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Based on observation and staff interview the facility is not assuring that 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. This deficient practice affects 2 of 2 smoke zones. The facility has a capacity of 25 with a census of 7.

Findings include:

During the tour on 4/17/12 between 12:30 PM and 3:45 PM the following is observed:

--1) There is unsealed sheet rock seams around pipes and sheet rock that had been installed to cover exposed wood up against the smoke barrier wall, and there is a small hole in the lower corner where wires have been removed on the West side of the one smoke barrier wall.
--2) There is exposed wood against the smoke barrier wall, a gap between the heating & cooling pips, two open wire chases and other gaps around conduits and wires on the East side of the one smoke barrier wall.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1

Based on observation and staff interview the facility failed to ensure proper separation of hazardous areas from other spaces. This deficient practice would allow for the spread of smoke and fire to travel into the adjacent area, affecting 1 of 2 smoke zones. The facility has a capacity of 25 with a census of 7.

Findings include:

During the tour on 4/17/12 between 12:30 PM and 3:45 PM the following is observed:

--1) There is no self closing device on the over 50 sq ft storage room, there are gaps around pipes and conduits on the east wall, and there is an access door through the east wall that has been screwed back onto the wall and there is a gap around the entire door. The access door, when removed, is open to the Boiler/Riser room - in the upper Loft Storage room.
--2) The under side of the Loft stairs are inside a small storage room. The stairs are plywood as well as a section of the floor that is exposed to the storage room that opens up into the Boiler/Riser room.
There is no one hour separation between the upper Loft storage room and the Boiler/Riser room.
--3) There is a small hole on the back wall and gaps around pipes on the corridor wall of the Storage room.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Based on observation and staff interview the facility fails to assure there is normal illumination in all exit corridors, failing to ensure that all areas of egress will not be left in total darkness. The deficient practice affects 1 of 2 smoke zones. The facility has a capacity of 25 with a census of 7.

Findings include:

During the tour on 4/17/12 between 12:30 PM and 3:45 PM it is observed there is no normal illumination in the East patient exit corridor, the OB exit corridor or at the Nurses' desk. All lights can be turned off with a manual switch.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Required illumination shall be arranged so that the failure of any single bulb or unit does not result in less than .2 foot-candles of illumination in any designated area. 2000 NFPA 101, 7.8.1.4

Based on record review and staff interview the facility failed to ensure that battery powered emergency lighting is tested for 90 minutes annually and documented. This deficient practice could result in the lights not operating for the minimum required time in the event of an emergency, affecting 1 of 2 smoke zones. The facility has a capacity of 25 with a census of 7.

Findings Include:

During the tour on 4/17/12 between 12:30 PM and 3:45 PM it is observed there was no annual 90 minute emergency light test conducted in Feb '12. The last 90 minute test is dated as Feb '11.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: 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 and 1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 2000 NFPA 101, 7.9.3

Based on record review and staff interview the facility failed to assure that fire drills are held at least quarterly on each shift. This deficient practice may prevent proper evacuation in a timely manner due to staff ' s inability to respond in the event of an emergency, affecting 2 of 2 smoke zones. This facility has a capacity of 25 with a census of 7.

Findings include:

During the tour on 4/17/12 between 12:30 PM and 3:45 PM the following is observed:

--1) There was no 2nd shift fire drill conducted for the first quarter of 2012.
--2) There was no 2nd shift fire drill conducted for the 2nd shift of the second quarter of 2011.
--3) There was no 1st shift fire drill conducted for the third quarter of 2011.
--4) There was no 1st shift fire drill conducted for the fourth quarter of 2011.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 19.7.1.2

Based on observation and staff interview, the facility failed to assure that the fire alarm system required for life safety is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. This deficiency fails to ensure that the fire alarm system control functions are working properly jeopardizing the safety of all building occupants. This deficiency would affect 2 of 2 smoke zones. This facility has a capacity 25 with a census of 7.

Findings include:

During the tour on 4/17/12 between 12:30 PM and 3:45 PM it is observed when the primary phone line was disconnected from the fire alarm panel - the monitoring company received the phone line fault within 3 minutes. The fire alarm sounded for a short time then went silent. The FAP (fire alarm panel) did not go into trouble mode. The alarm memory light was lit at all times surveyor was in the building.

Maintenance Staff A was present and acknowledged the finding. Maintenance Staff A stated the fire alarm company would be contacted for the corrections to be made.

NFPA Standard: Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2. 1999 NFPA 72, 7-2.2

Based on observation and staff interviews, the facility does not assure that the automatic fire sprinkler system is maintained properly. This deficient practice fails to prevent possible sagging of pipes, affecting 1 of 2 smoke zones. The facility has a capacity of 25 with a census of 7.

Findings include:

During the tour on 4/17/12 between 12:30 PM and 3:45 PM the following is observed:

--1) There is multiple IT wires attached to the sprinkler pipe in Central Supply and O.R. hallway.
--2) There is multiple wires attached to the sprinkler pipe by wire in the Store room.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. 1999 NFPA 13, 12.1

Based upon record review and staff interview the facility could not produce documentation indicating proper maintenance for the kitchen hood heat removal system as required by NFPA 96 " Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations " . Failure to clean these portions of the hood vapor removal system could cause a fire, affecting 1 of 2 smoke zones. The facility has a capacity of 25 with a census of 7.

Finding Include:

During the tour on 4/17/12 between 12:30 PM and 3:45 PM it is observed the kitchen hood flue has not been cleaned since Aug 2009.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s). 1998 NFPA 96, 8-3.1

Based on observation and staff interview the facility failed to ensure that the means of egress are continuously maintained free of all obstructions or impediments, which would prevent full instant use of the means of egress in the case of a fire or other emergency. This deficiency affects 1 of 2 smoke zones. This facility has a capacity of 25 with a census of 7.

Findings include:

During the tour on 4/17/12 between 12:30 PM and 3:45 PM it is observed there is a copy machine stored in the exit corridor across from the Nurses desk.

Maintenance Staff A was present and acknowledged the finding.

NFPA standards: No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof. 2000 NFPA 101, 7.1.10.2.1

Based on record review and staff interview, the facility fails to conduct and properly document testing and maintenance of the generator in accordance with NFPA 99 and NFPA 110. The deficient practice potentially reduces the reliability of the generator. The deficient practice affects 2 of 2 smoke zones. The facility has a capacity of 25 with a census of 7.

Findings include:

During the tour on 4/17/12 between 12:30 PM and 3:45 PM it is observed there is no transfer time recorded for the monthly load tests dated May '11, June '11, Sept '11 and Jan '12.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Generator sets or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures. 1999 NFPA 99, 3-4.4.1.1

Based on observation and staff interview the facility failed to assure that electrical equipment is properly maintained and installed in accordance with NFPA 70, National Electric Code. This deficient practice could cause an electrical failure or fire, affecting 1 out of 2 smoke zones. The facility has a capacity of 25 with a census of 7.

Findings include:

During the tour on 4/17/12 between 12:30 PM and 3:45 PM it is observed there is two open spaces in Electrical panel E in Central Supply.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: All energized distribution panels/components shall be provided with protective covers that keep personnel separated from live electrical components. NFPA 70, 1999 ed

Based on observation and staff interview the facility is not assuring that 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. This deficient practice affects 2 of 2 smoke zones. The facility has a capacity of 25 with a census of 7.

Findings include:

During the tour on 4/17/12 between 12:30 PM and 3:45 PM the following is observed:

--1) There is unsealed sheet rock seams around pipes and sheet rock that had been installed to cover exposed wood up against the smoke barrier wall, and there is a small hole in the lower corner where wires have been removed on the West side of the one smoke barrier wall.
--2) There is exposed wood against the smoke barrier wall, a gap between the heating & cooling pips, two open wire chases and other gaps around conduits and wires on the East side of the one smoke barrier wall.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1

Based on observation and staff interview the facility failed to ensure proper separation of hazardous areas from other spaces. This deficient practice would allow for the spread of smoke and fire to travel into the adjacent area, affecting 1 of 2 smoke zones. The facility has a capacity of 25 with a census of 7.

Findings include:

During the tour on 4/17/12 between 12:30 PM and 3:45 PM the following is observed:

--1) There is no self closing device on the over 50 sq ft storage room, there are gaps around pipes and conduits on the east wall, and there is an access door through the east wall that has been screwed back onto the wall and there is a gap around the entire door. The access door, when removed, is open to the Boiler/Riser room - in the upper Loft Storage room.
--2) The under side of the Loft stairs are inside a small storage room. The stairs are plywood as well as a section of the floor that is exposed to the storage room that opens up into the Boiler/Riser room.
There is no one hour separation between the upper Loft storage room and the Boiler/Riser room.
--3) There is a small hole on the back wall and gaps around pipes on the corridor wall of the Storage room.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Based on observation and staff interview the facility fails to assure there is normal illumination in all exit corridors, failing to ensure that all areas of egress will not be left in total darkness. The deficient practice affects 1 of 2 smoke zones. The facility has a capacity of 25 with a census of 7.

Findings include:

During the tour on 4/17/12 between 12:30 PM and 3:45 PM it is observed there is no normal illumination in the East patient exit corridor, the OB exit corridor or at the Nurses' desk. All lights can be turned off with a manual switch.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Required illumination shall be arranged so that the failure of any single bulb or unit does not result in less than .2 foot-candles of illumination in any designated area. 2000 NFPA 101, 7.8.1.4

Based on record review and staff interview the facility failed to ensure that battery powered emergency lighting is tested for 90 minutes annually and documented. This deficient practice could result in the lights not operating for the minimum required time in the event of an emergency, affecting 1 of 2 smoke zones. The facility has a capacity of 25 with a census of 7.

Findings Include:

During the tour on 4/17/12 between 12:30 PM and 3:45 PM it is observed there was no annual 90 minute emergency light test conducted in Feb '12. The last 90 minute test is dated as Feb '11.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: 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 and 1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 2000 NFPA 101, 7.9.3

Based on record review and staff interview the facility failed to assure that fire drills are held at least quarterly on each shift. This deficient practice may prevent proper evacuation in a timely manner due to staff ' s inability to respond in the event of an emergency, affecting 2 of 2 smoke zones. This facility has a capacity of 25 with a census of 7.

Findings include:

During the tour on 4/17/12 between 12:30 PM and 3:45 PM the following is observed:

--1) There was no 2nd shift fire drill conducted for the first quarter of 2012.
--2) There was no 2nd shift fire drill conducted for the 2nd shift of the second quarter of 2011.
--3) There was no 1st shift fire drill conducted for the third quarter of 2011.
--4) There was no 1st shift fire drill conducted for the fourth quarter of 2011.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 19.7.1.2

Based on observation and staff interview, the facility failed to assure that the fire alarm system required for life safety is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. This deficiency fails to ensure that the fire alarm system control functions are working properly jeopardizing the safety of all building occupants. This deficiency would affect 2 of 2 smoke zones. This facility has a capacity 25 with a census of 7.

Findings include:

During the tour on 4/17/12 between 12:30 PM and 3:45 PM it is observed when the primary phone line was disconnected from the fire alarm panel - the monitoring company received the phone line fault within 3 minutes. The fire alarm sounded for a short time then went silent. The FAP (fire alarm panel) did not go into trouble mode. The alarm memory light was lit at all times surveyor was in the building.

Maintenance Staff A was present and acknowledged the finding. Maintenance Staff A stated the fire alarm company would be contacted for the corrections to be made.

NFPA Standard: Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2. 1999 NFPA 72, 7-2.2

Based on observation and staff interviews, the facility does not assure that the automatic fire sprinkler system is maintained properly. This deficient practice fails to prevent possible sagging of pipes, affecting 1 of 2 smoke zones. The facility has a capacity of 25 with a census of 7.

Findings include:

During the tour on 4/17/12 between 12:30 PM and 3:45 PM the following is observed:

--1) There is multiple IT wires attached to the sprinkler pipe in Central Supply and O.R. hallway.
--2) There is multiple wires attached to the sprinkler pipe by wire in the Store room.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. 1999 NFPA 13, 12.1

Based upon record review and staff interview the facility could not produce documentation indicating proper maintenance for the kitchen hood heat removal system as required by NFPA 96 " Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations " . Failure to clean these portions of the hood vapor removal system could cause a fire, affecting 1 of 2 smoke zones. The facility has a capacity of 25 with a census of 7.

Finding Include:

During the tour on 4/17/12 between 12:30 PM and 3:45 PM it is observed the kitchen hood flue has not been cleaned since Aug 2009.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s). 1998 NFPA 96, 8-3.1

Based on observation and staff interview the facility failed to ensure that the means of egress are continuously maintained free of all obstructions or impediments, which would prevent full instant use of the means of egress in the case of a fire or other emergency. This deficiency affects 1 of 2 smoke zones. This facility has a capacity of 25 with a census of 7.

Findings include:

During the tour on 4/17/12 between 12:30 PM and 3:45 PM it is observed there is a copy machine stored in the exit corridor across from the Nurses desk.

Maintenance Staff A was present and acknowledged the finding.

NFPA standards: No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof. 2000 NFPA 101, 7.1.10.2.1

Based on record review and staff interview, the facility fails to conduct and properly document testing and maintenance of the generator in accordance with NFPA 99 and NFPA 110. The deficient practice potentially reduces the reliability of the generator. The deficient practice affects 2 of 2 smoke zones. The facility has a capacity of 25 with a census of 7.

Findings include:

During the tour on 4/17/12 between 12:30 PM and 3:45 PM it is observed there is no transfer time recorded for the monthly load tests dated May '11, June '11, Sept '11 and Jan '12.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Generator sets or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures. 1999 NFPA 99, 3-4.4.1.1

Based on observation and staff interview the facility failed to assure that electrical equipment is properly maintained and installed in accordance with NFPA 70, National Electric Code. This deficient practice could cause an electrical failure or fire, affecting 1 out of 2 smoke zones. The facility has a capacity of 25 with a census of 7.

Findings include:

During the tour on 4/17/12 between 12:30 PM and 3:45 PM it is observed there is two open spaces in Electrical panel E in Central Supply.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: All energized distribution panels/components shall be provided with protective covers that keep personnel separated from live electrical components. NFPA 70, 1999 ed