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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. The deficient practice could affect all occupants in 6 of 6 smoke zones. The facility has a capacity of 13 with a census of 3 in the hospital portion of the facility and a capacity of 44 with a census of 31 in the LTCU portion of the facility at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 04/05/2010, between 1:30 p.m. and 6:00 p.m., it is observed that the smoke barrier walls in the following locations have unsealed penetrations around wires, cables, pipes and/or conduit that pass through them:

-- 1. Near isolation room; non-approved expanding foam in use.
-- 2. West end of the 200 Hall, between the Hospital and the LTCU portion of the facility.
-- 3. West end of Hospital hallway, near the LTCU nurses' station.
-- 4. Near the main dining room.
-- 5. Three smoke barrier walls at time-clock area.

Staff A and B were present, aware of the findings, and acknowledged that previously applied materials did not seal gaps and would not resist the passage of fire or smoke.

Based upon staff interview and a review of records, the facility fails to assure that emergency lighting units are tested and maintained as required. The deficient practice reduces reliability that emergency lighting will be provided for a minimum of 90 minutes and affects 2 of 6 smoke zones. The facility has a capacity of 13 with a census of 3 in the hospital portion of the facility and a capacity of 44 with a census of 31 in the LTCU portion of the facility at the time of the survey.

During the tour conducted on 04/05/2010, between 1:30 p.m. and 6:00 p.m., a review of records revealed no 90-minute testing of the emergency lighting units within the last 12 months.

Staff A and B were present, aware of the findings, and stated that the testing had been completed but not documented and assured that the required testing would be documented in the future.

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 6 of 6 smoke zones. The facility has a capacity of 13 with a census of 3 in the hospital portion of the facility and a capacity of 44 with a census of 31 in the LTCU portion of the facility at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 04/05/10, between 1:30 p.m. and 6:00 p.m., a review of records for the most recent 4 quarters revealed the following:

-- 1. Fire drills are conducted within close proximity of each other:
a. Drills for the 1st Shift, 2nd, 3rd and 4th Qtrs of 2009 were held at 8:50 a.m., 10:00 a.m., and 9:30 a.m., respectively. Fire Drill for the 1st Shift, 1st Qtr of 2010 was held at 9:45 a.m.
b. Drills for the 2nd Shift, 4th Qtr 2009 and 2nd Shift, 1st Qtr 2010 were held at 6:30 p.m. and 6:00 p.m., respectively.

-- 2. No documented Fire Drills for the 2nd Shift, 2nd Qtr 2009 or 2nd Shift 3rd Qtr 2009.

-- 3. Documented Fire Drills do not include scenarios

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

Based on observation, record review and staff interview the facility fails to ensure that the automatic sprinkler system is installed in accordance with NFPA 13. This deficient practice does not ensure that the fire suppression system will function properly in the event of a fire, affecting 6 of 6 smoke zones. The facility has a capacity of 13 with a census of 3 in the hospital portion of the facility and a capacity of 44 with a census of 31 in the LTCU portion of the facility at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 04/05/10, between 1:30 p.m. and 6:00 p.m., a review of the facility's Code Footprint Site Plan dated 01/26/07 shows a Fire Department Connection (FDC) on the Southeast side of the building. Observation reveals that no FDC exists at that location.

Staff A and B verified the condition existed at the above location and is aware of the finding.

Based upon 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 full instant use in the case of fire or other emergency and affects 1 of 6 smoke zones. The facility has a capacity of 13 with a census of 3 in the hospital portion of the facility and a capacity of 44 with a census of 31 in the LTCU portion of the facility at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 04/08/10, between 10:30 a.m. and 1:30 p.m., it is observed that chairs and a table are located in the corridor near the North and West of the LTCU nurses' station. The area is used as a living space for one of the residents and extends into the corridor.

Staff C was present and acknowledged the findings. Staff C stated that the resident needs constant observation and would be relocated to an alternative area.

Based upon observation and staff interview, the facility fails to assure that electrical wiring and equipment is installed and maintained in accordance with NFPA 70. The deficient practice increases the risk of an electrical fire in 1 of 6 smoke zones. The facility has a capacity of 13 with a census of 3 in the hospital portion of the facility and a capacity of 44 with a census of 31 in the LTCU portion of the facility at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 04/05/2010, between 1:30 p.m. and 6:00 p.m., it is observed that Electrical Panel HB has two open spaces for breakers and that the panel was not locked at the time of the survey.

Staff A and B were present, aware of the findings, acknowledged that the spaces needed to be filled and the cabinet should be secured.

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. The deficient practice could affect all occupants in 6 of 6 smoke zones. The facility has a capacity of 13 with a census of 3 in the hospital portion of the facility and a capacity of 44 with a census of 31 in the LTCU portion of the facility at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 04/05/2010, between 1:30 p.m. and 6:00 p.m., it is observed that the smoke barrier walls in the following locations have unsealed penetrations around wires, cables, pipes and/or conduit that pass through them:

-- 1. Near isolation room; non-approved expanding foam in use.
-- 2. West end of the 200 Hall, between the Hospital and the LTCU portion of the facility.
-- 3. West end of Hospital hallway, near the LTCU nurses' station.
-- 4. Near the main dining room.
-- 5. Three smoke barrier walls at time-clock area.

Staff A and B were present, aware of the findings, and acknowledged that previously applied materials did not seal gaps and would not resist the passage of fire or smoke.

Based upon staff interview and a review of records, the facility fails to assure that emergency lighting units are tested and maintained as required. The deficient practice reduces reliability that emergency lighting will be provided for a minimum of 90 minutes and affects 2 of 6 smoke zones. The facility has a capacity of 13 with a census of 3 in the hospital portion of the facility and a capacity of 44 with a census of 31 in the LTCU portion of the facility at the time of the survey.

During the tour conducted on 04/05/2010, between 1:30 p.m. and 6:00 p.m., a review of records revealed no 90-minute testing of the emergency lighting units within the last 12 months.

Staff A and B were present, aware of the findings, and stated that the testing had been completed but not documented and assured that the required testing would be documented in the future.

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 6 of 6 smoke zones. The facility has a capacity of 13 with a census of 3 in the hospital portion of the facility and a capacity of 44 with a census of 31 in the LTCU portion of the facility at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 04/05/10, between 1:30 p.m. and 6:00 p.m., a review of records for the most recent 4 quarters revealed the following:

-- 1. Fire drills are conducted within close proximity of each other:
a. Drills for the 1st Shift, 2nd, 3rd and 4th Qtrs of 2009 were held at 8:50 a.m., 10:00 a.m., and 9:30 a.m., respectively. Fire Drill for the 1st Shift, 1st Qtr of 2010 was held at 9:45 a.m.
b. Drills for the 2nd Shift, 4th Qtr 2009 and 2nd Shift, 1st Qtr 2010 were held at 6:30 p.m. and 6:00 p.m., respectively.

-- 2. No documented Fire Drills for the 2nd Shift, 2nd Qtr 2009 or 2nd Shift 3rd Qtr 2009.

-- 3. Documented Fire Drills do not include scenarios

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

Based on observation, record review and staff interview the facility fails to ensure that the automatic sprinkler system is installed in accordance with NFPA 13. This deficient practice does not ensure that the fire suppression system will function properly in the event of a fire, affecting 6 of 6 smoke zones. The facility has a capacity of 13 with a census of 3 in the hospital portion of the facility and a capacity of 44 with a census of 31 in the LTCU portion of the facility at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 04/05/10, between 1:30 p.m. and 6:00 p.m., a review of the facility's Code Footprint Site Plan dated 01/26/07 shows a Fire Department Connection (FDC) on the Southeast side of the building. Observation reveals that no FDC exists at that location.

Staff A and B verified the condition existed at the above location and is aware of the finding.

Based upon 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 full instant use in the case of fire or other emergency and affects 1 of 6 smoke zones. The facility has a capacity of 13 with a census of 3 in the hospital portion of the facility and a capacity of 44 with a census of 31 in the LTCU portion of the facility at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 04/08/10, between 10:30 a.m. and 1:30 p.m., it is observed that chairs and a table are located in the corridor near the North and West of the LTCU nurses' station. The area is used as a living space for one of the residents and extends into the corridor.

Staff C was present and acknowledged the findings. Staff C stated that the resident needs constant observation and would be relocated to an alternative area.

Based upon observation and staff interview, the facility fails to assure that electrical wiring and equipment is installed and maintained in accordance with NFPA 70. The deficient practice increases the risk of an electrical fire in 1 of 6 smoke zones. The facility has a capacity of 13 with a census of 3 in the hospital portion of the facility and a capacity of 44 with a census of 31 in the LTCU portion of the facility at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 04/05/2010, between 1:30 p.m. and 6:00 p.m., it is observed that Electrical Panel HB has two open spaces for breakers and that the panel was not locked at the time of the survey.

Staff A and B were present, aware of the findings, acknowledged that the spaces needed to be filled and the cabinet should be secured.