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Based upon observation and staff interview, the facility fails to assure that spaces between penetrating items and smoke barriers are filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. The deficient practice would not prevent the passage of smoke to other areas of the building, affecting 6 patients, all staff and visitors in 2 of 3 smoke zones. The facility has a capacity of 12 with a census of 6 at the time of the survey.

Findings include:

During the tour conducted on 06/06/2013, at 3:30 p.m. it is observed:

-- 1. Smoke barrier wall near Dictation Room has unsealed penetrations around cables and wires.

Maintenance Director A and Safety Director A were present and acknowledged the presence of unsealed gaps in the smoke barrier wall.

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1

Based upon a review of records and staff interview, the facility fails to assure that fire drills are held at unexpected times, under varying conditions and at least once per shift per quarter. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of 12 of 12 patients, all staff and visitors, in the event of a fire, affecting 3 of 3 smoke zones. The facility has a capacity of 12 with a census of 6 at the time of the survey.

Findings include:

During the tour conducted on 06/06/2013, between 4:00 p.m. and 4:30 p.m., a review of records for the last 5 quarters revealed the following:

-- 1. Drills documented for the 1st Shift and 2nd Shift for the 1st Quarter of 2013 do not include participant names or signatures.

Maintenance Director A and Safety Director A were present and acknowledged the results of the record review.

NFPA Standard: 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, 19.7.1.2

Based upon observation and staff interview, the facility fails to assure that electrical wiring is in accordance with NFPA 70. The deficient practice increases the risk of an electrical fire, affecting all occupants, including approximately 12 of 12 patients in 3 of 3 smoke zones. The facility has a capacity of 12 with a census of 6 at the time of this survey.

Findings include:

During the portion of the tour conducted on 06/06/2013, between 3:00 p.m., and 4:30 p.m., it is observed:

-- 1. Electrical outlets near hand sinks in the Labratory are not protected by a GFCI breakers.

-- 2. Electrical outlets near hand sinks in patient rooms are not protected by GFCI breakers.

Maintenance Director A and Safety Director A were present and acknowledged the unprotected outlets.

NFPA Standard: All 125-volt, single-phase, 15- and 20-ampere receptacles installed in bathrooms, garages, storage areas, work areas, and area of similar use shall have Ground-Fault Circuit-Interrupter (GFCI) protection. 1999 NFPA 70, 210-8.