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Based on observation and interview, the facility failed to ensure all wall coverings and surfaces in two of two unsprinklered bedrooms of the sleep lab are of Class A or Class B flame spread rating in accordance with 19.3.3.2, or are treated with an appropriate flame retardant chemical on a regular basis, affecting staff and a facility census of three residents.

Findings included:

1. Observation from 6/1/10 at 1:48 P.M. showed finished wood paneling on one wall of each bedroom in the sleep laboratory. Both of the unsprinklered rooms were part of the original hospital structure and had been refurnished with a nine by twelve foot wood paneled accent wall, wall paper, carpeted floor and cloth window curtains to de-emphasize the institutional atmosphere. Each of the two rooms was separated from the corridor by an unrated, solid core door that positively latched when closed.

Document review and maintenance records showed the wood paneled walls carried a Class " C " fire rating (flame spread of 76-200), which is not acceptable in non-sprinklered locations.

During an interview on 6/2/10 at 9:30 A.M., the Director of Facilities said he could not locate any documentation of flame spread for the curtains or paneled wall. He said he was going to look for a product that could be used to treat the paneling and cause it to be flame retardant.

Based on observation and interview, the facility failed to ensure window curtains used in two of two bedrooms of the sleep lab are of flame resistant material in accordance with the provisions the NFPA 101, paragraph 10.3.4 and 19.7.5.1, or are treated with an appropriate flame retardant chemical on a regular basis, affecting staff and a facility census of three residents.

Findings included:

1. Observation from 6/1/10 at 1:48 P.M., showed unlabeled non-rated cloth window curtains in both rooms of a sleep laboratory. Both of the unsprinklered rooms were part of the original hospital structure and had been refurnished with a nine by twelve foot wood paneled accent wall, wall paper, carpeted floor and cloth window curtains to de-emphasize the institutional atmosphere.

Document review on 6/3/10 showed the wall paper and carpet on the floor certified as Class A material, wood paneled wall of Class C material. The window curtains in the two rooms were not rated or labeled.

During an interview on 6/2/10 at 9:30 A.M., the Director of Facilities said he had the curtains temporarily removed. He said he could not locate any documentation of flame spread for the curtains or paneled wall. He showed documentation the carpet met the standards for Class A materials. He said they would either be treated to render them flame retardant or would be replaced with curtains that met the Class A or B interior wall finish.

K135- Sterno and lighter fluid not stored in appropriate location.

Based on observation and interview, the facility failed to store flammable products in the kitchen in accordance with 8.4.1.1 to prevent the spread of smoke or flame in the kitchen area, potentially endangering staff and visitors in the adjacent dining room. The facility census was three patients.

Based on observation and interview, the facility failed to store flammable products in the kitchen in accordance with 8.4.1.1 to prevent the spread of smoke or flame in the kitchen area, potentially endangering staff and visitors in the adjacent dining room. The facility census was three patients.

Findings included:

Observation on 6/2/10 at 11:00 A.M. showed a box half full of seven ounce cans of Sterno brand gelled fuel and a partially used can of charcoal lighter fluid stored on a shelf in the kitchen near an entrance to the dining room.

Review of the label on the Sterno showed each can contained seven ounces (total product of approximately 36 seven ounce containers is 15.75 or 16 ounces) of flammable liquid gel, with the warning printed on the label: " FLAMMABLE-Eye Irritant. "

Review of the label on the charcoal lighter fluid showed it contained a similar warning, " EXTREMELY FLAMMABLE. "

During an interview on 6/2/10 at 11:15 A.M., the Director of Dietary Services said he could remove the cans to a detached garage for safe storage. He expressed concern regarding lack of easy access when maintenance personnel were not on site and the garage was locked. He said he would look into acquiring a small fire resistant container for holding flammables.

During an interview on 6/3/10 at 10:50 A.M., the Director of Facilities said there were no sprinklers in the kitchen or walk-in refrigerator.

Based on observation and interview, the facility failed to ensure all wall coverings and surfaces in two of two unsprinklered bedrooms of the sleep lab are of Class A or Class B flame spread rating in accordance with 19.3.3.2, or are treated with an appropriate flame retardant chemical on a regular basis, affecting staff and a facility census of three residents.

Findings included:

1. Observation from 6/1/10 at 1:48 P.M. showed finished wood paneling on one wall of each bedroom in the sleep laboratory. Both of the unsprinklered rooms were part of the original hospital structure and had been refurnished with a nine by twelve foot wood paneled accent wall, wall paper, carpeted floor and cloth window curtains to de-emphasize the institutional atmosphere. Each of the two rooms was separated from the corridor by an unrated, solid core door that positively latched when closed.

Document review and maintenance records showed the wood paneled walls carried a Class " C " fire rating (flame spread of 76-200), which is not acceptable in non-sprinklered locations.

During an interview on 6/2/10 at 9:30 A.M., the Director of Facilities said he could not locate any documentation of flame spread for the curtains or paneled wall. He said he was going to look for a product that could be used to treat the paneling and cause it to be flame retardant.

Based on observation and interview, the facility failed to ensure window curtains used in two of two bedrooms of the sleep lab are of flame resistant material in accordance with the provisions the NFPA 101, paragraph 10.3.4 and 19.7.5.1, or are treated with an appropriate flame retardant chemical on a regular basis, affecting staff and a facility census of three residents.

Findings included:

1. Observation from 6/1/10 at 1:48 P.M., showed unlabeled non-rated cloth window curtains in both rooms of a sleep laboratory. Both of the unsprinklered rooms were part of the original hospital structure and had been refurnished with a nine by twelve foot wood paneled accent wall, wall paper, carpeted floor and cloth window curtains to de-emphasize the institutional atmosphere.

Document review on 6/3/10 showed the wall paper and carpet on the floor certified as Class A material, wood paneled wall of Class C material. The window curtains in the two rooms were not rated or labeled.

During an interview on 6/2/10 at 9:30 A.M., the Director of Facilities said he had the curtains temporarily removed. He said he could not locate any documentation of flame spread for the curtains or paneled wall. He showed documentation the carpet met the standards for Class A materials. He said they would either be treated to render them flame retardant or would be replaced with curtains that met the Class A or B interior wall finish.

K135- Sterno and lighter fluid not stored in appropriate location.

Based on observation and interview, the facility failed to store flammable products in the kitchen in accordance with 8.4.1.1 to prevent the spread of smoke or flame in the kitchen area, potentially endangering staff and visitors in the adjacent dining room. The facility census was three patients.

Based on observation and interview, the facility failed to store flammable products in the kitchen in accordance with 8.4.1.1 to prevent the spread of smoke or flame in the kitchen area, potentially endangering staff and visitors in the adjacent dining room. The facility census was three patients.

Findings included:

Observation on 6/2/10 at 11:00 A.M. showed a box half full of seven ounce cans of Sterno brand gelled fuel and a partially used can of charcoal lighter fluid stored on a shelf in the kitchen near an entrance to the dining room.

Review of the label on the Sterno showed each can contained seven ounces (total product of approximately 36 seven ounce containers is 15.75 or 16 ounces) of flammable liquid gel, with the warning printed on the label: " FLAMMABLE-Eye Irritant. "

Review of the label on the charcoal lighter fluid showed it contained a similar warning, " EXTREMELY FLAMMABLE. "

During an interview on 6/2/10 at 11:15 A.M., the Director of Dietary Services said he could remove the cans to a detached garage for safe storage. He expressed concern regarding lack of easy access when maintenance personnel were not on site and the garage was locked. He said he would look into acquiring a small fire resistant container for holding flammables.

During an interview on 6/3/10 at 10:50 A.M., the Director of Facilities said there were no sprinklers in the kitchen or walk-in refrigerator.