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Based on observation and staff interview, the facility failed to assure that corridor doors close tightly to prevent gaps, allowing the spread of smoke and fire. This affects 1 of 3 smoke zones. The facility has a capacity of 13 with a census of 5.

Findings include:

During the tour on 3/6/12 between 1:00 PM and 5:30 PM it is observed the self closer is not latching the door to the door frame to the Mechanical room.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Based on observation and staff interview the facility is not assuring that one of four smoke barriers is 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 3 of 3 smoke zones. This facility has a capacity of 13 and a census of 5.

Findings include:

During the tour on 3/6/12 between 1:00 PM and 5:30 PM the following is observed:

--1) The lower section of the one (1) hour rated wall is missing on the Pre-Op smoke barrier wall, Pre-Op side of wall.
--2) There is two (2) large open wire chases above the ceiling tiles at the Pre-Op smoke barrier wall, both sides of wall.
--3) There is two (2) open wire chases and a gap around one of these chases on both sides of the DON 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 3 smoke zones. This facility has a capacity of 13 and a census of 5.

Findings include:

During the tour on 3/6/12 between 1:00 PM and 5:30 PM it is observed there is a gap around a sprinkler pipe that leads into the staff bathroom in the Shell 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 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 3 of 3 smoke zones. The facility has a capacity of 13 and a census of 5.

Findings Include:

During the tour on 3/6/12 between 1:00 PM and 5:30 PM the following is observed:

--1) There is no documentation available to inspector of the January 2012 annual 90 minute emergency light test. The last annual test is recorded as Jan '11, the facility is 2 months past due for the annual emergency light test.
--2) There is no documentation of the Jan '12 monthly emergency light check.
--3) The emergency light unit did not illuminate upon test in OR 4 and Electrical closet 1.

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 is not conducting fire drills as required quarterly on each shift and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency and affects 3 of 3 smoke zones. The facility has a capacity of 13 and a census of 5.

Findings include:

During the tour on 3/6/12 between 1:00 PM and 5:30 PM the following is observed:

--1) There was no scenario recorded on fire drills dated 6/26/11, 6/28/11, 8/21/11, 9/29/11 and 12/23/11.
--2) There were silent fire drills conducted after 6:00 AM on dates 3/29/11, 9/29/11 and 12/23/11.
--3) The fire drill conducted on 6/28/11 at 8:32 PM is recorded as a silent drill.

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 record review and staff interview, the facility failed to assure that the sprinkler system is maintained and tested in accordance with NFPA 13 and NFPA 25. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting 3 of 3 smoke zones. The facility has the capacity for 13 with a census of 5.

Findings include:

During the tour on 3/6/12 between 1:00 PM and 5:30 PM it is observed there is no monthly sprinkler checks being documented.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1

Based on observation and staff interview the facility failed to ensure that portable fire extinguishers are properly mounted. This deficient practice may prevent the portable fire extinguisher from being readily accessible due to difficulty in retrieving it from the mounting bracket, affecting 1 of 3 smoke zones. The facility has a capacity of 13 and a census of 5.

Findings include:

During the tour on 3/6/12 between 1:00 PM and 5:30 PM it is observed there is a fire extinguisher sitting on the floor and not mounted in OR 1.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas. 1998 NFPA 10, 1-6.3

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 3 of 3 smoke zones. This facility has a capacity of 13 with a census of 5.

Findings include:

During the tour on 3/6/12 between 1:00 PM and 5:30 PM the following is observed:

--1) There is a patient bed stored in the NE exit corridor at the exit door by room 7. The bed was documented at 3:50 PM as being in the exit corridor, and at 5:10 PM the bed was still in the exit corridor.
--2) There is a wheel chair stored in the NE exit corridor outside of patient room 10. The wheel chair was documented at 3:50 PM as being in the exit corridor, and at 5:10 PM the wheel chair was still in the exit corridor.
--3) There is three (3) office chairs, a wheeled wire rack and a bed side table stored in the Pain Clinic exit corridor at the SE exit door.
--4) There is storage of portable X-ray machines in the N exit corridor out of surgery in the Mechanical/Electrical room corridor. There is an exit sign in the NE hall of the surgery suite that directs one to the N exit door corridor, which there is also an exit sign posted above the N exit door. This N exit door had previously been the exterior of the building.

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 3 of 3 smoke zones. The facility has a capacity of 13 with a census of 5.

Findings include:

During the tour on 3/6/12 between 1:00 PM and 5:30 PM the following is observed:

--1) There is no records of weekly generator checks available to inspector.
--2) The last monthly load test is documented as 11/16/09. The facility is 2 years and 2 months over due for the monthly 30 minute generator load test. This is a 2nd year cited deficiency.

Maintenance Staff A was 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 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 2 out of 3 smoke zones. This facility has a capacity of 13 with a census of 5.

Findings include:

During the tour on 3/6/12 between 1:00 PM and 5:30 PM the following is observed:

--1) There are two large open junction boxes above the ceiling tiles at the PACU smoke barrier wall.
--2) There is an electrical panel obstructed with a metal rack and/or metal table outside of OR 2, outside of OR 4 and outside of OR 5 in the East OR corridor.
--3) There is an electrical panel obstructed with a walker and a portable toilet in the NE Soiled Utility room.
--4) There is an electrical outlet cover missing in the Mechanical room.

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

NFPA Standard: The width of the working space in front of the electrical equipment shall be the width of the equipment or 30 in. (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of the equipment doors or hinged panels. Minimum clear distance required for the working space of an electrical panel is 3 to 4 feet. 1999 NFPA 70, 110-26 (a)(1)(2).

Based on observation and staff interview, the facility failed to assure that corridor doors close tightly to prevent gaps, allowing the spread of smoke and fire. This affects 1 of 3 smoke zones. The facility has a capacity of 13 with a census of 5.

Findings include:

During the tour on 3/6/12 between 1:00 PM and 5:30 PM it is observed the self closer is not latching the door to the door frame to the Mechanical room.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Based on observation and staff interview the facility is not assuring that one of four smoke barriers is 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 3 of 3 smoke zones. This facility has a capacity of 13 and a census of 5.

Findings include:

During the tour on 3/6/12 between 1:00 PM and 5:30 PM the following is observed:

--1) The lower section of the one (1) hour rated wall is missing on the Pre-Op smoke barrier wall, Pre-Op side of wall.
--2) There is two (2) large open wire chases above the ceiling tiles at the Pre-Op smoke barrier wall, both sides of wall.
--3) There is two (2) open wire chases and a gap around one of these chases on both sides of the DON 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 3 smoke zones. This facility has a capacity of 13 and a census of 5.

Findings include:

During the tour on 3/6/12 between 1:00 PM and 5:30 PM it is observed there is a gap around a sprinkler pipe that leads into the staff bathroom in the Shell 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 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 3 of 3 smoke zones. The facility has a capacity of 13 and a census of 5.

Findings Include:

During the tour on 3/6/12 between 1:00 PM and 5:30 PM the following is observed:

--1) There is no documentation available to inspector of the January 2012 annual 90 minute emergency light test. The last annual test is recorded as Jan '11, the facility is 2 months past due for the annual emergency light test.
--2) There is no documentation of the Jan '12 monthly emergency light check.
--3) The emergency light unit did not illuminate upon test in OR 4 and Electrical closet 1.

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 is not conducting fire drills as required quarterly on each shift and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency and affects 3 of 3 smoke zones. The facility has a capacity of 13 and a census of 5.

Findings include:

During the tour on 3/6/12 between 1:00 PM and 5:30 PM the following is observed:

--1) There was no scenario recorded on fire drills dated 6/26/11, 6/28/11, 8/21/11, 9/29/11 and 12/23/11.
--2) There were silent fire drills conducted after 6:00 AM on dates 3/29/11, 9/29/11 and 12/23/11.
--3) The fire drill conducted on 6/28/11 at 8:32 PM is recorded as a silent drill.

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 record review and staff interview, the facility failed to assure that the sprinkler system is maintained and tested in accordance with NFPA 13 and NFPA 25. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting 3 of 3 smoke zones. The facility has the capacity for 13 with a census of 5.

Findings include:

During the tour on 3/6/12 between 1:00 PM and 5:30 PM it is observed there is no monthly sprinkler checks being documented.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1

Based on observation and staff interview the facility failed to ensure that portable fire extinguishers are properly mounted. This deficient practice may prevent the portable fire extinguisher from being readily accessible due to difficulty in retrieving it from the mounting bracket, affecting 1 of 3 smoke zones. The facility has a capacity of 13 and a census of 5.

Findings include:

During the tour on 3/6/12 between 1:00 PM and 5:30 PM it is observed there is a fire extinguisher sitting on the floor and not mounted in OR 1.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas. 1998 NFPA 10, 1-6.3

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 3 of 3 smoke zones. This facility has a capacity of 13 with a census of 5.

Findings include:

During the tour on 3/6/12 between 1:00 PM and 5:30 PM the following is observed:

--1) There is a patient bed stored in the NE exit corridor at the exit door by room 7. The bed was documented at 3:50 PM as being in the exit corridor, and at 5:10 PM the bed was still in the exit corridor.
--2) There is a wheel chair stored in the NE exit corridor outside of patient room 10. The wheel chair was documented at 3:50 PM as being in the exit corridor, and at 5:10 PM the wheel chair was still in the exit corridor.
--3) There is three (3) office chairs, a wheeled wire rack and a bed side table stored in the Pain Clinic exit corridor at the SE exit door.
--4) There is storage of portable X-ray machines in the N exit corridor out of surgery in the Mechanical/Electrical room corridor. There is an exit sign in the NE hall of the surgery suite that directs one to the N exit door corridor, which there is also an exit sign posted above the N exit door. This N exit door had previously been the exterior of the building.

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 3 of 3 smoke zones. The facility has a capacity of 13 with a census of 5.

Findings include:

During the tour on 3/6/12 between 1:00 PM and 5:30 PM the following is observed:

--1) There is no records of weekly generator checks available to inspector.
--2) The last monthly load test is documented as 11/16/09. The facility is 2 years and 2 months over due for the monthly 30 minute generator load test. This is a 2nd year cited deficiency.

Maintenance Staff A was 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 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 2 out of 3 smoke zones. This facility has a capacity of 13 with a census of 5.

Findings include:

During the tour on 3/6/12 between 1:00 PM and 5:30 PM the following is observed:

--1) There are two large open junction boxes above the ceiling tiles at the PACU smoke barrier wall.
--2) There is an electrical panel obstructed with a metal rack and/or metal table outside of OR 2, outside of OR 4 and outside of OR 5 in the East OR corridor.
--3) There is an electrical panel obstructed with a walker and a portable toilet in the NE Soiled Utility room.
--4) There is an electrical outlet cover missing in the Mechanical room.

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

NFPA Standard: The width of the working space in front of the electrical equipment shall be the width of the equipment or 30 in. (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of the equipment doors or hinged panels. Minimum clear distance required for the working space of an electrical panel is 3 to 4 feet. 1999 NFPA 70, 110-26 (a)(1)(2).