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Based on observation and interview, it was determined the facility did not maintain penetrations for five (Laboratory, Nursing Unit, Pharmacy and Administration) of seven smoke barrier walls with a fire rated material to resist the passage of smoke. The failed practice had the potential to affect all patients, staff, and visitors due to the inability of the smoke barrier walls to prevent the passage of smoke and fire through the unsealed penetrations. The facility had a census of 12 patients on 10/21/14. The findings follow:

A. On a tour of the facility with Plant Operations Director, on 10/23/14 at 0930, unsealed penetrations of the smoke barrier were observed at the following locations:
1) Two unsealed penetrations above the ceiling at the fire rated doors located near the Laboratory.
2) Two unsealed penetrations above the ceiling at the fire rated doors located in the north corridor of the Nursing Unit.
3) One unsealed penetration above the ceiling at the fire rated doors located in the south corridor of the Nursing Unit.
4) One unsealed penetration above the ceiling at the fire rated doors located near Pharmacy.
5) Two unsealed penetrations above the ceiling at the fire rated doors located near the Administration.
B. The Plant Operations Director verified the unsealed penetrations at the time of each observation

Based on observation and interview, it was determined the Medical Records Rooms and Secondary Medical Records Room used to store paper medical records were not protected as hazardous areas due to a lack of fire rated doors with automatic closing devices and compromised fire rated construction due to a missing section of the fire rated wall. The failed practice had the potential to affect all patients, staff, and visitors due to the potential spread of fire and smoke that originated in the medical records room. The facility had a census of 12 patients on 10/21/14. The findings follow:

A. On a tour of the facility on 10/23/14 at 0945 with the Plant Operations Director the following observations were made:
1) The doors to the Medical Records Room were not fire-rated and did not have automatic closing devices.
2) The door to the Secondary Medical Records Room was not fire rated and did not have an automatic closing device. A section of the wall to the room had been removed, leaving only a single layer of gypsum board and the metal wall studs exposed. Two layers of gypsum board, one on each side of the metal wall stud, were required for a 1 hour fire resistance rating. Therefore, the fire resistance of section of the wall with the missing gypsum board was compromised.
B. The Plant Operations Director verified the findings at A.1-2 as each observation was made.

Based on observation and interview, it was determined the facility failed to secure 24 of 24 oxygen cylinders located in the Medical Gas Room to prevent damage or dislocation as required in NFPA 99, Section 4-3.1.1.2. The failed practice had the potential to affect 12 of 12 patients on the 10/21/14 and all staff and visitors. The findings follow:

A. On a tour of the facility on 10/23/14 at 1030 with the Plant Operations Director, 24 medical gas cylinders located in the Gas Storage Room were observed unsecured with a chain or other fastening device.
B. The Plant Operations Director verified the unsecured cylinders on 10/23/14 at 1030.

Based on interview, it was determined the facility failed to inspect fire and smoke dampers every 4 years (or every six years under CMS Waiver per Survey and Certification Letter 10-04-LSC dated October 30, 2009). Failure to inspect fire and smoke dampers prevents the facility from ensuring the reliability of the dampers to close in the event of a fire or smoke event. The failed practice had the potential to affect 12 of 12 patients on 10/21/14 and all staff and visitors. The findings follow:

In an interview on 10/21/14 at 1514, the Plant Operations Director verified there was no documentation of fire and smoke damper inspection available for review and confirmed the dampers had never been inspected since the building was opened in 2006.

(Reference NFPA 90A, Section 3-4.7)

Based on observation and interview, it was determined the facility failed to post signage to prohibit smoking on one of one Medical Gas Room door. The failed practice has the potential to affect all patients, staff, and visitors due to the potential of fire and explosion presented by smoking in the area of the Medical Gas Room. The facility had a census of 12 patients on 10/21/14. The findings follow:

A. On a tour of the facility on 10/23/14 at 1030 with the Plant Operations Director, the Medical Gas Room was observed without signage to prohibit smoking in the area.
B. The Plant Operations Director verified there was no signage to prohibit smoking at the Medical Gas Room.

Based on observation and interview, it was determined the facility did not maintain penetrations for five (Laboratory, Nursing Unit, Pharmacy and Administration) of seven smoke barrier walls with a fire rated material to resist the passage of smoke. The failed practice had the potential to affect all patients, staff, and visitors due to the inability of the smoke barrier walls to prevent the passage of smoke and fire through the unsealed penetrations. The facility had a census of 12 patients on 10/21/14. The findings follow:

A. On a tour of the facility with Plant Operations Director, on 10/23/14 at 0930, unsealed penetrations of the smoke barrier were observed at the following locations:
1) Two unsealed penetrations above the ceiling at the fire rated doors located near the Laboratory.
2) Two unsealed penetrations above the ceiling at the fire rated doors located in the north corridor of the Nursing Unit.
3) One unsealed penetration above the ceiling at the fire rated doors located in the south corridor of the Nursing Unit.
4) One unsealed penetration above the ceiling at the fire rated doors located near Pharmacy.
5) Two unsealed penetrations above the ceiling at the fire rated doors located near the Administration.
B. The Plant Operations Director verified the unsealed penetrations at the time of each observation

Based on observation and interview, it was determined the Medical Records Rooms and Secondary Medical Records Room used to store paper medical records were not protected as hazardous areas due to a lack of fire rated doors with automatic closing devices and compromised fire rated construction due to a missing section of the fire rated wall. The failed practice had the potential to affect all patients, staff, and visitors due to the potential spread of fire and smoke that originated in the medical records room. The facility had a census of 12 patients on 10/21/14. The findings follow:

A. On a tour of the facility on 10/23/14 at 0945 with the Plant Operations Director the following observations were made:
1) The doors to the Medical Records Room were not fire-rated and did not have automatic closing devices.
2) The door to the Secondary Medical Records Room was not fire rated and did not have an automatic closing device. A section of the wall to the room had been removed, leaving only a single layer of gypsum board and the metal wall studs exposed. Two layers of gypsum board, one on each side of the metal wall stud, were required for a 1 hour fire resistance rating. Therefore, the fire resistance of section of the wall with the missing gypsum board was compromised.
B. The Plant Operations Director verified the findings at A.1-2 as each observation was made.

Based on observation and interview, it was determined the facility failed to secure 24 of 24 oxygen cylinders located in the Medical Gas Room to prevent damage or dislocation as required in NFPA 99, Section 4-3.1.1.2. The failed practice had the potential to affect 12 of 12 patients on the 10/21/14 and all staff and visitors. The findings follow:

A. On a tour of the facility on 10/23/14 at 1030 with the Plant Operations Director, 24 medical gas cylinders located in the Gas Storage Room were observed unsecured with a chain or other fastening device.
B. The Plant Operations Director verified the unsecured cylinders on 10/23/14 at 1030.

Based on interview, it was determined the facility failed to inspect fire and smoke dampers every 4 years (or every six years under CMS Waiver per Survey and Certification Letter 10-04-LSC dated October 30, 2009). Failure to inspect fire and smoke dampers prevents the facility from ensuring the reliability of the dampers to close in the event of a fire or smoke event. The failed practice had the potential to affect 12 of 12 patients on 10/21/14 and all staff and visitors. The findings follow:

In an interview on 10/21/14 at 1514, the Plant Operations Director verified there was no documentation of fire and smoke damper inspection available for review and confirmed the dampers had never been inspected since the building was opened in 2006.

(Reference NFPA 90A, Section 3-4.7)

Based on observation and interview, it was determined the facility failed to post signage to prohibit smoking on one of one Medical Gas Room door. The failed practice has the potential to affect all patients, staff, and visitors due to the potential of fire and explosion presented by smoking in the area of the Medical Gas Room. The facility had a census of 12 patients on 10/21/14. The findings follow:

A. On a tour of the facility on 10/23/14 at 1030 with the Plant Operations Director, the Medical Gas Room was observed without signage to prohibit smoking in the area.
B. The Plant Operations Director verified there was no signage to prohibit smoking at the Medical Gas Room.