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Based on observation during tour and staff verification it was determined this facility failed to ensure the smoke barriers were constructed to provide at least one half hour fire resistance rating as required in NFPA 101 chapter 19.3.7.3 in accordance with Section 8.3. The facility census was 17 at the time of the survey.

Findings include:

Tour of the facility's main building took place on 02/01/10 to 02/03/10 with the facility supervisor (staff M).
Penetrations were observed in the one half hour smoke barrier in the following location:

First Floor:
* From within central registration, facing the smoke barrier wall boarding the south side of the department and above the ceiling tile, observation was made of two unsealed open end conduits and one unsealed curved conduit passing through the smoke barrier.
* In the corridor beside the central registration window, above the smoke barrier doors and ceiling tile, observation was made of an approximate one foot by one foot penetration and two unsealed conduits.
* From the corridor side facing the smoke barrier between the window and entrance door of central registration a large four foot by four and a half foot open area was observed.
* Within stress lab room number 2 above the ceiling tile, observation was made of a flex conduit passing through an unsealed one inch open area in the two hour fire/smoke barrier.
* Within the human resource office and above the ceiling tile, observation was made of a one inch open area in the two hour fire/smoke barrier.

Second Floor:
* Above the fire rated doors leading into the endoscopy recovery area and above the ceiling tile, observation was made of an unsealed two inch conduit penetrating the fire/smoke barrier.
* Above the west smoke barrier doors (from the corridor side across from the medical surgical department) leading into the recovery room, observation was made of two one and a half inch open end conduits.
* Above the fire rated smoke barrier doors leading into the surgery holding area, observation was made of two open end conduits and an approximate two foot by seven foot long opening above the duct in the smoke barrier.
* From the corridor side above the ceiling tile and above the fire rated door leading into the surgery scheduling room, observation was made of an approximate six foot long by one inch wide opening where the drywall meets the upper deck.
* Within the surgery break room and above the ceiling tile facing the smoke barrier, observation was made of three open end conduits.
* In the fire/smoke barrier above the fire rated doors and above the ceiling tile located between the soiled and clean storage rooms of the surgery department, observation was made of an approximate twelve inch by eight inch opening, eight inch by six inch opening, unsealed support beam, a water line passing through an unsealed sleeve and three one half inch open end conduits.
* In the smoke barrier of the corridor across from the surgery's conference room and above the ceiling tile, observation was made of a two foot by two foot opening, four unsealed conduits and approximately 20 foot by one inch unsealed area where the drywall meets the upper deck.
* Above the fire rated doors beside operating room # 6 and above the ceiling tile, observation was made of nine unsealed conduits and an approximate 24 inch by two inch opening.
* Within the corridor across from the surgical holding area doors facing the smoke barrier of the medical surgical department and above the ceiling tile, observation was made of one unsealed curved conduit.

Fourth Floor:
* In the smoke barrier of the corridor located between the stairwell and the critical care unit entrance door, above the ceiling tile, observation was made of an approximate three foot by one inch opening below the duct and several wires passing through another unsealed penetration.

Fifth Floor:
* Across from the nurse's station in the smoke barrier above the ceiling tile, observation was made of two open end copper lines and an approximate eight inch by two inch open area around a steel wall support.


These findings was verified by staff M during the tour on 02/01/10 through 02/03/10.

Based on observation during tour and staff verification it was determined this facility failed to ensure that one stairway and it's components was enclosed so as to provide at least a one hour fire protection rating. This had the potential to affect all those utilizing the facility's services. The facility census was 17 at the time of the survey.

Findings include:

Tour of the facility's main building took place on 02/01/10 to 02/03/10 with the facility supervisor (staff M). At approximately 9:30 AM on 02/03/10 while touring the third floor, observation was made of the west stairwell door which did not positive latch when closed. This stairwell was located by the nutrition counseling room # 326.

Verification of this observation was made by staff M at the time of the tour stated above.

Based on observation during tour and staff verification it was determined this facility failed to ensure that one stairway and it's components was enclosed so as to provide at least a one hour fire protection rating. This had the potential to affect all those utilizing the facility's services. The facility census was 17 at the time of the survey.

Findings include:

Tour of the facility's new addition took place on 02/01/10 to 02/03/10 with the facility supervisor (staff M). At approximately 8:30 AM on 02/03/10 while touring the second floor, observation was made of the south stairwell door # 1 of the outpatient surgery waiting area, which did not positive latch when closed.


Verification of this observation was made by staff M at the time of the tour stated above.

Based on observation during tour and staff interview and verification this facility failed to ensure that exit egress accesses were arranged so that exits were accessible at all times. This had the potential to affect all those utilizing this facility. The facility had a census of 17 patients at the time of the survey.

Findings include:

Tour of the facility's main building took place on 02/01/10 to 02/03/10 with the facility supervisor (staff M). At approximately 11:30 AM on 02/02/10 while touring the first floor, observation was made of the designated exit discharge leading out from the cafe. This door exits out directly onto an approximate 55 foot by 38 foot cement patio bordered with an approximate 5 foot wide landscaping along its perimeter. Beyond the landscaping is an approximate 140 foot section of grassy area reaching to the public way. At approximately 50 foot beyond the landscaping and on the grassy area, the elevation of the ground drops dramatically (approximately 5-6 feet) causing a steep decline.

Verification of this observation was made by staff M at the time of the tour stated above.

Based on staff interview it was determined this facility failed to properly maintain the sprinkler system in accordance with National Fire Protection Agency (NFPA) 25, standard for inspection, testing and maintenance.

Findings include:

Tour of this business occupancy took place on 02/03/10 at approximately 11:45 AM with the facilities manager (staff M). During the tour observation was made of a storage room with one sprinkler head. Staff M stated this is the only sprinklered room in this facility. When a request was made for the necessary documentation for the maintenance of this sprinkler system, staff M stated he/she does not have any documentation since he/she thought there was no requirement for this in a business occupancy. This finding was confirmed during this interview on 02/03/10 at approximately 12:10 PM.

Based on record review and staff interview, it was determined that this facility failed to maintain documented evidence that relative humidity (RH) was maintained equal to or greater than 35 per cent in all 8 operating rooms and one C-section room. The facility census was 17 at the time of the survey.

Findings include:

Tour of the facility's main building took place on 02/01/10 to 02/03/10 with the facility supervisor (staff M). At approximately 3:30 PM on 02/02/10 while touring the second floor surgery area, the question was asked of staff M whether there is monitoring of humidity levels in the operating rooms. Staff M stated they do monitor humidity levels and it is registered within the H-Vac system and can be accessed on the computer. A request was made for the humidity level readings for the year 2009 and staff M stated they monitor but do not record any humidity level readings.

Based on observation and staff interview, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all patient's, staff and visitors utilizing the facility. The patient census was 17 at the time of the survey.

Findings include:

Tour of the facility's main building took place on 02/01/10 to 02/03/10 with the facility supervisor (staff M). During the tour observation was made of several smoke detectors which were located where airflow patterns may prevent the normal operation of of the detector. These were observed in the following areas, although this may not include a comprehensive list of all smoke detectors near air handling systems.

First Floor:
* Near the east entrance door into the cafe.
* Within the cafe serving area behind the serving counter.
* Within the radiology check in room.

Second Floor:
* In the surgery department between operating rooms # 2 and # 3.
*Behind the nurse's station in the copy room and within the nurse's work room.

Third Floor:
* Within obstetrics room # 384.
* Within recovery room # 382.

Fifth Floor:
* Within the psychiatric offices, two separate rooms across from the nurses station.


These findings were verified by staff M during tour on 02/01/10 through 02/03/10.

Based on observation and staff interview, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all patient's, staff and visitors utilizing the facility. The patient census was 17 at the time of the survey.

Findings include:

Tour of the facility's new addition took place on 02/01/10 to 02/03/10 with the facility supervisor (staff M). During the tour observation was made of several smoke detectors which were located where airflow patterns may prevent the normal operation of of the detector. These were observed in the following areas, although this may not include a comprehensive list of all smoke detectors near air handling systems.

Ground Floor:
* At the front entrance corridor near the door to the administration offices.
* In the corridor between the administrative offices and the Beck meeting rooms.
* At the back side of the Beck meeting rooms.
* In the nutritional rooms connected to the Beck meeting rooms.
* In front of the southeast elevators.
* To the left of the south visitors elevators within a small enclosure.

Second Floor:
* Within the small waiting area of the cath lab.
* Within the clean storage room of the cath lab.

These findings were verified and acknowledged by staff M during tour on 02/01/10 to 02/03/10.

Based on observation during tour and staff verification it was determined this facility failed to ensure the smoke barriers were constructed to provide at least one half hour fire resistance rating as required in NFPA 101 chapter 19.3.7.3 in accordance with Section 8.3. The facility census was 17 at the time of the survey.

Findings include:

Tour of the facility's main building took place on 02/01/10 to 02/03/10 with the facility supervisor (staff M).
Penetrations were observed in the one half hour smoke barrier in the following location:

First Floor:
* From within central registration, facing the smoke barrier wall boarding the south side of the department and above the ceiling tile, observation was made of two unsealed open end conduits and one unsealed curved conduit passing through the smoke barrier.
* In the corridor beside the central registration window, above the smoke barrier doors and ceiling tile, observation was made of an approximate one foot by one foot penetration and two unsealed conduits.
* From the corridor side facing the smoke barrier between the window and entrance door of central registration a large four foot by four and a half foot open area was observed.
* Within stress lab room number 2 above the ceiling tile, observation was made of a flex conduit passing through an unsealed one inch open area in the two hour fire/smoke barrier.
* Within the human resource office and above the ceiling tile, observation was made of a one inch open area in the two hour fire/smoke barrier.

Second Floor:
* Above the fire rated doors leading into the endoscopy recovery area and above the ceiling tile, observation was made of an unsealed two inch conduit penetrating the fire/smoke barrier.
* Above the west smoke barrier doors (from the corridor side across from the medical surgical department) leading into the recovery room, observation was made of two one and a half inch open end conduits.
* Above the fire rated smoke barrier doors leading into the surgery holding area, observation was made of two open end conduits and an approximate two foot by seven foot long opening above the duct in the smoke barrier.
* From the corridor side above the ceiling tile and above the fire rated door leading into the surgery scheduling room, observation was made of an approximate six foot long by one inch wide opening where the drywall meets the upper deck.
* Within the surgery break room and above the ceiling tile facing the smoke barrier, observation was made of three open end conduits.
* In the fire/smoke barrier above the fire rated doors and above the ceiling tile located between the soiled and clean storage rooms of the surgery department, observation was made of an approximate twelve inch by eight inch opening, eight inch by six inch opening, unsealed support beam, a water line passing through an unsealed sleeve and three one half inch open end conduits.
* In the smoke barrier of the corridor across from the surgery's conference room and above the ceiling tile, observation was made of a two foot by two foot opening, four unsealed conduits and approximately 20 foot by one inch unsealed area where the drywall meets the upper deck.
* Above the fire rated doors beside operating room # 6 and above the ceiling tile, observation was made of nine unsealed conduits and an approximate 24 inch by two inch opening.
* Within the corridor across from the surgical holding area doors facing the smoke barrier of the medical surgical department and above the ceiling tile, observation was made of one unsealed curved conduit.

Fourth Floor:
* In the smoke barrier of the corridor located between the stairwell and the critical care unit entrance door, above the ceiling tile, observation was made of an approximate three foot by one inch opening below the duct and several wires passing through another unsealed penetration.

Fifth Floor:
* Across from the nurse's station in the smoke barrier above the ceiling tile, observation was made of two open end copper lines and an approximate eight inch by two inch open area around a steel wall support.


These findings was verified by staff M during the tour on 02/01/10 through 02/03/10.

Based on observation during tour and staff verification it was determined this facility failed to ensure that one stairway and it's components was enclosed so as to provide at least a one hour fire protection rating. This had the potential to affect all those utilizing the facility's services. The facility census was 17 at the time of the survey.

Findings include:

Tour of the facility's main building took place on 02/01/10 to 02/03/10 with the facility supervisor (staff M). At approximately 9:30 AM on 02/03/10 while touring the third floor, observation was made of the west stairwell door which did not positive latch when closed. This stairwell was located by the nutrition counseling room # 326.

Verification of this observation was made by staff M at the time of the tour stated above.

Based on observation during tour and staff verification it was determined this facility failed to ensure that one stairway and it's components was enclosed so as to provide at least a one hour fire protection rating. This had the potential to affect all those utilizing the facility's services. The facility census was 17 at the time of the survey.

Findings include:

Tour of the facility's new addition took place on 02/01/10 to 02/03/10 with the facility supervisor (staff M). At approximately 8:30 AM on 02/03/10 while touring the second floor, observation was made of the south stairwell door # 1 of the outpatient surgery waiting area, which did not positive latch when closed.


Verification of this observation was made by staff M at the time of the tour stated above.

Based on observation during tour and staff interview and verification this facility failed to ensure that exit egress accesses were arranged so that exits were accessible at all times. This had the potential to affect all those utilizing this facility. The facility had a census of 17 patients at the time of the survey.

Findings include:

Tour of the facility's main building took place on 02/01/10 to 02/03/10 with the facility supervisor (staff M). At approximately 11:30 AM on 02/02/10 while touring the first floor, observation was made of the designated exit discharge leading out from the cafe. This door exits out directly onto an approximate 55 foot by 38 foot cement patio bordered with an approximate 5 foot wide landscaping along its perimeter. Beyond the landscaping is an approximate 140 foot section of grassy area reaching to the public way. At approximately 50 foot beyond the landscaping and on the grassy area, the elevation of the ground drops dramatically (approximately 5-6 feet) causing a steep decline.

Verification of this observation was made by staff M at the time of the tour stated above.

Based on staff interview it was determined this facility failed to properly maintain the sprinkler system in accordance with National Fire Protection Agency (NFPA) 25, standard for inspection, testing and maintenance.

Findings include:

Tour of this business occupancy took place on 02/03/10 at approximately 11:45 AM with the facilities manager (staff M). During the tour observation was made of a storage room with one sprinkler head. Staff M stated this is the only sprinklered room in this facility. When a request was made for the necessary documentation for the maintenance of this sprinkler system, staff M stated he/she does not have any documentation since he/she thought there was no requirement for this in a business occupancy. This finding was confirmed during this interview on 02/03/10 at approximately 12:10 PM.

Based on record review and staff interview, it was determined that this facility failed to maintain documented evidence that relative humidity (RH) was maintained equal to or greater than 35 per cent in all 8 operating rooms and one C-section room. The facility census was 17 at the time of the survey.

Findings include:

Tour of the facility's main building took place on 02/01/10 to 02/03/10 with the facility supervisor (staff M). At approximately 3:30 PM on 02/02/10 while touring the second floor surgery area, the question was asked of staff M whether there is monitoring of humidity levels in the operating rooms. Staff M stated they do monitor humidity levels and it is registered within the H-Vac system and can be accessed on the computer. A request was made for the humidity level readings for the year 2009 and staff M stated they monitor but do not record any humidity level readings.

Based on observation and staff interview, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all patient's, staff and visitors utilizing the facility. The patient census was 17 at the time of the survey.

Findings include:

Tour of the facility's main building took place on 02/01/10 to 02/03/10 with the facility supervisor (staff M). During the tour observation was made of several smoke detectors which were located where airflow patterns may prevent the normal operation of of the detector. These were observed in the following areas, although this may not include a comprehensive list of all smoke detectors near air handling systems.

First Floor:
* Near the east entrance door into the cafe.
* Within the cafe serving area behind the serving counter.
* Within the radiology check in room.

Second Floor:
* In the surgery department between operating rooms # 2 and # 3.
*Behind the nurse's station in the copy room and within the nurse's work room.

Third Floor:
* Within obstetrics room # 384.
* Within recovery room # 382.

Fifth Floor:
* Within the psychiatric offices, two separate rooms across from the nurses station.


These findings were verified by staff M during tour on 02/01/10 through 02/03/10.

Based on observation and staff interview, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all patient's, staff and visitors utilizing the facility. The patient census was 17 at the time of the survey.

Findings include:

Tour of the facility's new addition took place on 02/01/10 to 02/03/10 with the facility supervisor (staff M). During the tour observation was made of several smoke detectors which were located where airflow patterns may prevent the normal operation of of the detector. These were observed in the following areas, although this may not include a comprehensive list of all smoke detectors near air handling systems.

Ground Floor:
* At the front entrance corridor near the door to the administration offices.
* In the corridor between the administrative offices and the Beck meeting rooms.
* At the back side of the Beck meeting rooms.
* In the nutritional rooms connected to the Beck meeting rooms.
* In front of the southeast elevators.
* To the left of the south visitors elevators within a small enclosure.

Second Floor:
* Within the small waiting area of the cath lab.
* Within the clean storage room of the cath lab.

These findings were verified and acknowledged by staff M during tour on 02/01/10 to 02/03/10.