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Based on observation, document review, and interview, the provider failed to maintain corridor separation from use areas by walls with at least a 30 minute fire resistance rating in the corridor. There was no documentation indicating combination smoke/fire dampers in the corridor walls and lay-in ceiling had been checked annually for functional operation in accordance with NFPA 90. The provider must comply with the National Fire Protection Association (NFPA) 90, Article 3-3.5 through 5-3.2 (see attachment). Findings include:

1. Observation at 1:30 p.m. revealed unsealed openings around the ductwork penetrations of the corridor walls adjacent to the smoke barrier walls in the south corridor at the north wall. The building had a return air plenum in the corridor system above the lay-in ceiling. All corridor wall penetration openings above the lay-in ceiling must be sealed with an approved firestop material.

2. Document review revealed there was no documentation indicating the corridor, lay-in ceiling, or smoke barrier wall combination fire/smoke dampers had been annually checked and maintained for functional operation in accordance with NFPA 90. The corridors had a return air plenum above the lay-in acoustical ceiling which negated any smoke-tight classification for the lay-in ceiling. Interview with the maintenance supervisor at 2:00 p.m. revealed she was unaware of the damper testing requirement.

Based on observation and interview, the provider failed to maintain the 30 minute fire resistive rating of smoke barrier walls. The smoke barrier walls above the lay-in acoustical ceiling were not sealed at the roof deck and at wiring penetrations. Findings include:

1. Observation from 2:30 p.m. to 2:45 p.m. on 3/01/11 revealed the east side of the smoke barrier wall for the south corridor was not sealed at the roof deck. A 2 inch conduit penetrating the smoke barrier wall and containing control wiring was not sealed. The east side of the north corridor smoke barrier wall was also not sealed at the roof deck. Interview with the maintenance supervisor at the time of the observations confirmed those findings. She stated the contractors must not have finished sealing the smoke barriers at the time of the initial construction.

Based on observation and interview, the provider failed to maintain two sets of smoke barrier doors. Smoke barrier doors are required to be self-closing and rabbets, bevels, or astragals are required at the meeting edges. Findings include:

1. Observation at 11:00 a.m. on 3/01/11 revealed the alternate swinging smoke barrier doors in the west ends of the two corridors were not equipped with rabbets, bevels, or astragals. Interview with the administrator at 3:45 p.m. confirmed that condition. He revealed the doors had been installed that way at the time of the initial construction 4 years ago.

Based on observation and interview, the provider failed to maintain proper separation of hazardous areas. The corridor double-doors for the mechanical room had a 1/2 inch gap at the bottom and a 3/8 inch gap at the top when closed. Findings include:

1. Observation at 1:45 p.m. on 3/01/11 revealed the corridor double-doors for the mechanical room had a 1/2 inch gap at the bottom and a 3/8 inch gap at the top when closed. Interview with the maintenance supervisor at the time of the observation revealed the doors had been that way since the original installation 4 years ago.

Based on record review and interview, the provider failed to ensure the automatic sprinkler system had the required quarterly flow testing performed during the previous twelve months. Record review of the previous twelve months fire sprinkler system inspections revealed quarterly flow testing documentation was not available. Findings include:

1. Review of the provider's automatic sprinkler system inspection reports at 8:45 a.m. on 3/01/11 revealed quarterly flow testing documentation was not available. Interview with the maintenance supervisor at the time of the record review indicated he was unaware of the quarterly flow testing requirements.

Based on document review and interview, the provider's administrative policy did not state notification to the SD Department of Health, Office of Licensure and Certification via facsimile to (605) 773-6667 was required when the fire sprinkler system was out of service for more than 4 hours in a 24 hour period. Findings include:

1. Document review revealed the provider's administrative policy did not state notification to the SD Department of Health, Office of Licensure and Certification via facsimile was required when the fire sprinkler system was out of service for more than 4 hours in a 24 hour period. Notification by facsimile to (605) 773-6667 would be the approved method (other methods would be considered supplemental but not acceptable as the primary means of notification). Interview with the maintenance supervisor at 2:00 p.m. revealed the policies would be revised for compliance with the requirement.

Based on document review and interview, the provider's administrative policy did not state notification to the SD Department of Health, Office of Licensure and Certification via facsimile to (605) 773-6667 was required when the fire alarm system was out of service for more than 4 hours in a 24 hour period. Findings include:

1. Document review revealed the provider's administrative policy did not state notification to the SD Department of Health, Office of Licensure and Certification via facsimile was required when the fire alarm system was out of service for more than 4 hours in a 24 hour period. Notification by facsimile to (605) 773-6667 would be the approved method (other methods would be considered supplemental but not acceptable as the primary means of notification). Interview with the maintenance supervisor at 2:00 p.m. revealed the policies would be revised for compliance with the requirement.

Based on observation and interview, the provider failed to properly install alcohol based hand rub (ABHR) containers at two randomly observed resident rooms. ABHR was found over or adjacent to light switches or electrical receptacles in patient rooms 4 and 5. Findings include:

1. Observation from 10:30 a.m. to 10:45 a.m. revealed Ecolab Quik Care ABHR containers were installed over an electrical source in patient rooms 4 and 5. Interview with the maintenance supervisor at the times of the observations revealed the supplier had installed the ABHR units. She further stated she would relocate the ABHR containers to acceptable locations as soon as possible.

Based on observation, document review, and interview, the provider failed to maintain corridor separation from use areas by walls with at least a 30 minute fire resistance rating in the corridor. There was no documentation indicating combination smoke/fire dampers in the corridor walls and lay-in ceiling had been checked annually for functional operation in accordance with NFPA 90. The provider must comply with the National Fire Protection Association (NFPA) 90, Article 3-3.5 through 5-3.2 (see attachment). Findings include:

1. Observation at 1:30 p.m. revealed unsealed openings around the ductwork penetrations of the corridor walls adjacent to the smoke barrier walls in the south corridor at the north wall. The building had a return air plenum in the corridor system above the lay-in ceiling. All corridor wall penetration openings above the lay-in ceiling must be sealed with an approved firestop material.

2. Document review revealed there was no documentation indicating the corridor, lay-in ceiling, or smoke barrier wall combination fire/smoke dampers had been annually checked and maintained for functional operation in accordance with NFPA 90. The corridors had a return air plenum above the lay-in acoustical ceiling which negated any smoke-tight classification for the lay-in ceiling. Interview with the maintenance supervisor at 2:00 p.m. revealed she was unaware of the damper testing requirement.

Based on observation and interview, the provider failed to maintain the 30 minute fire resistive rating of smoke barrier walls. The smoke barrier walls above the lay-in acoustical ceiling were not sealed at the roof deck and at wiring penetrations. Findings include:

1. Observation from 2:30 p.m. to 2:45 p.m. on 3/01/11 revealed the east side of the smoke barrier wall for the south corridor was not sealed at the roof deck. A 2 inch conduit penetrating the smoke barrier wall and containing control wiring was not sealed. The east side of the north corridor smoke barrier wall was also not sealed at the roof deck. Interview with the maintenance supervisor at the time of the observations confirmed those findings. She stated the contractors must not have finished sealing the smoke barriers at the time of the initial construction.

Based on observation and interview, the provider failed to maintain two sets of smoke barrier doors. Smoke barrier doors are required to be self-closing and rabbets, bevels, or astragals are required at the meeting edges. Findings include:

1. Observation at 11:00 a.m. on 3/01/11 revealed the alternate swinging smoke barrier doors in the west ends of the two corridors were not equipped with rabbets, bevels, or astragals. Interview with the administrator at 3:45 p.m. confirmed that condition. He revealed the doors had been installed that way at the time of the initial construction 4 years ago.

Based on observation and interview, the provider failed to maintain proper separation of hazardous areas. The corridor double-doors for the mechanical room had a 1/2 inch gap at the bottom and a 3/8 inch gap at the top when closed. Findings include:

1. Observation at 1:45 p.m. on 3/01/11 revealed the corridor double-doors for the mechanical room had a 1/2 inch gap at the bottom and a 3/8 inch gap at the top when closed. Interview with the maintenance supervisor at the time of the observation revealed the doors had been that way since the original installation 4 years ago.

Based on record review and interview, the provider failed to ensure the automatic sprinkler system had the required quarterly flow testing performed during the previous twelve months. Record review of the previous twelve months fire sprinkler system inspections revealed quarterly flow testing documentation was not available. Findings include:

1. Review of the provider's automatic sprinkler system inspection reports at 8:45 a.m. on 3/01/11 revealed quarterly flow testing documentation was not available. Interview with the maintenance supervisor at the time of the record review indicated he was unaware of the quarterly flow testing requirements.

Based on document review and interview, the provider's administrative policy did not state notification to the SD Department of Health, Office of Licensure and Certification via facsimile to (605) 773-6667 was required when the fire sprinkler system was out of service for more than 4 hours in a 24 hour period. Findings include:

1. Document review revealed the provider's administrative policy did not state notification to the SD Department of Health, Office of Licensure and Certification via facsimile was required when the fire sprinkler system was out of service for more than 4 hours in a 24 hour period. Notification by facsimile to (605) 773-6667 would be the approved method (other methods would be considered supplemental but not acceptable as the primary means of notification). Interview with the maintenance supervisor at 2:00 p.m. revealed the policies would be revised for compliance with the requirement.

Based on document review and interview, the provider's administrative policy did not state notification to the SD Department of Health, Office of Licensure and Certification via facsimile to (605) 773-6667 was required when the fire alarm system was out of service for more than 4 hours in a 24 hour period. Findings include:

1. Document review revealed the provider's administrative policy did not state notification to the SD Department of Health, Office of Licensure and Certification via facsimile was required when the fire alarm system was out of service for more than 4 hours in a 24 hour period. Notification by facsimile to (605) 773-6667 would be the approved method (other methods would be considered supplemental but not acceptable as the primary means of notification). Interview with the maintenance supervisor at 2:00 p.m. revealed the policies would be revised for compliance with the requirement.