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Based on observation and staff interviews, the facility fails to assure that the 2 hour wall separating the hospital from the business occupancy is sealed, failing to provide the proper fire resistance rating. This deficient practice affects all occupants and approximately 6 patients in 2 of 3 smoke zones. The facility has a capacity of 10 patients with a census of 6 at the time of survey.

Findings Include:

During the tour on 11/21/13, it is observed:

1. At 12:25 p.m., that there is an unsealed penetration around a data conduit in the two hour wall above the North door to the business occupancy.

2. At 12:36 p.m., that there are unsealed penetrations around cable and conduit in the two hour wall located above the South door to the business occupancy.

The Facilities Technician and Director of IT were present and acknowledged the findings.

NFPA Standard: Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition. Communicating openings in the fire barriers shall be permitted only in corridors and protected by approved self-closing fire doors. 2000 NFPA 101, 18/19.1.1.4.1 and 18/19.1.1.4.2.

NFPA Standard: Occupied buildings shall meet the minimum construction requirements of the occupancy chapters and NFPA 220. Additions or connected structures of different construction types shall have the ratings and classification based on: separate buildings if a 2-hour or greater vertically-aligned fire barrier wall in accordance with NFPA 221 exists between the buildings, or the least fire-resistive type of construction of the connected portions. 2000 NFPA 101, 8.2.1.

Based on observation and staff interview, the facility fails to assure that spaces between penetrating items and smoke barriers are filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. The deficient practice could allow the passage of smoke and fire product to spread beyond the smoke barrier, affecting all occupants and all patients in 3 of 3 smoke zones. The facility has a capacity of 10 and a census of 6 at the time of the survey.

Findings Include:

During the tour conducted 11/21/13, it is observed:

1. At 12:30 p.m., that above the East smoke barrier door leading to the PACU there are unsealed penetrations around data cables.

2. At 12:33 p.m., that above the West smoke barrier door leading to the PACU there are two approximately 2 inch holes that are not sealed, and there are unsealed penetrations around two conduits and data cables.

The Facilities Technician and Director of IT were 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 record review and staff interview, the facility fails to test the battery powered emergency lighting monthly and annually as required by NFPA 101 7.9.3 This deficient practice could prevent areas to be properly illuminated in the event of an emergency, affecting all occupants and all patients in 3 of 3 smoke zones. The facility has a capacity of 10 and a census of 6 at the time of the survey.

Findings include:

During the tour conducted 11/21/13, at 11:15 a.m. during record review, it is observed that there is no documentation that monthly 30 second checks of the emergency lights from April to September of 2013 were performed.

The Chief Nursing Officer, Facilities technician, and Director of IT were 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 fails to assure that fire drills are 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, staff, and visitors in the event of a fire. The deficiency affects all occupants and all patients in 3 of 3 smoke zones. The facility has a capacity of 10 and a census of 6 at the time of the survey.

Findings Include:

During the tour conducted 11/21/13, at 11:30 a.m. during record review, it is observed that there is no documentation showing a fire drill was performed the 3rd quarter of 2013 on the second shift.

The Chief of Nursing, Facilities Technician, and Director of IT were 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. The fire alarm shall be transmitted the day before or the day after the coded drill. 2000 NFPA 101, 19.7.1.2

Based on record review and staff interview, it is observed that the facility failed to maintain and test the fire alarm system in accordance with NFPA 72, 2000 ed. This deficient practice could cause the fire alarm system to fail or malfunction in the event of an emergency affecting all occupants and all patients in 3 of 3 smoke zones. The facility has a capacity of 10 and a census of 6 at the time of the survey.

Findings Include:

During the tour conducted 11/21/13, at 11:13 a.m. during record review, it is observed that the annual fire alarm system report from F.E. Moran dated 1/31/13 states that manual pull station #8 needs a new cut in the wall plate and that smoke detectors #17, 20, and 76 are located too close to vents. There is no documentation that these issues have been addressed.

The Chief Nursing Officer, Facilities Technician, and Director of IT were present and acknowledged the finding.

NFPA Standard: A permanent record of all inspections, testing, and maintenance shall be maintained that includes periodic tests and applicable information, per 1999 NFPA 72, 7-5.2.2 and figure 7-5.2.2; A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70. 2000 NFPA 101, 9.6.1.4

Based upon a review of records and staff interview, the facility fails to assure that the automatic sprinkler system is inspected, tested, and maintained in accordance with NFPA 25. The deficient practice could result in the unexpected failure of the automatic fire sprinkler system, affecting all occupants and all patients in 3 of 3 smoke zones. The facility has a capacity of 10 and a census of 6 at the time of the survey.

Findings include:

During the tour conducted 11/21/13, at 11:00 a.m. during record review, it is observed:

1. That monthly visual checks of the wet pipe sprinkler system were not documented between March and September of 2013.

2. There is no documentation that the quarterly flow test of the sprinkler system for the first quarter of 2013 was performed.

The Chief Nursing Officer, Facilities Technician, and Director of IT were present and acknowledged the findings.

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 on observation, staff interview and record review, the facility failed to maintain and test the emergency generator as per NFPA 110. This deficient practice could result in failure of the generator to provide emergency power in the event of power loss. The deficient practice could affect all occupants and all patients in 3 of 3 smoke zones. The facility has a capacity of 10 and a census of 6 at the time of the survey.

Findings include:

During the tour conducted on 11/21/13, at 10:53 a.m. during record review, it is observed:

1. That from 3/18/13 to 7/19/13 and from 7/22/13 to 10/14/13 that weekly visual checks of the generator were not being documented.

2. That from March to October of 2013 there is no documentation of 30 minute monthly load tests of the generator.

3. That the generator is not being run at a minimum of 30% of its capacity during the 30 minute monthly load test for each month of the year. There is no documentation of an annual load bank test.

The Chief of Nursing, Facilities Technician, and Director of IT were present and acknowledged the finding.

NFPA Standard: Level 1 and level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes. 1999 NFPA 110, 6.4.1 and 6.4.2

NFPA Standard: Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods: (a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating (b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. The date and time of day for required testing shall be decided by the owner, based on facility operations. 1999 NFPA 110, 6-4.2

NFPA Standard: Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours. 1999 NFPA 110, 6-4.2.2