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Based on observations and interview, the facility has failed to properly construct and maintain a required 2-hour fire separation, in accordance with NFPA 101 (2000), Chapter 19, Sections 19.1.1.4 and 19.1.2.1. In a fire emergency, this deficient practice could adversely affect the safety of 3 patients, staff and visitors.

FINDINGS INCLUDE:

During the facility tour between the hours of 10:00 AM and 12:30 PM on 4/08/2015, observation revealed:

1. A non-conforming structure of wood frame construction, which was attached to the exterior wall of the hospital on the west side of the building, outside of the Maintenance Corridor exit discharge doors.


2. The 2 hour fire separation wall between the Hospital and the Pines Assisted Living has penetrations above the lay-in ceiling.

3.The door in the 2 hour fire separation the Hospital and the Pines Assisted Living does not positively latch. The door handle has been strapped in manner to prevent the door latch from positively latching into the door frame.

4.The rated wall in the Ambulance Garage has penetrations in the wall that need to be sealed.



This finding was confirmed with the Chief Building Engineer (GB) at the time of discovery.

Based on observation and a staff interview, the facility failed to maintain one or more corridor doors in the means of egress in accordance with the requirements at NFPA 101 (2000) Chapter 19, Section 19.3.6.3. and Chapter 7, Section 7.2. In a fire emergency, this deficient practice could adversely affect any patients, staff or visitors within the affected smoke compartment.

FINDINGS INCLUDE:

During the facility tour between the hours of 10:00 AM and 12:30 PM on 4/08/2015, observation revealed:

1. Corridor doors on rooms: 210, 203-S, 204-Tand 204-U were not equipped with positive latching hardware.

2. Corridor doors on rooms: 206, 207, 210, and 211 have two hole openings near the door handles that go completely thru the door and tops of these doors have approximately 1/2 inch gap that prevents the door from sealing against the door frame.

3. Corridor doors 203-S and 204-T have roller latches installed on the doors.


This finding was confirmed with the Chief Building Engineer (GB) at the time of discovery.

Based on observation and staff interview, the facility failed to maintain hazardous area in accordance with the following requirements of 2000 NFPA 101, Section 8.4.1 and/or 19.3.5.4.


Findings include:

During the facility tour between the hours of 10:00 AM and 12:30 PM on 4/08/2015, observation revealed:

1. Soiled Utility Room 204-4 does not have a self-closing device.

2. Linen Storage Room (which is over 50 sq.ft.) between room 207 and 209 did not have a fire rated door present that would positively latch into the door frame.

3.Therapy Room between room 207 and 209 did not have a fire rated door present that would positively latch into the door frame.


These findings was confirmed with the Chief Building Engineer (GB) at the time of discovery.

Based on observation and staff interview, the facility failed to provide reliable lighting for all components of the means of egress as required by 2000 NFPA 101, Section 19..2.9.1, 7.8, and 7.9.

Findings include:

During the facility tour between the hours of 10:00 AM and 12:30 PM on 4/08/2015, observation revealed:

That the exit discharge between the Hospital and Pines Assisted Living did not have a two bulb fixture on exterior of building.

This finding was confirmed with the Chief Building Engineer (GB) at the time of discovery.

Based upon a review of available reports, records and interview, it was determined the facility had failed to conduct one or more fire drills on a quarterly basis for each shift, in accordance with NFPA 101 (2000) Chapter 19, Section 19.7.1.2.. In a fire emergency, this deficient practice could adversely affect the safety of 3 of 20 patients, staff and visitors throughout the facility.

FINDINGS INCLUDE:

During the facility tour between the hours of 10:00 AM and 12:30 PM on 4/08/2015, a review of the facility's fire drill reports was conducted with the Chief Building Engineer [GB]. it was noted that the facility operates two 12-hour shifts in each 24-hour period. A review of available documentation confirmed that required fire drills were not conducted on the Night-shift [19:00 hours to 07:00 hours] during the previous 1st and 3rd Quarters and on the Day-shift [07:00 hours to 19:00 hours] as calculated commencing with April, 2014, forward through March, 2015 not in accordance with section 19.7.1.2.

Based on documentation review and staff interview, the facility failed maintain the fire alarm system in accordance with the requirement 1999 NFPA 72, Sections 7-3.2 and 7-3.2.1.

Findings include:

On facility tour between the hours of 10:00 AM and 12:30 PM on 4/08/2015, during documentation review it was revealed that the bi-annual smoke detector sensitivity testing documentation was not available for review.


This finding was confirmed with the Chief Building Engineer (GB) at the time of discovery.

Based on documentation review and interview with staff, the facility has failed to properly inspect and maintain the automatic sprinkler system in accordance with NFPA 101 LSC (00) section 19.7.6, 4.6.12. This deficient practice does not ensure that the fire sprinkler system is functioning properly and is fully operational in the event of a fire and could negatively affect all patients.

Findings include:

During the facility tour between the hours of 10:00 AM and 12:30 PM on 4/08/2015, during documentation review with the Chief Building Engineer , it was revealed that the facility failed to provide documentation of the quarterly fire sprinkler flow tests inspections required by NFPA 13(99) and NFPA 25(98).

Based on observation and a staff interview with the Hospital Administrator (MR), it was determined that a Commercial Style Gas Oven that is used occasionally for staff functions was not protected in accordance with NFPA 101 (00) section 19.3.2.6 and 9.2.3 and NFPA 96 (98). In a fire emergency within the staff lounge, this deficient practice could adversely affect all patients, staff and visitors.


FINDINGS INCLUDE:

During the facility tour between the hours of 10:00 AM and 12:30 PM on 4/08/2015, it was observed during an inspection of the facility's staff lounge area, room# 323, that a commercial oven was sitting under an exhaust hood with no automatic fire extinguishing system providing fire protection for the oven,, in accordance with NFPA 96 (98) Chapter 7, Section 7-6.2.

This finding was confirmed with the Chief Building Engineer (GB) at the time of discovery.

Based on observation and interview, the facility was storing medical gas cylinders in a manner not in conformance with NFPA 99 (1999 edition) Chapter 4, Section 4-3.1.1.1.

FINDINGS INCLUDE:

During the facility tour between the hours of 10:00 AM and 12:30 PM on 4/08/2015, observation revealed:

1.Four (4) oxygen cylinders stored inside of the Environmental Services Room #406. These cylinders were stored on the floor surface, in an upright position, and had combustible material stored within five feet of the oxygen cylinders.

2. There was no sign present on the door of Room #406 indicating that oxygen was stored within this room.

This finding was confirmed with the Chief Building Engineer (GB) at the time of discovery.

During documentation review and interview, the facility has failed to properly document weekly and monthly inspections of the emergency generator in accordance with NFPA 99 and NFPA 110. This deficient practice could affect all 3 patients, staff and visitors in the event of a loss of power and generator failure.

Findings include:

During the facility tour between the hours of 10:00 AM and 12:30 PM on 4/08/2015, during documentation review it was revealed that:

1.The weekly generator inspections several weeks were not recorded during the past year indicating a weekly inspection of the emergency generator occurred, only dates listed were the weeks of 2/16/15, 1/13/15, 1/7/15 and 12/17/14 and,

2.There was no documentation available for review that documented the monthly emergency generator inspections and that the generator load test had occurred during the 2015 or 2014. The Facility failed to maintain and to document all the required information during monthly generator load test in accordance with NFPA 110 (99).

Based on observations and interview, the facility has failed to properly construct and maintain a required 2-hour fire separation, in accordance with NFPA 101 (2000), Chapter 19, Sections 19.1.1.4 and 19.1.2.1. In a fire emergency, this deficient practice could adversely affect the safety of 3 patients, staff and visitors.

FINDINGS INCLUDE:

During the facility tour between the hours of 10:00 AM and 12:30 PM on 4/08/2015, observation revealed:

1. A non-conforming structure of wood frame construction, which was attached to the exterior wall of the hospital on the west side of the building, outside of the Maintenance Corridor exit discharge doors.


2. The 2 hour fire separation wall between the Hospital and the Pines Assisted Living has penetrations above the lay-in ceiling.

3.The door in the 2 hour fire separation the Hospital and the Pines Assisted Living does not positively latch. The door handle has been strapped in manner to prevent the door latch from positively latching into the door frame.

4.The rated wall in the Ambulance Garage has penetrations in the wall that need to be sealed.



This finding was confirmed with the Chief Building Engineer (GB) at the time of discovery.

Based on observation and a staff interview, the facility failed to maintain one or more corridor doors in the means of egress in accordance with the requirements at NFPA 101 (2000) Chapter 19, Section 19.3.6.3. and Chapter 7, Section 7.2. In a fire emergency, this deficient practice could adversely affect any patients, staff or visitors within the affected smoke compartment.

FINDINGS INCLUDE:

During the facility tour between the hours of 10:00 AM and 12:30 PM on 4/08/2015, observation revealed:

1. Corridor doors on rooms: 210, 203-S, 204-Tand 204-U were not equipped with positive latching hardware.

2. Corridor doors on rooms: 206, 207, 210, and 211 have two hole openings near the door handles that go completely thru the door and tops of these doors have approximately 1/2 inch gap that prevents the door from sealing against the door frame.

3. Corridor doors 203-S and 204-T have roller latches installed on the doors.


This finding was confirmed with the Chief Building Engineer (GB) at the time of discovery.

Based on observation and staff interview, the facility failed to maintain hazardous area in accordance with the following requirements of 2000 NFPA 101, Section 8.4.1 and/or 19.3.5.4.


Findings include:

During the facility tour between the hours of 10:00 AM and 12:30 PM on 4/08/2015, observation revealed:

1. Soiled Utility Room 204-4 does not have a self-closing device.

2. Linen Storage Room (which is over 50 sq.ft.) between room 207 and 209 did not have a fire rated door present that would positively latch into the door frame.

3.Therapy Room between room 207 and 209 did not have a fire rated door present that would positively latch into the door frame.


These findings was confirmed with the Chief Building Engineer (GB) at the time of discovery.

Based on observation and staff interview, the facility failed to provide reliable lighting for all components of the means of egress as required by 2000 NFPA 101, Section 19..2.9.1, 7.8, and 7.9.

Findings include:

During the facility tour between the hours of 10:00 AM and 12:30 PM on 4/08/2015, observation revealed:

That the exit discharge between the Hospital and Pines Assisted Living did not have a two bulb fixture on exterior of building.

This finding was confirmed with the Chief Building Engineer (GB) at the time of discovery.

Based upon a review of available reports, records and interview, it was determined the facility had failed to conduct one or more fire drills on a quarterly basis for each shift, in accordance with NFPA 101 (2000) Chapter 19, Section 19.7.1.2.. In a fire emergency, this deficient practice could adversely affect the safety of 3 of 20 patients, staff and visitors throughout the facility.

FINDINGS INCLUDE:

During the facility tour between the hours of 10:00 AM and 12:30 PM on 4/08/2015, a review of the facility's fire drill reports was conducted with the Chief Building Engineer [GB]. it was noted that the facility operates two 12-hour shifts in each 24-hour period. A review of available documentation confirmed that required fire drills were not conducted on the Night-shift [19:00 hours to 07:00 hours] during the previous 1st and 3rd Quarters and on the Day-shift [07:00 hours to 19:00 hours] as calculated commencing with April, 2014, forward through March, 2015 not in accordance with section 19.7.1.2.

Based on documentation review and staff interview, the facility failed maintain the fire alarm system in accordance with the requirement 1999 NFPA 72, Sections 7-3.2 and 7-3.2.1.

Findings include:

On facility tour between the hours of 10:00 AM and 12:30 PM on 4/08/2015, during documentation review it was revealed that the bi-annual smoke detector sensitivity testing documentation was not available for review.


This finding was confirmed with the Chief Building Engineer (GB) at the time of discovery.

Based on documentation review and interview with staff, the facility has failed to properly inspect and maintain the automatic sprinkler system in accordance with NFPA 101 LSC (00) section 19.7.6, 4.6.12. This deficient practice does not ensure that the fire sprinkler system is functioning properly and is fully operational in the event of a fire and could negatively affect all patients.

Findings include:

During the facility tour between the hours of 10:00 AM and 12:30 PM on 4/08/2015, during documentation review with the Chief Building Engineer , it was revealed that the facility failed to provide documentation of the quarterly fire sprinkler flow tests inspections required by NFPA 13(99) and NFPA 25(98).

Based on observation and a staff interview with the Hospital Administrator (MR), it was determined that a Commercial Style Gas Oven that is used occasionally for staff functions was not protected in accordance with NFPA 101 (00) section 19.3.2.6 and 9.2.3 and NFPA 96 (98). In a fire emergency within the staff lounge, this deficient practice could adversely affect all patients, staff and visitors.


FINDINGS INCLUDE:

During the facility tour between the hours of 10:00 AM and 12:30 PM on 4/08/2015, it was observed during an inspection of the facility's staff lounge area, room# 323, that a commercial oven was sitting under an exhaust hood with no automatic fire extinguishing system providing fire protection for the oven,, in accordance with NFPA 96 (98) Chapter 7, Section 7-6.2.

This finding was confirmed with the Chief Building Engineer (GB) at the time of discovery.

Based on observation and interview, the facility was storing medical gas cylinders in a manner not in conformance with NFPA 99 (1999 edition) Chapter 4, Section 4-3.1.1.1.

FINDINGS INCLUDE:

During the facility tour between the hours of 10:00 AM and 12:30 PM on 4/08/2015, observation revealed:

1.Four (4) oxygen cylinders stored inside of the Environmental Services Room #406. These cylinders were stored on the floor surface, in an upright position, and had combustible material stored within five feet of the oxygen cylinders.

2. There was no sign present on the door of Room #406 indicating that oxygen was stored within this room.

This finding was confirmed with the Chief Building Engineer (GB) at the time of discovery.

During documentation review and interview, the facility has failed to properly document weekly and monthly inspections of the emergency generator in accordance with NFPA 99 and NFPA 110. This deficient practice could affect all 3 patients, staff and visitors in the event of a loss of power and generator failure.

Findings include:

During the facility tour between the hours of 10:00 AM and 12:30 PM on 4/08/2015, during documentation review it was revealed that:

1.The weekly generator inspections several weeks were not recorded during the past year indicating a weekly inspection of the emergency generator occurred, only dates listed were the weeks of 2/16/15, 1/13/15, 1/7/15 and 12/17/14 and,

2.There was no documentation available for review that documented the monthly emergency generator inspections and that the generator load test had occurred during the 2015 or 2014. The Facility failed to maintain and to document all the required information during monthly generator load test in accordance with NFPA 110 (99).