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Based on observation and staff interview, this facility is not providing a firewall with a two-hour fire rating between the hospital and the clinic portion of the facility. The wall is penetrated above the lay-in ceiling tile above the two hour rated door assembly. This deficient practice affects all occupants including staff, visitors and residents. This facility has a capacity of 49 and a census of 18 residents.

Findings include:

Observation and staff interview on 9/24/15 at 9:52 a.m., the two-hour firewall located between the hospital and the clinic had a 1/2 inch penetration surrounding a cable bundle above the ceiling tile at the two hour rated door assembly. According to Maintenance Staff, this was the two-hour firewall intended to separate the occupancies.

Based on observation and staff interview, this facility is not assuring that two of nineteen smoke barriers is 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 patients in two of nineteen smoke zones. This facility has a capacity of 49 with a census of 18 residents.

Findings include:

Observation and staff interview on 9/24/15 at 9:10 a.m., the South Wing (North Side) above smoke doors had a 1/2 inch penetration surrounding a IT wire. According to the facility layout, this was a required barrier. Maintenance Staff confirmed this observation during the survey process.

Based on observation and staff interview, this facility is not assuring that two of nineteen smoke barriers is 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 patients in two of nineteen smoke zones. This facility has a capacity of 49 with a census of 18 residents.

Findings include:

Observation and staff interview on 9/24/15 at 9:42 a.m., revealed the West Wing Community Health North Side above smoke doors had a 1/2 inch penetration surrounding a IT wire and fire alarm cable. According to the facility layout, this was a required barrier. Maintenance Staff confirmed this observation during the survey process.

(A)
Based on observation and staff interview, the facility failed to prohibit the use of electric plastic surge protection devices within the facility without over current protection and properly use power strips. The location of deficient practice was located in one of nineteen smoke compartments. The facility census was 49 with a capacity of 18.

Findings include:

Observation and staff interview on 9/24/15 at 9:35 a.m., a plastic surge protector was observed to be in use for a microwave/toaster oven/toaster in the Employee's Lounge. Maintenance Staff confirmed this observation during the survey process.



(B)
Based on observation and staff 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 49 and a census of 18 at the time of the survey.

Findings Include:

Observation and staff interview on 9/24/15 at 9:45 a.m., revealed the facility failed to provide a Ground Fault Circuit Interrupter (GFCI) electrical outlet underneath the water fountain located on the 2nd floor West Wing. Maintenance Staff verified this observation during the survey process.


(C)
Based on observation and staff 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 in the Clinic.

Findings Include:

Observation and staff interview on 9/24/15 at 10:06 a.m., revealed the facility failed to provide a Ground Fault Circuit Interrupter (GFCI) electrical outlet next to the sink in Nurses Station #1. Maintenance Staff verified this observation during the survey process.

Based on observation and staff interview, this facility is not providing a firewall with a two-hour fire rating between the hospital and the clinic portion of the facility. The wall is penetrated above the lay-in ceiling tile above the two hour rated door assembly. This deficient practice affects all occupants including staff, visitors and residents. This facility has a capacity of 49 and a census of 18 residents.

Findings include:

Observation and staff interview on 9/24/15 at 9:52 a.m., the two-hour firewall located between the hospital and the clinic had a 1/2 inch penetration surrounding a cable bundle above the ceiling tile at the two hour rated door assembly. According to Maintenance Staff, this was the two-hour firewall intended to separate the occupancies.

Based on observation and staff interview, this facility is not assuring that two of nineteen smoke barriers is 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 patients in two of nineteen smoke zones. This facility has a capacity of 49 with a census of 18 residents.

Findings include:

Observation and staff interview on 9/24/15 at 9:10 a.m., the South Wing (North Side) above smoke doors had a 1/2 inch penetration surrounding a IT wire. According to the facility layout, this was a required barrier. Maintenance Staff confirmed this observation during the survey process.

Based on observation and staff interview, this facility is not assuring that two of nineteen smoke barriers is 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 patients in two of nineteen smoke zones. This facility has a capacity of 49 with a census of 18 residents.

Findings include:

Observation and staff interview on 9/24/15 at 9:42 a.m., revealed the West Wing Community Health North Side above smoke doors had a 1/2 inch penetration surrounding a IT wire and fire alarm cable. According to the facility layout, this was a required barrier. Maintenance Staff confirmed this observation during the survey process.

Based upon observation, record review and interview, the facility failed to hold fire drills under varied conditions at different times for the second shift (four out of four quarters) as required by Section A.19.7.1.2 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition. 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 49 with a census of 18 patients.

Findings include:

Observation of record review and interview on 9/24/15, the facility fire drill documentation showed that the second shift drills were conducted within the same hour for all four quarters. Maintenance Staff verified the documentation during the survey process.

(A)
Based on observation and staff interview, the facility failed to prohibit the use of electric plastic surge protection devices within the facility without over current protection and properly use power strips. The location of deficient practice was located in one of nineteen smoke compartments. The facility census was 49 with a capacity of 18.

Findings include:

Observation and staff interview on 9/24/15 at 9:35 a.m., a plastic surge protector was observed to be in use for a microwave/toaster oven/toaster in the Employee's Lounge. Maintenance Staff confirmed this observation during the survey process.



(B)
Based on observation and staff 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 49 and a census of 18 at the time of the survey.

Findings Include:

Observation and staff interview on 9/24/15 at 9:45 a.m., revealed the facility failed to provide a Ground Fault Circuit Interrupter (GFCI) electrical outlet underneath the water fountain located on the 2nd floor West Wing. Maintenance Staff verified this observation during the survey process.


(C)
Based on observation and staff 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 in the Clinic.

Findings Include:

Observation and staff interview on 9/24/15 at 10:06 a.m., revealed the facility failed to provide a Ground Fault Circuit Interrupter (GFCI) electrical outlet next to the sink in Nurses Station #1. Maintenance Staff verified this observation during the survey process.