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Based on observations during tour and staff interview, the facility failed to provide smoke barriers that formed at least two smoke compartments constructed to provide at least a one half hour fire resistance rating. This had the potential to affect all patients, staff and visitors utilizing the facility. The patient census was 15 at the time of the survey.

Findings include:

Tour of the facility took place on 03/09/10, with Staff T, Staff U, Staff V and Staff W.
Penetrations were observed in the one half hour rated smoke barrier above the ceiling tile in the following locations:

First floor:
* Near the southwest entrance door to the emergency department, a four inch open end conduit was observed.
* Within the emergency department staff locker area, one open end conduit was observed.
* Three unsealed conduits were observed above the medical records window # 1800.
* At the entrance of the cafeteria and above the drop down door, two open end conduits were observed.
* From within the vending machine area outside of the cafeteria, a four inch unsealed water line and conduit was observed.

Second floor:
* Within the surgery waiting area, north wall, one unsealed conduit was observed. East wall, one unsealed conduit was observed. South wall, three unsealed conduits were observed.
* In the smoke barrier across from the rehab waiting area, one unsealed conduit was observed.
* Above the rest rooms bordering the northwest corner of the pharmacy department, observation was made of an unsealed conduit with a red wire passing through.
* To the left of the fore-mentioned rest rooms and near room # 2300, observation was made of a three inch conduit with the fire rated seal falling out, leaving a large opening within the conduit.
* Above the door of room # P023A and above the double doors beside room # P023A, observation was made of an approximate eight foot section (each area) by a quarter inch wide unsealed area, where the drywall meets the upper deck.
* In the smoke barrier across from elevator # 2, observation was made of an approximate two inch unsealed water line.
* Above the double doors in the smoke barrier entering into the outpatient unit, observation was made of an unsealed 18 inch by quarter inch area at the top of the duct passing through the smoke barrier. Additionally, observation was made of two unsealed conduits and an approximate six feet by quarter inch section of unsealed drywall, where it meets the upper deck.
* Within room # 2118, observation was made of an approximate two inch by two inch penetration with a wire passing through.

Third floor:
* Within room # 3123, observation was made of a half inch open end conduit.
* Within room # 3124, observation was made of an unsealed channel passing thorough.
* Within the soiled utility room, observation was made of a half inch open end conduit located in the east wall.
* Within medication room # 3132, observation was made of two open end conduits in the north wall and one open end conduit in the east wall.
* Outside of the medication room # 3132 and to the left of the smoke barrier doors, observation was made of two penetrations approximately one half inch round.
* Within room # 3111, observation was made of a half inch open end conduit with red and gray wires passing through.

These observations were verified by Staff U during the tour on 03/09/10.

Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that four doors in the smoke barriers were smoke resistant when in the closed position utilizing rabbets, bevels or astragals. This could affect all individuals utilizing the services of this smoke compartment. The facility census was 15 at the time of the survey.

Findings include:

Tour of the facility took place on 03/09/10 with Staff T, Staff U, Staff V and Staff W.
Although the smoke barrier doors were verified as beveled, gaps greater than 1/8 of an inch were observed between the rated smoke barrier doors when in the closed position at the following locations:

First floor:
* Beside room P101A
* Near the lobby and room 1400

Third floor:
* West side of the nurses station
* East side of the nurses station


These observations were verified by Staff members T, U and V during the tour on 03/09/10.

Based on observations during tour and staff interview, the facility failed to provide at least a one hour fire rated construction for hazardous areas in accordance with NFPA 8.4. This had the potential to affect all patients, staff and visitors utilizing these areas. The current census was 15 patients.

Findings include:

Tour of the facility took place on 03/09/10 with Staff T, Staff U, Staff V and Staff W.
Penetrations were observed in the one hour rated barrier above the ceiling tile in the following locations:

First floor:
* Within the bio-hazard room located beside room # 1112, observation was made of four unsealed conduits in the south wall.
* Within room # 1112, observation was made of four unsealed conduits.
* Within the emergency department room # 1923, observation was made of eight unsealed conduits.
* Within the X-ray film room # 1702, observation was made of eight penetrations. North wall had two unsealed conduits. South wall had one unsealed conduit. East wall had one unsealed black water line and one unsealed curved conduit. West wall had one unsealed black water line, one unsealed curved conduit and one unsealed support beam.


These observations were verified by Staff U during the tour on 03/09/10.

Based on observation and staff interview, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all patient's, staff and visitors utilizing the facility. The patient census was 15 at the time of the survey.

Findings include:

Tour of the facility took place on 03/09/10, with Staff T, Staff U, Staff V and Staff W.
Observation was made of several smoke detectors which were mounted in areas affected by the supply or return air flow from diffusers served by the air-handling system. This may not be a comprehensive list of all smoke detectors within the facility located near air handling diffusers. The smoke detectors identified were located at:

First floor:
* Within the medical records department.
* Within the ambulatory emergency department waiting room.
* Within the lab office.
* Within the outpatient clinic/lab waiting area and the office located inside the unit.
* Within the dishwasher room.
* At the front entrance of the cafeteria and above the cashier area.
* By room # 1926.

Second floor:
* Visitors lounge by room # P201F (equipment room).
* Within the IT department.
* Within the rehab waiting room and rehab reception area.
* In the back side of the pharmacy, south corridor, located by the rest rooms.
* Within the computer training room.

Third floor:
* Within the patient waiting area.
* By elevator # 3.


These observations were verified by Staff members T, U and V during the tour on 03/09/10.