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Based on observation and interview, the facility is not ensuring that common wall separated from other areas by partitions and self-closing doors to ensure a two-hour fire-resistance rating. This deficient practice affects all occupants in both buildings due to this would not stop the spread of fire and smoke, in the event of a fire. This facility has a capacity of 25 and a census of 13 residents.

Findings include:

1. Observation on 11/3/11 at approximately 9:15 a.m., revealed that the separation doors located by the Registration area between Hospital and the Clinic building contained approximately 1/2 inch gap between the double doors. The separation wall was a 2 hour fire rated wall.

2. Observation on 11/3/11 at approximately 9:15 a.m., revealed in the 2 hour wall above the ceiling tiles over the east separation doors located by the Registration area between Hospital and the Clinic building contained a wire bundle with a 1 inch hole above the wires. There was also a 1 1/2 inch hole that contained fire caulk that was falling out exposing a 1/2 inch hole.

3. Observation on 11/3/11 at approximately 9:05 a.m., revealed that the Clinic building separation doors located by the Pharmacy contained approximately 1/2 inch gap between the double doors. The separation wall was a 2 hour fire rated wall.

4. Observation on 11/3/11 at approximately 8:20 a.m., revealed in the 2 hour wall above the ceiling tiles in the IT corridor next to the separation door contained a 2 inch hole on the Materials side.

Maintenance Staff (A) confirmed these observations.

Based on observation, the facility is not ensuring that doors to resident rooms are free of impediments that would prevent the door from closing tightly into the door frame. This deficient practice affects all occupants in one of seven smoke zones, as the doors would not prevent the spread of fire and smoke. This facility has a capacity of 25 and a census of 13 residents.

Findings include:

1. Observation on 11/3/11 at approximately 9:10 a.m., revealed that the resident room door of room #9 failed to positive latch with in the door frame.

2. Observation on 11/3/11 at approximately 8:40 a.m., revealed that the resident room door of room #21 failed to positive latch with in the door frame.

Maintenance Staff (A) verified these observations.

Based on observation and interview, the facility failed to provide a fire rated shaft between floors. The shaft opening in the Basement East Stairway was located with in one of seven smoke compartments on the first floor and ends in the basement level. The facility has 25 certified beds and at the time of the survey the census was 13.

Findings include:

Observation on 11/3/11 at 9:50 a.m., revealed the East Stairway has a one hour fire rated shaft and door that was self closing. At the basement level above the ceiling tiles there was a 4 inch pipe with 1/4 opening around the pipe. There was a 1/2 inch flexible conduit penetrating the wall under the 4 inch pipe with approximately a 1 1/2 hole around the conduit. The drywall joints were not taped and mudded as required for the 1 hour assembly.

Maintenance Staff (A) confirmed these observations during the survey process.

Based on observation and interview, this facility is not assuring that smoke barriers are 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 all occupants of the building, including staff, visitors and residents in two of seven smoke zones. This facility has a capacity of 25 with a census of 13 residents.

Findings include:

1. Observation and interview on 11-3-11 at approximately 9:00 a.m., the East Patient Hall above the ceiling tiles over the 1 1/2 hour doors contained a plastic pipe penetration with a 1/2 inch gap around the plastic pipe. This wall also contained 2 purple plastic pipes penetrating the wall with 1/4 to 1/2 inch gaps around the pipes.

2. Observation and interview on 11-3-11 at approximately 9:04 a.m., the Patient Hall above the ceiling tiles over the west 1 1/2 hour fire doors the smoke wall contained a 1/2 inch hole around communication wires.

Maintenance Staff (A) confirmed these observations.

Based on observation, staff interview and record review this facility is not providing unobstructed corridors that provides a clear path of egress for one of seven smoke zones. The facility is also not providing sufficient egress corridors due to projections on the walls in one corridor. This facility has a capacity of 25 with a census of 13.

Findings include:

Observation and interview on 11/3/11 at approximately 9:00 a.m., revealed that the Patent Wing had hinged charting stations in the corridor. Some of these stations were in the down position and did not automatically retract with upward force on the tray.

Maintenance Staff (A) verified the observation. According to the facility layout, this was a required exit.

Based on record review and interview, the facility failed to document the emergency egress lighting monthly. This deficient practice affects two of seven smoke compartments and all occupants of the facility. This facility has a capacity of 25 and a census of 13 residents.

Findings include:

Record review and interview of the facility's maintenance records on 11/2/11, revealed that there was no documentation regarding the testing of the emergency battery lighting system for one month. According to Maintenance Staff A, the lights were tested weekly and monthly, but there was no documentation to show that the monthly tests were conducted for 30 seconds for the month of September in the year 2011.

Maintenance Staff (B) verified this record review.

Based on observation and interview, the facility did not provide a directional exit signs at the end of a resident corridor for one of seven smoke zones. This deficient practice effects all residents, staff and visitors in this facility with a capacity of 25. The facility had a census of 13 residents.

Findings include:

Observations on 11/03/11, revealed the exit corridors in the Patient wing was not equipped with exit signs on the end of the corridors next to the smoke doors. It was observed that when looking west from the Administration area the Patient Wing did not have an exit sign over the East Patient Wing doors and over the doors at the New Patient Wing.

According to the facility layout, which is used in conjunction with the emergency procedures, this designated exit is a required exit.

Maintenance Staff (A) verified these observations.

Based upon record review and interview, the facility failed to conduct all required fire drills for four of four quarters reviewed. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This facility has a capacity of 25 with a census of 13.
Findings include:
Record review on 11/2/11, revealed the facility fire drill documentation showed that the facility failed to conduct a fire drill in the second, third and fourth quarters for the second shift of the year 2011. The facility failed to conduct drills for all four quarters in the third shifts. The facility has overlapping shifts with some shifts on a 7 a.m. to 3 p.m., 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m. and Nursing Staff on a 7 a.m. to 7 p.m. and 7 p.m. to 7 a.m. With the frequency of the drills as they were conducted all staff would not be participating in the drills.
Maintenance Staff(A) verified the documentation.

Based on observation and interview, the facility failed to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25, by ensuring that the sprinkler system is maintained with all component parts. This item could effect the operation of the sprinkler system in the event of a fire emergency. This deficient practice affects all occupants in this facility with a capacity of 25 and a census of 13.

Findings include:

1. Observations and interview on 11/3/11 at 8:30 a.m., showed that the sprinkler heads located in both Restrooms in the Administration area were missing the escutcheon rings.

2. Observation on 11/3/11 at approximately 8:20 a.m., revealed that the IT Server room corridor was not provided with automatic sprinkler coverage. The area would not be provided with protection if the corridor fire door is in the closed position.

3. Observation on 11/3/11 at approximately 8:22 a.m., revealed that the IT Server room was only protected with an FM 200 system and was not provided with an automatic sprinkler system.

4. Observation on 11/3/11 at approximately 9:20 a.m., revealed that the Registration Center Cubical was not provided with an automatic sprinkler system. Maintenance Staff (A) stated that the cubical walls were moved approximately two weeks ago which interfered with the sprinkler coverage.

5. Observation on 11/3/11 at approximately 10:10 a.m., revealed that the Physical Therapy PCP room was not provided with automatic sprinkler coverage

6. Observation on 11/3/11 at approximately 10:15 a.m., revealed that the Laboratory Break room was not provided with automatic sprinkler coverage

Maintenance Staff (A) verified these observations.

Based on observation and interview, the facility is not maintaining the sprinkler system in accordance with the 1998 edition of NFPA 25, 2-2.1.1, by ensuring that sprinkler heads are free of foreign material. This can effect the operation of the heads by obstructing spray patterns, delay the response time or even cause the heads to be inoperable which can compromise the effectiveness of the fire suppression system and place occupants at risk of injury in the event of a fire. This deficient practice affects all occupants including staff, visitors and residents in one of seven smoke zones. The facility had a capacity of 25 and a census of 13 at the time of survey.

Findings include:

Observations and interview on 11-3-11 at approximately 9:40 a.m., revealed that the sprinkler head in the Kitchen over the Serving Table was coated with dust that covered nearly one-half of the deflectors.

Maintenance Staff (A) verified this observation.

Based on observation and interview, the facility failed to maintain and test fire extinguishers as required. All fire extinguishers in seven of seven smoke compartments were affected by the deficient practice. The facility has 25 certified beds and at the time of the survey the census was 13.

Findings include:

Observation of the fire extinguishers on 11/3/11, revealed that the fire extinguishers through out the facility were missing the monthly inspections for the month of March in the 2011 year.

Maintenance Staff (A) verified this observation.

Based on record review and interview, the facility failed to inspect the Hood Suppression system every 6 months as required. This could affect the Kitchen smoke compartment and all occupants in one of eleven smoke compartments in the building . This facility has a capacity of 25 and a census of 13 residents.

Findings include:

During the record review of the facility ' s fire safety components on 11/2/11, revealed that the Hood Suppression System was inspected on 6-28-10 by Protex Central. The facility was unable to provide documentation of an inspection for the system after 6-28-10. The inspection tag for the system also indicated the last inspection was 6-28-10.

Maintenance Staff (A) confirmed this record review.

Based on observation and staff interview, the facility (hospital at 1316 South Main, Clarion) is not assuring that the laboratory emergency shower that is in place for emergencies with corrosive substances is accessible in the event of an emergency. This deficient practice affects occupants of the laboratory. This facility has a capacity of 25 with a census of 13 residents in the critical access care hospital.

Findings include:

Observation and interview on 11/3/11 at approximately 10:40 a.m., revealed the Laboratory was equipped with an emergency shower. This shower was blocked from access by equipment components under the shower and eye wash unit.

Maintenance Staff (A) verified this observation.

Based on observation and interview, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition, placing the Staff and Residents of the facility at risk in the event of a fire. The facility had a capacity of 25 and a census of 13 at the time of the survey.

Findings Include:

1. Observations on 11/3/11 at approximately 10:45 a.m., revealed the facility failed to maintain the Ground Fault Circuit Interrupter electrical outlet in the Laboratory next to the sink. It could not be determined if the electrical outlets were Ground Fault Circuit Interrupters.

2. Observations on 11/3/11 at approximately 10:12 a.m., revealed the facility failed to maintain a three feet clearance in-front of the electrical panels in the Basement Electrical room.

3. Observation on 11/3/11 at approximately 10:12 a.m., revealed that the front cover of electrical panel #2 in the Basement Electrical room was secured by only 2 screws exposing the wires in the panel.

Maintenance Staff (A) verified these observations.