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Based on observation and staff interview, the facility fails to assure that barrier walls are maintained and are free of penetrations. The deficient practice compromises the fire resistance rating of the wall and would not prevent the passage of fire or smoke to other areas of the building, affecting 1 patient in 1 of 5 smoke zones. The facility has a capacity of 24 with a census of 1 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 10/17/14, at 12:15 p.m., it is observed that the 2 hour fire barrier wall separating the Hospital and the Specialty clinic has a 1'x13' gap at the top of the wall and unsealed gaps around scissor beams and conduit in the CFO's office.

Maintenance Supervisor was present and acknowledged the findings.

NFPA Standard: Floor-ceiling assemblies and walls used as fire barriers, including supporting construction, shall be of a design that has been tested to meet the conditions of acceptance of NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials. Fire barriers shall be continuous in accordance with 8.2.2.2 per NFPA 101, 8.2.3.1.1. Space between wires and similar building service equipment that pass through fire barriers shall be protected by filling the space with a material that is capable of maintaining the fire resistance of the fire barrier or shall be protected by an approved device that is designed for the specific purpose 2000 NFPA 101, 8.2.3.2.4.

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 deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all residents and occupants in the event of a fire, affecting all patients, visitors and staff in 5 of 5 smoke zones. The facility has a capacity 24 of with a census of 1 at the time of the survey.

Findings include:

During the tour conducted on 10/17/14, a review of records, at 9:30 a.m., for the last 5 quarters revealed the following:

-1) There was no drill conducted during the 3rd qtr of 2014 on the 2nd shift.

-2) There was no time recorded for the drill on 5/5/14.

Maintenance Supervisor was present and acknowledged the results of the record review.

NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. The fire alarm shall be transmitted the day before or the day after the coded drill. 2000 NFPA 101, 19.7.1.2

Based upon observation and staff interview, the facility fails to assure that electrical wiring is in accordance with NFPA 70 and fails to prohibit the use of flexible cords and cables as permanent wiring. The deficient practice increases the risk of an electrical fire, affecting 1 patient and all visitors and staff in 1 of 5 smoke zones. The facility has a capacity of 24 with a census of 1 at the time of the survey.

Findings include:

During the tour conducted on 10/17/14, at 12:30 p.m., it is observed that there is an extension cord permanently powering the temperature control unit for the pharmacy refrigerator.

Maintenance Supervisor was present and acknowledged the finding.

NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8

Based on observation and staff interview, the facility fails to assure that barrier walls are maintained and are free of penetrations. The deficient practice compromises the fire resistance rating of the wall and would not prevent the passage of fire or smoke to other areas of the building, affecting 1 patient in 1 of 5 smoke zones. The facility has a capacity of 24 with a census of 1 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 10/17/14, at 12:15 p.m., it is observed that the 2 hour fire barrier wall separating the Hospital and the Specialty clinic has a 1'x13' gap at the top of the wall and unsealed gaps around scissor beams and conduit in the CFO's office.

Maintenance Supervisor was present and acknowledged the findings.

NFPA Standard: Floor-ceiling assemblies and walls used as fire barriers, including supporting construction, shall be of a design that has been tested to meet the conditions of acceptance of NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials. Fire barriers shall be continuous in accordance with 8.2.2.2 per NFPA 101, 8.2.3.1.1. Space between wires and similar building service equipment that pass through fire barriers shall be protected by filling the space with a material that is capable of maintaining the fire resistance of the fire barrier or shall be protected by an approved device that is designed for the specific purpose 2000 NFPA 101, 8.2.3.2.4.

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 deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all residents and occupants in the event of a fire, affecting all patients, visitors and staff in 5 of 5 smoke zones. The facility has a capacity 24 of with a census of 1 at the time of the survey.

Findings include:

During the tour conducted on 10/17/14, a review of records, at 9:30 a.m., for the last 5 quarters revealed the following:

-1) There was no drill conducted during the 3rd qtr of 2014 on the 2nd shift.

-2) There was no time recorded for the drill on 5/5/14.

Maintenance Supervisor was present and acknowledged the results of the record review.

NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. The fire alarm shall be transmitted the day before or the day after the coded drill. 2000 NFPA 101, 19.7.1.2

Based upon observation and staff interview, the facility fails to assure that electrical wiring is in accordance with NFPA 70 and fails to prohibit the use of flexible cords and cables as permanent wiring. The deficient practice increases the risk of an electrical fire, affecting 1 patient and all visitors and staff in 1 of 5 smoke zones. The facility has a capacity of 24 with a census of 1 at the time of the survey.

Findings include:

During the tour conducted on 10/17/14, at 12:30 p.m., it is observed that there is an extension cord permanently powering the temperature control unit for the pharmacy refrigerator.

Maintenance Supervisor was present and acknowledged the finding.

NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8