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Referenced code: Title 42 CFR 482.41 (b)

Based on observation and interview, it was determined the facility failed to maintain the fire and smoke rated barrier in one (above the fire-rated doors near the Courtyard labeled "Healing Garden") of six areas observed by protecting penetrations in the barrier with a system or material capable of limiting the transfer of smoke. The failed practice had the potential to affect all patients, visitors, and staff because it could not be assured that smoke would not spread from one side of the barrier to the other in the event of a fire and smoke event. Findings follow:

A. While touring the facility with the Maintenance Supervisor on 03/28/2017 at 1320, two penetrations in the fire-rated barrier above the fire-rated doors near the Courtyard were not sealed with a system or material capable of limiting the transfer of smoke from one side of the barrier to the other.
B. During the tour, the Maintenance Supervisor verified the penetrations were not sealed with a material capable of limiting the transfer of smoke from one side of the barriers to the other.

Referenced code: NFPA 101; 2012 edition, Section 8.4.4.1

Based on interview with the Maintenance Supervisor, there was no evidence available for review that maintenance and testing had been performed on the fire alarm system for 12 of 12 months requested. The failed practice had the potential to affect all patients, visitors, and staff because it could not be assured the alarm system would function properly during a fire emergency. Findings follow:

A. During an interview with the Maintenance Supervisor on 11/29/2017 at 0900, documentation a fire alarm inspection and testing had been performed was requested for the previous 12 months. Following an investigation by the Maintenance Supervisor it was revealed no documentation was available maintenance and testing had been performed on the fire alarm system by the monitoring company.

Based on interview with the Maintenance Supervisor, there ws no evidence available for review that maintenance and testing had been performed on the fire alarm system for 12 of 12 months requested. The failed practice had the potential to affect all patients, visitors, and staff because it could not be assured the alarm system would function during a fire emergency. Findings follow:

A. During an interview with the Maintenance Supervisor on 11/29/2017 at 0900, documentation a fire alarm inspection and testing had been performed was requested for the previous 12 months. Following an investigation by the Maintenance Supervisor it was revealed no documentation was available maintenance and testing had been performed on the fire alarm system by the monitoring company.

Based on review of the Fire Drill log and interview, no evidence was presented to document four (second quarter: first and second shifts, third quarter: fist and second shifts) of eight required fire drills from the second quarter of 2016 through the first quarter of 2017 had been performed. Failure to perform the required fire drills had the potential to affect the health and safety of all patients, visitors, and staff because the facility could not assure that the facility staff would be prepared to respond appropriately during a fire emergency. Findings follow:

A. Review of the Fire Drill log on 03/28/2017 at 0930 revealed no documentation of fire drills had been performed for the first and second shifts of the second and third quarters of 2016 performed.
B. During an interview on 03/29/2017 at1000, the Maintenance Supervisor verified there was no documentation available which demonstrated all of the required fire drills had been performed.

Referenced codes: Title 42 CFR 485.623(c); NFPA 101: Section 19.7.1.6

Based on review of the Fire Drill log and interview, there was no evidence presented that 4 (second quarter: first and second shifts, third quarter: fist and second shifts) of 8 required fire drills from the second quarter of 2016 through the first quarter of 2017 had been performed. Failure to perform the required fire drills had the potential to affect the health and safety of all patients, visitors, and staff because the facility could not assure that the facility staff would be prepared to respond appropriately during a fire emergency. Findings follow:

A. Review of the Fire Drill log on 03/28/2017 at 0930 revealed no evidence fire drills had been performed for the first and second shifts of the second and third quarters of 2016 were performed.
B. During an interview on 03/29/2017 at 1000, the Maintenance Supervisor verified there was no documentation available which demonstrated all of the required fire drills had been performed.

Referenced codes: Title 42 CFR 485.623(c); NFPA 101: Section 19.7.1.6

Based on observation and interview, it was observed the electrical panels in two (waiting area near patient rooms and Dietary storage) of seven areas observed did not have a minimum of 36 inches (three feet) of working space in front of the panels because of equipment stored in these areas. The failed practice had the potential to affect all patients, visitors, and staff because rapid access to the panels could not be gained in the event of an emergency. Findings follow:

A. While touring the facility on 03/28/2017 at 1400, chairs were observed in front of the electrical panels in the waiting area near the patient sleeping rooms.
B. While touring the facility on 03/28/2017 at 1415, a desk was observed in front of the electrical panels in the dietary storage area.
C. During the tour, it was verified by the Maintenance Supervisor the electrical panels did not have the minimum 36 inches of working space in front of them.

Referenced Codes: NFPA 99, 2012 edition; Section: 6.3.2.1; NFPA 70, 2011 edition; Section: 110.26