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Based on observation and staff interview, the facility does not provide a firewall with at least a two-hour fire resistance rating between the hospital and LTCU portion of the facility. The communicating opening compromises the fire-resistance rating of the designated firewall. The deficient practice affects 1 of 3 smoke zones. The facility has a capacity of 25 with a census of 2 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 05/27/2010, between 2:30 PM and 5:30 PM, it is observed that the facility has a door in a 2-hr wall separation between the hospital and the LTCU dining area that is not in connecting corridors. The 1 1/2 hour rated door has an automatic closing device and supervised smoke detection is located within the area.

Staff A and B were present, aware of the findings, and acknowledged that the fire-resistance of the wall is compromised.

Based on observation and staff interview the facility is not providing appropriate construction standards as required by the life safety code. This deficient practice fails to prevent the containment of smoke and/or fire, affecting 1 of 3 smoke zones. The facility has a capacity of 25 with a census of 2 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 05/27/2010, between 2:30 PM and 5:30 PM, it is observed that the ceiling tiles are incomplete located near the facility's General Office.

Staff A and B were present and acknowledged the deficiency.

Based on observation and staff interview, the facility fails to assure that smoke barriers provide at least a one half hour fire rating. The deficient practice would not prevent the passage of fire or smoke to other areas of the building, affecting 2 of 3 smoke zones. The facility has a capacity of 25 with a census of 2 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 05/27/2010, between 2:30 PM and 5:30 p.m., it is observed that the smoke barrier wall near the facility's General Office has non-approved expanding foam used in penetrations around wires and cable that pass through it.

Staff A and B were present and acknowledged that the gaps are not sealed and would not resist the passage of fire or smoke.

Based upon observation and staff interview, the facility fails to assure that hazardous areas are separated from other spaces by doors that are self closing. The deficient practice would not prevent the passage of fire or smoke to other areas of the building, affecting 1 of 3 smoke zones. The facility has a capacity of 25 with census of 2 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 05/27/2010, between 2:30 PM and 5:30 PM, it is observed that Room 109 has been converted to a storage room; no self-closing device has been provided.

Staff A and B were present and aware of the findings. Staff A stated that he would install a self-closer on the door.

Based upon a review of records and staff interview, the facility fails to assure that fire drills are held at unexpected times, under varying conditions and at least once per shift per quarter. This has the potential of affecting staff preparation and experience in providing for the protection of all residents, staff and visitors in the event of a fire, affecting 3 of 3 smoke zones. The facility has a capacity of 25 with a census of 2 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 05/27/2010, between 2:30 PM and 5:30 PM, a review of records revealed the following:

-- 1. Fire drills are conducted within close proximity of each other: Fire Drills for the 1st Shift, 2nd Qtr 2009 and 3rd Qtr 2009, were held at 1:33 PM and 1:40 PM, respectively.

Staff A and B were present and acknowledged the results of the record review.

Based on staff interview and a review of records, the facility fails to assure that cooking facilities are tested and maintained in accordance with NFPA 96. The deficient practice increases the risk of fire and smoke in 1 of 3 smoke zones, reducing the reliability of the fire suppression system. The facility has a capacity of 25 with a census of 2 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 05/27/2010, between 2:30 PM and 5:30 PM, a review of records for the suppression system revealed that the cylinder is past due for hydrostatic testing.

Staff A and B were present and acknowledged the findings. Staff A stated that he would contact the vendor and request that the testing be performed immediately.

Based on observation and staff interview, the facility fails to assure that means of egress are continuously maintained free of all obstructions or impediments. The deficient practice would prevent the full instant use of the egress pathway, affecting 1 of 3 smoke zones. The facility has a capacity of 25 with a census of 2 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 05/27/2010, between 2:30 PM and 5:30 PM, it is observed that wheelchairs and other combustible items are stored at the emergency room exit.

Staff A were present, acknowledged the presence of the items and agreed that the items should not be stored in the corridor.

Based upon observation and record review, the facility fails to conduct and properly document testing and maintenance of generators in accordance with NFPA 99 and NFPA 110. The deficient practice potentially reduces the reliability of the generators affecting 3 of 3 smoke zones. The facility has a capacity of 25 with a census of 2 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 05/27/2010, between 2:30 PM and 5:30 PM, a review of records for the last four quarters revealed:

-- 1. No documented monthly load test for November 2009.
-- 2. No transfers time were recorded for the months of May, June, July, August, 2009; January, February 2010.

Staff A and B were present and aware of the results of the record review.