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Based on observation and staff interview, the facility failed to provide appropriate construction standards as required by the life safety code for separation of a construction area from the existing Health Care facility. This deficient practice would allow for smoke and fire to spread more rapidly to other areas of the facility, including exit pathways. These conditions could affect 5 of the 5 smoke zones. This facility has a capacity of 22 and a census of 5 residents.

Findings Include:

On 1/19/2011 between 1:30 AM and 3:45 PM the following conditions are observed:

The drywall interior walls being built for the Phase One of the construction were not completed while the existing hospital was in active use. This condition included no tape and seal finish for all of the seams and only one layer of sheetrock for the separation in some places. This separation wall is over 150 feet long and has direct connection to several smoke zones and most of the primary exiting for the facility.

There was no separation provided for the new electrical equipment room to the exit corridor for the kitchen and break area.

Staff M and the representative of the General Contractor who has job oversight responsibility were present and verified these conditions. All deficiencies were discussed and work was commencing for immediate repairs while the inspector was on the site. The approved Code Footprint and an approved Plan for Temporary Exiting were also reviewed for compliance.

Record review of the following NFPA Standard revealed: 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.

Based on observation and staff interview, The facility failed to ensure that the Medication room was provided with 24 hour task and emergency lighting. This condition would affect 1 of the 5 smoke zones. The facility has a capacity of 22 and a census of 5.
Findings include:
On 1/19/2011, between 1:00 PM and 4:30 PM, The following condition was observed:
No emergency light fixture or emergency generator lighting was provided for the new location of the Medication Room.
Staff A was present and verified this condition. Emergency lighting would be installed immediately.
The research of the NFPA Standard revealed: 7.9.2.2* The emergency lighting system shall be arranged to
provide the required illumination automatically in the event of any of the following:
(1) Interruption of normal lighting such as any failure of a
public utility or other outside electrical power supply
(2) Opening of a circuit breaker or fuse
(3) Manual act(s), including accidental opening of a switch
controlling normal lighting facilities
Emergency lighting shall be provided for minimun 90 minute (1 1/2 hour) duration shall be provided. 2000 NFPA 101; 7.9

Based on observation, staff interview, and record review, the facility failed to assure fire drills were scheduled and occurred at random times and in unexpected conditions. This condition could effect proper staff reactions to an actual emergency evacuation. This would affect 5 of the 5 smoke zones. The facility has a capacity of 22 and a census of 5.
Findings Include:
During the record review on 1/19/2011, between 10:00 AM and 12:30 PM, the following was observed;

The facility failed to document drills occurring in a random and unexpected fashion of all three shifts and for all annual quarters for 2010.

1. All drills for the 1st shift for four quarters of 2010 occurred between 10:07 AM and 10:16 AM or a 9:00 minute span.

2. All drills for the 2nd shift for four quarters of 2010 occurred between 14.32 PM and 14:59 PM or a 27:00 minute span.

3. All drills for the 3rd shift for four quarters of 2010 occurred between 06:04 AM and 06:25 AM or a 21:00 minute span.

Staff A and Staff M were present and verified that this drill scheduling was existing. Plans would be put in place to immediately provide for random fire drills.

Record review of the following NFPA Standard revealed: 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. 2000 NFPA 101, 18/19.7.1.2.