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Based on observation and interview, the facility failed to maintain a 2 hour rated fire resistant wall between the Hospital and the Administration area in accordance with Section 19.1.1.4.1 of the 2000 Life Safety Code. This facility had a capacity of 25 patients and a census of 18 patients.
Findings include:
Observations and interview on 2-19-14 revealed the following:
1. A wire penetration (approximately 1/2 inches in size) located in the 2 hour fire wall above the corridor doors that separate the Administration Area from the Hospital.
2. A wire penetration (approximately 1/2 inches in size) located in the 2 hour fire wall above the corridor door #150H.
3. A wire penetration (approximately 1/2 inches in size) located in the 2 hour fire wall above the corridor door #1600.
4. Two holes (approximately 1 inch by 2 inches in size) located in the 2 hour fire wall near the East Laboratory Reception Desk.
Maintenance Supervisor A verified these observations at the time of the survey process.

Based on observations and interview, the facility failed to maintain 3 hazardous rooms properly separated by allowing penetrations to be present. The facility had a capacity of 25 patients and a census of 18 patients.

Findings include:

Observations and interview on 2-19-14 revealed the following:

1. A pipe penetration (approximately 1/2 inch in size), a conduit penetration (approximately 1/4 inch in size, and a wire penetration (approximately 1/4 inch in size), located above the east door of the Boiler Room.

2. A pipe penetration (approximately 1/2 inches in size) located above the North Laundry Room door.

3. A wire penetration (approximately 1/4 inch in size) located in the north wall of Electrical Room #3801.

Maintenance Supervisor A verified these observations at the time of the survey process.

(A)
Based on record review and interview, the facility failed to provide documentation that the battery back-up emergency lighting system was being properly tested on a annual basis for 90 minutes. The facility had a license capacity of 25 patients and a census of 15 patients.

Findings include:

Record review and interview on 2-19-14 revealed the absence of the required 90 minute annual testing of the facilities battery back-up emergency lighting system.

Maintenance Supervisor A verified this observation at the time of the survey process.

(B)
Based on observations and interview, the facility failed to maintain 1 emergency light unit in proper working order. The facility had a license capacity of 25 patients and a census of 18 patients.

Findings include:

Observations and interview on 2-19-14 revealed the emergency light unit located in Electrical Room #5 failed to operate on battery backup when tested.

Maintenance Supervisor A verified this observation 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 alter the times of the fire drills. The facility had a capacity of 25 patients and a census of 18 patients.

Findings include:

Record review and interview on 2-19-14 revealed the facility failed to alter the times of the fire drills that were conducted on the 1st nursing shift during the previous 12 months. The times of the 4 documented drills only varied approximately 42 minutes.

Maintenance Supervisor A verified this observation at the time of the survey process.

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 smoke detectors. The facility had a license of 25 patients and a census of 18 patients.

Findings include:

Observations and interview on 2-19-14 revealed a smoke detector was located closer than 3 feet from an air diffuser (HVAC) in the ceiling of Room #4703.

Maintenance Supervisor A verified this observation during the survey process.

Based on observations 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. The facility had a license of 201 residents and a census of 135 residents.

Findings include:

Observations and interview on 2-19-14 revealed the following:

1. The absence of a locking mechanism on the electrical breaker that is dedicated to the fire alarm system to the main Hospital. This breaker shall be locked in the "On" position.

2. The absence of a locking mechanism on the electrical breaker that is dedicated to the fire alarm system to the Dialysis Building. This breaker shall be locked in the "On" position.


Maintenance Supervisor A verified this observation during the survey process.

Based on record review and interview, the facility failed to properly document the required testing of the facilities emergency generator, in accordance with National Fire Protection Association (NFPA) Standards 99, 1999 Edition. The facility had a license of 25 patients and a census of 18 patients.

Finding include:

Record review and interview on 2-19-14 revealed the facility failed to document the amperage and voltage readings from the generator during the monthly load test.

Maintenance Supervisor A verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain a 2 hour rated fire resistant wall between the Hospital and the Administration area in accordance with Section 19.1.1.4.1 of the 2000 Life Safety Code. This facility had a capacity of 25 patients and a census of 18 patients.
Findings include:
Observations and interview on 2-19-14 revealed the following:
1. A wire penetration (approximately 1/2 inches in size) located in the 2 hour fire wall above the corridor doors that separate the Administration Area from the Hospital.
2. A wire penetration (approximately 1/2 inches in size) located in the 2 hour fire wall above the corridor door #150H.
3. A wire penetration (approximately 1/2 inches in size) located in the 2 hour fire wall above the corridor door #1600.
4. Two holes (approximately 1 inch by 2 inches in size) located in the 2 hour fire wall near the East Laboratory Reception Desk.
Maintenance Supervisor A verified these observations at the time of the survey process.

Based on observations and interview, the facility failed to maintain 3 hazardous rooms properly separated by allowing penetrations to be present. The facility had a capacity of 25 patients and a census of 18 patients.

Findings include:

Observations and interview on 2-19-14 revealed the following:

1. A pipe penetration (approximately 1/2 inch in size), a conduit penetration (approximately 1/4 inch in size, and a wire penetration (approximately 1/4 inch in size), located above the east door of the Boiler Room.

2. A pipe penetration (approximately 1/2 inches in size) located above the North Laundry Room door.

3. A wire penetration (approximately 1/4 inch in size) located in the north wall of Electrical Room #3801.

Maintenance Supervisor A verified these observations at the time of the survey process.

(A)
Based on record review and interview, the facility failed to provide documentation that the battery back-up emergency lighting system was being properly tested on a annual basis for 90 minutes. The facility had a license capacity of 25 patients and a census of 15 patients.

Findings include:

Record review and interview on 2-19-14 revealed the absence of the required 90 minute annual testing of the facilities battery back-up emergency lighting system.

Maintenance Supervisor A verified this observation at the time of the survey process.

(B)
Based on observations and interview, the facility failed to maintain 1 emergency light unit in proper working order. The facility had a license capacity of 25 patients and a census of 18 patients.

Findings include:

Observations and interview on 2-19-14 revealed the emergency light unit located in Electrical Room #5 failed to operate on battery backup when tested.

Maintenance Supervisor A verified this observation 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 alter the times of the fire drills. The facility had a capacity of 25 patients and a census of 18 patients.

Findings include:

Record review and interview on 2-19-14 revealed the facility failed to alter the times of the fire drills that were conducted on the 1st nursing shift during the previous 12 months. The times of the 4 documented drills only varied approximately 42 minutes.

Maintenance Supervisor A verified this observation at the time of the survey process.

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 smoke detectors. The facility had a license of 25 patients and a census of 18 patients.

Findings include:

Observations and interview on 2-19-14 revealed a smoke detector was located closer than 3 feet from an air diffuser (HVAC) in the ceiling of Room #4703.

Maintenance Supervisor A verified this observation during the survey process.

Based on observations 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. The facility had a license of 201 residents and a census of 135 residents.

Findings include:

Observations and interview on 2-19-14 revealed the following:

1. The absence of a locking mechanism on the electrical breaker that is dedicated to the fire alarm system to the main Hospital. This breaker shall be locked in the "On" position.

2. The absence of a locking mechanism on the electrical breaker that is dedicated to the fire alarm system to the Dialysis Building. This breaker shall be locked in the "On" position.


Maintenance Supervisor A verified this observation during the survey process.

Based on record review and interview, the facility failed to properly document the required testing of the facilities emergency generator, in accordance with National Fire Protection Association (NFPA) Standards 99, 1999 Edition. The facility had a license of 25 patients and a census of 18 patients.

Finding include:

Record review and interview on 2-19-14 revealed the facility failed to document the amperage and voltage readings from the generator during the monthly load test.

Maintenance Supervisor A verified this observation at the time of the survey process.