacity of 80 patients and a census of 19 patients.

Findings include:

Observations and interview on 8-27-15, between the hours of 9:15 am and 11:32 am, revealed the following:

1. Vinyl mini-blinds in the I.T Office.
2. Vinyl mini-blinds in Patient Room #300.
3. Vinyl mini-blinds in Patient Room #305.
4. Vinyl mini-blinds in the Cardio-Pulmonary Services Room.

Hospital Staff A, B, and C verified these observations at the time of the survey process.

(A)
Based on observations 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, by failing to install a Ground Fault Circuit Interrupter electrical outlet in required area's. This affects 2 smoke zones in the hospital. The facility had a capacity of 80 patients and a census of 19 patients.

Findings include:

Observations and interview on 8-27-15 at approximately 9:53 and 10:03 am, revealed the absence of a required GFCI electrical outlet near the sink in the following rooms:

1. The Nurses Lounge by the Unassigned Space.
2. The 3rd Floor Nurses Lounge.

Hospital Staff A, B and C verified these observations at the time of the survey process.


(B)
Based on observations 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 by an electrical junction box to be uncovered, exposing wires. This affects 1 smoke zone in the hospital. The facility had a capacity of 80 patients and a census of 19 patients.

Findings include:

Observations and interview on 8-27-15 at approximately 9:33 am, revealed a large electrical junction box, with exposed wires, that failed to have cover placed on it located in the Boiler Room.

Hospital Staff A, B and C verified these observations at the time of the survey process.

Based on observations and interview, the facility failed to maintain 3 smoke barriers free of penetrations. This affects 6 smoke zones within the hospital. The facility had a license of 80 patients and a census of 19 patients.

Findings include:

Observations and interview on 8-27-15, between the hours of 9:47 am and 11:14 am revealed the following:

1. A center of conduit penetration (approximately 1/2 inch in size) located above the suspended ceiling in the smoke barrier located near the Endoscope Room.

2. A gap around several conduits (approximately 4 inches by 5 inches in size) located above the suspended ceiling in the smoke barrier near the Radiology Waiting Room.

3. A wire penetration (approximately 1/2 inch in size) located above the suspended ceiling in the Administration Area Smoke Barrier near the Gift Shop.

Hospital Staff A, B and C verified these observations at the time of the survey process.

Based on observations and interview, the facility failed to maintain 1 hazardous room properly separated. This affects 1 smoke zone in the hospital. The facility had a license capacity of 80 patients and a census of 19 patients.

Findings include:

Observations and interview on 8-27-15 at approximately 9:42 am, revealed a hole (approximately 2 inches in size) and a conduit penetration (approximately 3/4 inches in size) located in the wall of the Short Stay Electrical Room.

Hospital Staff A, B and C verified these observations at the time of the survey process.

Based on record review and interview, the facility failed to comply with the fire drill requirements by failing to vary the times of the fire drills. This would affect all smoke zones within the hospital The facility had a capacity of 80 patients and a census of 19 patients.

Findings include:

Record review and interview on 8-24-15 at approximately 2:41 pm, revealed the facility failed to vary the times of the fire drills that were conducted on the 2nd and 3rd nursing shifts. During the previous 12 months, the 2nd shift fire drills only varied 40 minutes. Also, on the 3rd shift, the fire drills only varied 47 minutes.

Hospital Staff Members A, B and C verified these observations at the time of the survey process.

(A)
Based on record review and interview, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code, 1999 edition, by failing to manually lock the electrical breaker that is dedicated to the fire alarm system. This affects all the smoke zones in the hospital. The facility had a license of 80 patients and a census of 19 patients.

Findings include:

Record review and interview on 8-27-15 at approximately 9:42 am, revealed the absence of a locking mechanism on the electrical breaker that is dedicated to the buildings fire alarm system. This breaker shall be locked in the "On" position.

Hospital Staff A, B and C verified this observation during the survey process.


(B)
Based on observations and interview, the facility failed to provide the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code, 1999 edition, by improperly locating 9 smoke detectors. This affects 7 smoke zones within the facility. The facility had a license of 80 patients and a census of 19 patients

Findings include:

Observations and interview on 8-27-15, between the hours of 10:18 am and 11;44 am, revealed smoke detectors that were located closer than 3 feet from an air diffuser (HVAC) in the following locations:

1. The smoke detector in the 2nd Floor Kitchen.
2. The smoke detector in the Main Entrance Vestibule.
3. The smoke detector near the Information Desk.
4. The smoke detector in the Charge Nurse's Office.
5. The smoke detector in the 3rd Floor Nurse's Lounge.
6. The smoke detector in the 3rd Floor Clean Linen Room.
7. The smoke detector in the Laboratory Break Room.
8. The smoke detector in the Lab EKG area.
9. The smoke detector in the Gift Shop.

Hospital Staff A, B and C verified these observations during the survey process.

Based on observations and interview, the facility failed to provide drapery, curtains, including cubicle curtains in accordance with provisions of 10.3.1 of the Life Safety Code and NFPA 13, Standard for Installation of Sprinkler Systems, 1999 edition by allowing non-conforming mini-blinds. This affects 3 smoke zones in the hospital. The facility had a capacity of 80 patients and a census of 19 patients.

Findings include:

Observations and interview on 8-27-15, between the hours of 9:15 am and 11:32 am, revealed the following:

1. Vinyl mini-blinds in the I.T Office.
2. Vinyl mini-blinds in Patient Room #300.
3. Vinyl mini-blinds in Patient Room #305.
4. Vinyl mini-blinds in the Cardio-Pulmonary Services Room.

Hospital Staff A, B, and C verified these observations at the time of the survey process.

(A)
Based on observations 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, by failing to install a Ground Fault Circuit Interrupter electrical outlet in required area's. This affects 2 smoke zones in the hospital. The facility had a capacity of 80 patients and a census of 19 patients.

Findings include:

Observations and interview on 8-27-15 at approximately 9:53 and 10:03 am, revealed the absence of a required GFCI electrical outlet near the sink in the following rooms:

1. The Nurses Lounge by the Unassigned Space.
2. The 3rd Floor Nurses Lounge.

Hospital Staff A, B and C verified these observations at the time of the survey process.


(B)
Based on observations 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 by an electrical junction box to be uncovered, exposing wires. This affects 1 smoke zone in the hospital. The facility had a capacity of 80 patients and a census of 19 patients.

Findings include:

Observations and interview on 8-27-15 at approximately 9:33 am, revealed a large electrical junction box, with exposed wires, that failed to have cover placed on it located in the Boiler Room.

Hospital Staff A, B and C verified these observations at the time of the survey process.