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Based on observation and interview, the facility failed to ensure the integrity of smoke and fire barriers provide a minimum one hour fire resistance rating in accordance with 8.3 and 18.3.7.3, to prevent the potential spread of smoke and fire from one section of the building to other areas. This deficient practice potentially affects all visitors, staff and patient census. The facility census was five.

Findings included:

1. Observations on 02/02/12 from 1:30 PM through 3:00 PM showed the following:
-A one half-inch diameter opening next to a damper and a one half-inch high by one eight inch wide holes in the one hour wall above the entrance to Radiology.
-A one half-inch wide annular space around a communication cable that penetrated a wall above the double doors to the emergency department.

During an interview on 02/02/12 at 2:40 PM, Staff O, Plant Operations Manager stated he did not know about the holes. He stated it had been almost two years since he had been up in the ceilings to check smoke and fire barriers. He said he'd recently been working on the light above that same door and never noticed the holes.

Based on document review and interview, the facility failed to show evidence they conducted fire drills during the past 12 months on a minimum quarterly basis, or not less than once in each 3-month period in accordance with 18.7.1.2. This deficient practice affects all visitors, staff and patient census. The facility census was five.

Findings included:

1. Document review on 02/01/12 at 2:00 PM through 3:00 PM, showed only one fire drill dated 1/27/12. No written schedule or other supporting information was available for the previous 12 months of 2011.

During an interview on 02/01/12 at 2:00 PM, Staff O, Plant Operations Manager stated that he generally runs the drills twice a year on both 12 hour shifts. He stated he does not have a formal schedule and has not been documenting the dates, time or any information.

Based on record review and interview, the facility failed to establish and conduct an approved inspection, testing and maintenance program that meets the Chapter 10 requirements of the Code for inspection, testing and maintenance. This deficient practice affects all visitors, staff and patient census. The facility census was five.

Finding included:

1. Document review on 02/01/12 at 2:00 PM through 3:00 PM, showed no written information or schedule for a regular inspection, testing and maintenance program of the fire alarm system by an approved authority as follows:
-Factory trained and certified by a national institute;
-National Institute for Certification in Engineering Technologies fire alarm certified.
-International Municipal Signal Association fire alarm certified;
-Contracted provider with personnel trained and qualified by an organization listed by a national testing laboratory for the servicing of fire alarm systems.

During an interview on 02/01/12 at 2:00 PM Staff O, Plant Operations Manager stated that he did not have a policy or annual inspections of the fire alarm system. He stated that if a trouble signal sounded he would check the system for malfunctions. He stated and showed documented evidence the alarm system does automatically transmit a signal to a remote station that notifies the county Sheriff and Volunteer Fire Department.

Based on record review and interview, the facility failed to test all smoke detectors at least annually in accordance with 10.4.3 of NFPA 72. This deficient practice affects all visitors, staff and patient census. The facility census was five.

Findings Include:

1. Record review and interview on 02/01/12 at 2:00 through 3:00 PM showed the facility failed to test all smoke detectors at least annually to ensure that each detector is operative and produces the intended response.

During an interview on 02/01/12 at 2:30 PM, Staff O, Plant Operations Manager, stated that he has had the system tested by an approved (trained, qualified, certified) or an electrical contractor or suitable alternative for the last year or more. He stated that he visually checks the alarm panel daily and is notified by the switchboard operator if any trouble or alarm signals sound. He stated he uses a test spray during fire drill training to set the fire alarm system off. He stated he does not have a written procedure for testing smoke detectors.

Based on interview the facility failed to conduct the last quarterly inspection of the automatic sprinkler system in accordance with 18.3.5 and failed to maintain a minimum clearance to storage accordance with 8.5.6.1 between boxed items stacked on shelves and the single sprinkler head in a closet located in Physical Therapy. These potentially deficient practices affected the staff, visitors and the patient census. The facility census was five.

1. Record review on 02/01/12 at 1:00 PM, showed the facility's sprinkler service and repair vendor did not conduct the last two quarterly inspections of a 12 month period. The last annual inspection which included the wet system, a pre-action system (for the communications/signal room) and five backflow devices was completed by an outside contractor on 6/17/11.

2. Observation on 01/30/12 at 3:20 PM showed boxes of pipettes, sterile glass vials and other boxed storage stacked on top shelves to within two inches of the ceiling and pendant type head for an automatic sprinkler, where it would directly impede the intended spray pattern of the fire suppression system.

During an interview on 02/01/12 at 1:30 PM Staff O, Plant Operations Manager, stated the sprinkler company was making regular visits to the facility and suddenly stopped coming out after the last visit on 6/17/11. He stated he later learned the sprinkler company was afraid they would not be paid for their next so they refused to return for the last two quarterly inspections, defaulting on a contractual obligation of four visits per year. He stated the lawyers had contacted the company and were holding them responsible for completing their obligation. He stated that he did not know the final outcome or if the hospital would be negotiating a contract with another company to do their inspections on fire extinguishers, kitchen suppression system and automatic sprinkler system.

During an interview on 01/30/12 at 3:20 PM, Staff O, Plant Operations Manager agreed with the observation and stated that the closet was used by the laboratory because the lab did not have enough storage space.

Based on record review and interview the facility failed to maintain the facility's sole Emergency Power Supply System (EPSS) and generator in accordance with NFPA 110, chapter 6-4.2.2, which requires an annual load bank test with supplemental loads that adequately test the generator's full range of available power. This deficient practice affects all occupants in the facility. The facility census was five.

Findings include:

1. Record review of maintenance logs on 02/01/12 at 2:30 PM, showed monthly inspection and tests of the EPSS and generator, (including transfer to full facility electrical load). However, there was no documentation of an annual load bank test with a supplemental load to test the generator's capability to supply a continuous, reliable source of electrical power at full potential power range.

During an interview on 02/01/12 at 2:30 PM, Staff O stated the current facility electrical demand is less 30 percent of the than the manufacturer's full power rating as listed on the nameplate for the diesel generator. He stated that he does monthly load tests with the full facility load, but cannot remember ever having a load bank brought in to test the generator beyond the facility's current power demands.