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Based on observations and staff interview, this facility is not providing firewalls with a two-hour fire rating throughout the facility in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2000 edition. The facility has a capacity of 25 with a census of 13 patients.

Findings include:

Observations and staff interview on 12/7/15, between 1045 a.m. and 4:30 p.m., revealed the following deficiencies:

1. There was an open pipe, (approximately 1/4 inch), with communications lines running through it that was not sealed, extending through the 2 Hour Wall in the corridor by Door 5.
2. There was a penetration, (approximately 1 inch), around a pipe extending through the 2 hour wall separating the 2003 Building from the Level 1 Clinic Building.
3. There was a penetration, (approximately 1/4 inch), around a sprinkler pipe extending through the 2 Hour Wall separating the Emergency Department from the Ambulance Garage.
4. There was an open pipe, (approximately 1/2 inch), with communications lines running through it that was not sealed, extending through the 2 Hour Wall separating the Emergency Department from the Ambulance Garage.

Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, this facility failed to maintain smoke barriers in accordance with National Fire Protection Association (NFPA) Standard 101, 2000 edition, 19.3.7.3. Smoke barriers shall be continuous from outside wall to outside wall and from floor to a roof extending through all concealed spaces. Smoke barriers shall have a fire resistance rating of not less than 1/2 hour. The facility has a capacity of 25 with a census of 13 patients.

Findings include:

Observations and staff interview on 12/7/15, between 10:45 a.m. and 4:30 p.m., revealed the following deficiencies:

1. There was an open pipe, (approximately 4 inches), with communications lines running through it, extending through the smoke barrier wall by Room 101.
2. There was a penetration, (approximately 1/2 inch), around a piece of angle iron, extending through the smoke barrier wall by Room 101.
3. There were two open pipes, ( both approximately 4 inches), with communications lines running through them, extending through the smoke barrier wall in the Emergency Department by Exam Room 4.

Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, the facility failed to provide separation of hazardous areas from other compartments in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition, 19.3.2.1. The facility is composed of protected fire resistive construction equipped with a sprinkler system. Where a sprinkler system option is used to provide separation, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. The facility has a capacity of 25 with a census of 13 patients.

Findings include:

Observations and staff interview on 12/7/15 at 2:53 p.m., revealed the following deficiencies:

1. There was a penetration, (approximately 1/4 inch), around a pipe extending through the ceiling of the Kitchen.
2. There was a penetration, (approximately 3/16 inch), around a pipe hanger extending through the ceiling of the Kitchen.

Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, the facility failed to provide an exit sign in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition. Exits shall be marked by an approved sign readily visible from any direction of exit access. The facility has a capacity of 25 with a census of 13 patients.

Findings include:

Observation and staff interview on 12/7/15 at 2:45 p.m., revealed a missing exit sign in the corridor by the Kitchen Exit. Interview with Maintenance Staff A indicated the facility took the sign down while replacing the ceiling tile grid.

Based upon record review and staff interview, the facility failed to hold fire drills under varied conditions at different times of the day for one of four quarters reviewed. Fire drills shall be held at unexpected times under varying conditions, at least quarterly on each shift. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all patients in the event of a fire. The facility has a capacity of 25 with a census of 13 patients.

Findings include:

Record review and staff interview on 12/7/15 at 12:24 p.m., revealed no documentation of a fire drill conducted on the 3rd Shift in 1st Quarter of 2015. Interview with facility staff revealed the facility's former Facilities Director had mistakenly believed that the facility was only running two shifts. The former Facility Director had relayed this information to the State Fire Marshal's Office and had received authorization to only run two fire drills. The current Facility Director indicated that the information was incorrect and that the facility was in fact running three shifts.

Based on record review, observations and staff interview, the facility failed to provide a properly maintained fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, the National Fire Alarm Code, 1999 edition. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 13 patients.

Findings include:

Record review, observations and staff interview on 12/7/15, between 10:45 a.m. and 4:30 p.m., revealed the following deficiencies:

1. There was only one available fire alarm inspection report for 2015, dated 5/7/15.
2. Available documentation of fire alarm inspection reports indicated a period in excess of 6 months between inspections, dated 9/18/14 to 5/7/15.
3. The circuit breaker supplying power to the fire alarm system was not mechanically protected.
4. The location of the power supply for the fire alarm system was not labeled at the main fire alarm control panel.

Maintenance Staff A verified record review and observations during the survey process.

Based on observations and staff interview, 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. Installation of a smoke detector close to an air supply or return vent can impede the operation of the smoke detector. The facility has a capacity of 25 with a census of 13 patients.

Findings include:

Observation and staff interview on 12/7/15 at 1:43 p.m., revealed the following deficiencies:

1. There was a smoke detector installed within three feet of an air supply or return vent in the corridor by POD B.
2. There was a smoke detector installed within three feet of an air supply or return vent in the Soiled Utility Room by Room 123.

Maintenance Staff A verified observations during the survey process.

Based on record review, observations and staff interview, the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25, 1998 edition. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 13 patients.

Findings include:

Record review, observations and staff interview on 12/7/15, between 10:45 a.m. and 4:30 p.m., revealed the following deficiencies:

1. There was no available documentation of quarterly sprinkler system inspections for the 2nd and 4th Quarters of 2014.
2. There were no spare concealed type sprinkler heads in the sprinkler system maintenance box.
3. There was not a service wrench in the sprinkler system maintenance box.
4. There was a recessed sprinkler head missing a cover in Room 222.

Maintenance Staff A verified record review and observations during the survey process.

Based on observation and staff interview, the facility failed to maintain portable fire extinguishers in accordance with National Fire Protection Association (NFPA) Standard 10, Standard for Portable Fire Extinguishers, 1998 edition. The facility has a capacity of 25 with a census of 13 patients.

Findings include:

Observation and staff interview on 12/7/15 at 1:20 p.m., revealed the fire extinguisher in the Network Room was last inspected in August of 2014. Maintenance Staff A verified observations during the survey process.

Based on record review and staff interview, the facility failed to maintain the hood and fire-extinguishing equipment in accordance with National Fire Protection Association (NFPA) Standard 96, the standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 edition. The facility has a capacity of 25 with a census of 13 patients.

Findings include:

Record review and staff interview on 12/7/15, between 10:45 a.m. and 4:30 p.m., revealed the following deficiencies:

1. There was only one available inspection report for the Kitchen hood and duct extinguishment system for 2015, dated 11/19/15.
2. Available documentation of inspection reports for the Kitchen hood and duct system indicated that the system was not inspected every 6 months as required for 2014. Inspection reports were dated 3/12/14 and 5/23/14 for 2014.
3. There was no available documentation of monthly visual inspections of the Kitchen hood and duct system.
4. The inspection report for the Kitchen hood and duct system indicated deficiencies. The deficiencies were listed as follows: Failure of the mechanical gas shut off device. Piping that was in need of repair. There was no record that these issues were corrected.

Maintenance Staff A verified record review during the survey process.

Based on observation and staff interview, the facility failed to provide a remote manual stop station for the emergency generator set as required by National Fire Protection Association, NFPA 110, 1999 edition 3-5.5.6. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 13 patients.

Findings include,

Observation and staff interview on 12/7/15 at 2:00 p.m., revealed the facility failed to provide a remote manual stop station for the primary emergency generator set, located outside of the room containing the generator.

Maintenance Staff A verified observations during the survey process.

Based on observation and staff 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. The facility has a capacity of 25 with a census of 13 patients.

Findings include:

Observation and staff interview on 12/7/15 at 3:34 p.m., revealed an open electrical junction box in the corridor of the 1965 Building by the Network Room. Maintenance Staff A verified observations during the survey process.

Based on staff interview and record review, this facility is not assuring that a policy is in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than four hours in any twenty-four hour period. The lack of procedures could effect the actions taken by staff in the event of an emergency. This deficient practice affects all occupants of the building, including staff, visitors and residents. The facility has a capacity of 25 with a census of 13 patients.

Findings include:

Staff interview and record review on 12/7/15 at 11:21 a.m., revealed the facility does not have a policy in place regarding the procedures to be taken in the even the sprinkler system is out of service for more any four hours in a twenty-four hour period.

Maintenance Staff A verified record review during the survey process.

Based on staff interview and record review, this facility is not assuring that a policy is in place regarding the procedures to be taken in the event that the fire alarm system is out of service for more than four hours in any twenty-four hour period. The lack of procedures could effect the actions taken by staff in the event of an emergency. This deficient practice affects all occupants of the building, including staff, visitors and residents. The facility has a capacity of 25 with a census of 13 patients.

Findings include:

Staff interview and record review on 12/7/15 at 11:21 a.m., revealed the facility does not have a policy in place regarding the procedures to be taken in the even the fire alarm system is out of service for more any four hours in a twenty-four hour period.

Maintenance Staff A verified record review during the survey process.

Based on observations and staff interview, this facility is not providing firewalls with a two-hour fire rating throughout the facility in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2000 edition. The facility has a capacity of 25 with a census of 13 patients.

Findings include:

Observations and staff interview on 12/7/15, between 1045 a.m. and 4:30 p.m., revealed the following deficiencies:

1. There was an open pipe, (approximately 1/4 inch), with communications lines running through it that was not sealed, extending through the 2 Hour Wall in the corridor by Door 5.
2. There was a penetration, (approximately 1 inch), around a pipe extending through the 2 hour wall separating the 2003 Building from the Level 1 Clinic Building.
3. There was a penetration, (approximately 1/4 inch), around a sprinkler pipe extending through the 2 Hour Wall separating the Emergency Department from the Ambulance Garage.
4. There was an open pipe, (approximately 1/2 inch), with communications lines running through it that was not sealed, extending through the 2 Hour Wall separating the Emergency Department from the Ambulance Garage.

Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, this facility failed to maintain smoke barriers in accordance with National Fire Protection Association (NFPA) Standard 101, 2000 edition, 19.3.7.3. Smoke barriers shall be continuous from outside wall to outside wall and from floor to a roof extending through all concealed spaces. Smoke barriers shall have a fire resistance rating of not less than 1/2 hour. The facility has a capacity of 25 with a census of 13 patients.

Findings include:

Observations and staff interview on 12/7/15, between 10:45 a.m. and 4:30 p.m., revealed the following deficiencies:

1. There was an open pipe, (approximately 4 inches), with communications lines running through it, extending through the smoke barrier wall by Room 101.
2. There was a penetration, (approximately 1/2 inch), around a piece of angle iron, extending through the smoke barrier wall by Room 101.
3. There were two open pipes, ( both approximately 4 inches), with communications lines running through them, extending through the smoke barrier wall in the Emergency Department by Exam Room 4.

Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, the facility failed to provide separation of hazardous areas from other compartments in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition, 19.3.2.1. The facility is composed of protected fire resistive construction equipped with a sprinkler system. Where a sprinkler system option is used to provide separation, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. The facility has a capacity of 25 with a census of 13 patients.

Findings include:

Observations and staff interview on 12/7/15 at 2:53 p.m., revealed the following deficiencies:

1. There was a penetration, (approximately 1/4 inch), around a pipe extending through the ceiling of the Kitchen.
2. There was a penetration, (approximately 3/16 inch), around a pipe hanger extending through the ceiling of the Kitchen.

Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, the facility failed to provide an exit sign in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition. Exits shall be marked by an approved sign readily visible from any direction of exit access. The facility has a capacity of 25 with a census of 13 patients.

Findings include:

Observation and staff interview on 12/7/15 at 2:45 p.m., revealed a missing exit sign in the corridor by the Kitchen Exit. Interview with Maintenance Staff A indicated the facility took the sign down while replacing the ceiling tile grid.

Based upon record review and staff interview, the facility failed to hold fire drills under varied conditions at different times of the day for one of four quarters reviewed. Fire drills shall be held at unexpected times under varying conditions, at least quarterly on each shift. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all patients in the event of a fire. The facility has a capacity of 25 with a census of 13 patients.

Findings include:

Record review and staff interview on 12/7/15 at 12:24 p.m., revealed no documentation of a fire drill conducted on the 3rd Shift in 1st Quarter of 2015. Interview with facility staff revealed the facility's former Facilities Director had mistakenly believed that the facility was only running two shifts. The former Facility Director had relayed this information to the State Fire Marshal's Office and had received authorization to only run two fire drills. The current Facility Director indicated that the information was incorrect and that the facility was in fact running three shifts.

Based on record review, observations and staff interview, the facility failed to provide a properly maintained fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, the National Fire Alarm Code, 1999 edition. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 13 patients.

Findings include:

Record review, observations and staff interview on 12/7/15, between 10:45 a.m. and 4:30 p.m., revealed the following deficiencies:

1. There was only one available fire alarm inspection report for 2015, dated 5/7/15.
2. Available documentation of fire alarm inspection reports indicated a period in excess of 6 months between inspections, dated 9/18/14 to 5/7/15.
3. The circuit breaker supplying power to the fire alarm system was not mechanically protected.
4. The location of the power supply for the fire alarm system was not labeled at the main fire alarm control panel.

Maintenance Staff A verified record review and observations during the survey process.

Based on observations and staff interview, 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. Installation of a smoke detector close to an air supply or return vent can impede the operation of the smoke detector. The facility has a capacity of 25 with a census of 13 patients.

Findings include:

Observation and staff interview on 12/7/15 at 1:43 p.m., revealed the following deficiencies:

1. There was a smoke detector installed within three feet of an air supply or return vent in the corridor by POD B.
2. There was a smoke detector installed within three feet of an air supply or return vent in the Soiled Utility Room by Room 123.

Maintenance Staff A verified observations during the survey process.

Based on record review, observations and staff interview, the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25, 1998 edition. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 13 patients.

Findings include:

Record review, observations and staff interview on 12/7/15, between 10:45 a.m. and 4:30 p.m., revealed the following deficiencies:

1. There was no available documentation of quarterly sprinkler system inspections for the 2nd and 4th Quarters of 2014.
2. There were no spare concealed type sprinkler heads in the sprinkler system maintenance box.
3. There was not a service wrench in the sprinkler system maintenance box.
4. There was a recessed sprinkler head missing a cover in Room 222.

Maintenance Staff A verified record review and observations during the survey process.

Based on observation and staff interview, the facility failed to maintain portable fire extinguishers in accordance with National Fire Protection Association (NFPA) Standard 10, Standard for Portable Fire Extinguishers, 1998 edition. The facility has a capacity of 25 with a census of 13 patients.

Findings include:

Observation and staff interview on 12/7/15 at 1:20 p.m., revealed the fire extinguisher in the Network Room was last inspected in August of 2014. Maintenance Staff A verified observations during the survey process.

Based on record review and staff interview, the facility failed to maintain the hood and fire-extinguishing equipment in accordance with National Fire Protection Association (NFPA) Standard 96, the standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 edition. The facility has a capacity of 25 with a census of 13 patients.

Findings include:

Record review and staff interview on 12/7/15, between 10:45 a.m. and 4:30 p.m., revealed the following deficiencies:

1. There was only one available inspection report for the Kitchen hood and duct extinguishment system for 2015, dated 11/19/15.
2. Available documentation of inspection reports for the Kitchen hood and duct system indicated that the system was not inspected every 6 months as required for 2014. Inspection reports were dated 3/12/14 and 5/23/14 for 2014.
3. There was no available documentation of monthly visual inspections of the Kitchen hood and duct system.
4. The inspection report for the Kitchen hood and duct system indicated deficiencies. The deficiencies were listed as follows: Failure of the mechanical gas shut off device. Piping that was in need of repair. There was no record that these issues were corrected.

Maintenance Staff A verified record review during the survey process.

Based on observation and staff interview, the facility failed to provide a remote manual stop station for the emergency generator set as required by National Fire Protection Association, NFPA 110, 1999 edition 3-5.5.6. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 13 patients.

Findings include,

Observation and staff interview on 12/7/15 at 2:00 p.m., revealed the facility failed to provide a remote manual stop station for the primary emergency generator set, located outside of the room containing the generator.

Maintenance Staff A verified observations during the survey process.

Based on observation and staff 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. The facility has a capacity of 25 with a census of 13 patients.

Findings include:

Observation and staff interview on 12/7/15 at 3:34 p.m., revealed an open electrical junction box in the corridor of the 1965 Building by the Network Room. Maintenance Staff A verified observations during the survey process.

Based on staff interview and record review, this facility is not assuring that a policy is in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than four hours in any twenty-four hour period. The lack of procedures could effect the actions taken by staff in the event of an emergency. This deficient practice affects all occupants of the building, including staff, visitors and residents. The facility has a capacity of 25 with a census of 13 patients.

Findings include:

Staff interview and record review on 12/7/15 at 11:21 a.m., revealed the facility does not have a policy in place regarding the procedures to be taken in the even the sprinkler system is out of service for more any four hours in a twenty-four hour period.

Maintenance Staff A verified record review during the survey process.

Based on staff interview and record review, this facility is not assuring that a policy is in place regarding the procedures to be taken in the event that the fire alarm system is out of service for more than four hours in any twenty-four hour period. The lack of procedures could effect the actions taken by staff in the event of an emergency. This deficient practice affects all occupants of the building, including staff, visitors and residents. The facility has a capacity of 25 with a census of 13 patients.

Findings include:

Staff interview and record review on 12/7/15 at 11:21 a.m., revealed the facility does not have a policy in place regarding the procedures to be taken in the even the fire alarm system is out of service for more any four hours in a twenty-four hour period.

Maintenance Staff A verified record review during the survey process.