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Based on observation, it was determined the one hour fire resistance of smoke barrier walls was compromised at 7 of 11 locations observed due to unsealed penetrations of the smoke barrier walls. Failure to properly seal penetrations of smoke barrier walls has the potential to affect the health and safety of patients, visitors, and staff because a compromised smoke barrier wall allows the passage of fire and smoke from one side of the smoke barrier to the other. The failed practice had the potential to affect 12 of 12 patients on census on 01/04/11and all staff and visitors. The findings follow:

A. On a tour of the facility on 01/05/11 at 1300 with the Director of Maintenance, unsealed penetrations of the smoke barrier walls were observed at the following locations:
1) Above the ceiling at the smoke barrier doors at the 400 Patient Wing, three penetrations of the smoke barrier wall were not sealed with a fire rated material.
2) Above the ceiling at the smoke barrier doors at the 100 Patient Wing, one penetration of the smoke barrier wall was not sealed with a fire rated material.
3) Above the ceiling at the smoke barrier doors near the Nursing Administration Office, one penetration of the smoke barrier wall was not sealed with a fire rated material.
4) Above the ceiling at the smoke barrier doors near the Operating Suite entrance, one penetration of the smoke barrier wall was not sealed with a fire rated material.
5) Above the ceiling at the smoke barrier doors near the Maintenance Office, one penetration of the smoke barrier wall was not sealed with a fire rated material.
6) Above the ceiling at the smoke barrier doors near the Dietary Department, three penetrations of the smoke barrier wall were not sealed with a fire rated material.
7) Above the ceiling at the smoke barrier doors near the Accounting Department, one penetration of the smoke barrier wall was not sealed with a fire rated material.
B. The Director of Maintenance verified the above unsealed penetrations at the time they were observed.

Based on interview, it was determined the facility failed to inspect fire and smoke dampers every 4 years (or every six years under CMS Waiver per S&C Letter 10-04-LSC dated October 30, 2009). Failure to inspect fire and smoke dampers prevents the facility from ensuring the reliability of the dampers to close in the event of a fire or smoke event. The failed practice had the potential to affect 12 of 12 patients on census on 01/04/11and all staff and visitors. The findings follow:

In an interview conducted on 01/05/11 at 0945 the Director of Maintenance stated there was no documentation of fire and smoke damper inspection available for review. He stated he had no knowledge of fire and smoke damper inspection ever being conducted at the facility.

(Reference NFPA 90A, Section 3-4.7)

Based on observation, it was determined the one hour fire resistance of smoke barrier walls was compromised at 7 of 11 locations observed due to unsealed penetrations of the smoke barrier walls. Failure to properly seal penetrations of smoke barrier walls has the potential to affect the health and safety of patients, visitors, and staff because a compromised smoke barrier wall allows the passage of fire and smoke from one side of the smoke barrier to the other. The failed practice had the potential to affect 12 of 12 patients on census on 01/04/11and all staff and visitors. The findings follow:

A. On a tour of the facility on 01/05/11 at 1300 with the Director of Maintenance, unsealed penetrations of the smoke barrier walls were observed at the following locations:
1) Above the ceiling at the smoke barrier doors at the 400 Patient Wing, three penetrations of the smoke barrier wall were not sealed with a fire rated material.
2) Above the ceiling at the smoke barrier doors at the 100 Patient Wing, one penetration of the smoke barrier wall was not sealed with a fire rated material.
3) Above the ceiling at the smoke barrier doors near the Nursing Administration Office, one penetration of the smoke barrier wall was not sealed with a fire rated material.
4) Above the ceiling at the smoke barrier doors near the Operating Suite entrance, one penetration of the smoke barrier wall was not sealed with a fire rated material.
5) Above the ceiling at the smoke barrier doors near the Maintenance Office, one penetration of the smoke barrier wall was not sealed with a fire rated material.
6) Above the ceiling at the smoke barrier doors near the Dietary Department, three penetrations of the smoke barrier wall were not sealed with a fire rated material.
7) Above the ceiling at the smoke barrier doors near the Accounting Department, one penetration of the smoke barrier wall was not sealed with a fire rated material.
B. The Director of Maintenance verified the above unsealed penetrations at the time they were observed.

Based on interview, it was determined the facility failed to inspect fire and smoke dampers every 4 years (or every six years under CMS Waiver per S&C Letter 10-04-LSC dated October 30, 2009). Failure to inspect fire and smoke dampers prevents the facility from ensuring the reliability of the dampers to close in the event of a fire or smoke event. The failed practice had the potential to affect 12 of 12 patients on census on 01/04/11and all staff and visitors. The findings follow:

In an interview conducted on 01/05/11 at 0945 the Director of Maintenance stated there was no documentation of fire and smoke damper inspection available for review. He stated he had no knowledge of fire and smoke damper inspection ever being conducted at the facility.

(Reference NFPA 90A, Section 3-4.7)