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Based on observation and staff interview, the facility fails to ensure proper separation of hazardous areas from other spaces. This deficient practice would allow for the spread of smoke and fire into adjacent areas, affecting all occupants in 1 of 3 smoke zones. The facility has a capacity of 15 with a census of 1 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 04/13/2010, between 1:30 p.m. and 5:30 p.m. it is observed that there are gaps around pipes and conduit in the one-hour rated wall separating the basement mechanical room and corridor.

Staff A, B and C were present and acknowledged that the gaps are not sealed and would not resist the passage of fire or smoke. Staff C corrected the deficiency prior to completion of the tour.

Based upon observation, a review of records and staff interview, the facility fails to assure that not less than two exits, remote from each other, are provided from each fire section of the building as required by NFPA 101 18.2.4.1, 18.2.4.2, 18.2.4.3. The deficient practice does not provide a second exit in the event of an emergency, affecting 1 of 3 smoke zones. The facility has a capacity of 15 with a census of 1 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 04/13/2010, between 1:30 p.m. and 5:30 p.m., a review of records reveals that the Pharmacy, designated as "Smoke Compartment 3", does not have a second exit as required and shown in the facility's Code Plan dated 02/24/2010.

Staff A, B and C were present and acknowledged that the second exit does not currently exist. Staff B stated that materials are ordered and that the area will remain unoccupied until the second exit is complete.

Based on observation and staff interview, the facility fails to assure that oxygen cylinders are properly stored. The deficient practice does not assure that cylinders are protected in accordance with NFPA 99, affecting 1 of 3 smoke zones. The facility has a capacity of 15 with a census of 1 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 04/13/2009, between 1:30 p.m. and 5:30 p.m., it is observed that oxygen cylinders in the medical gas storage room are stored in mixed fashion in a single cart, with no separation or identification of empty and full cylinders.

Staff A and B were present and aware of the findings. Staff B immediately separated empty cylinders from full cylinders.

Based on a review of records and staff interview, the facility fails to conduct and properly document weekly testing of the generator in accordance with NFPA 99 and NFPA 110. The deficient practice reduces the reliability of the generator and affects 3 of 3 smoke zones. The facility has a capacity of 15 with a census of 1 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 04/13/2010, between 1:30 p.m. and 5:30 p.m., a review of records from February 2010 (initial opening for the facility) thru 04/13/2010 revealed no documented weekly inspection and testing of the facility's generator.

Staff A and B were present and aware of the findings. Staff A stated that the inspection and testing had been completed although not documented.

Based on observation and staff interview, the facility fails to ensure proper separation of hazardous areas from other spaces. This deficient practice would allow for the spread of smoke and fire into adjacent areas, affecting all occupants in 1 of 3 smoke zones. The facility has a capacity of 15 with a census of 1 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 04/13/2010, between 1:30 p.m. and 5:30 p.m. it is observed that there are gaps around pipes and conduit in the one-hour rated wall separating the basement mechanical room and corridor.

Staff A, B and C were present and acknowledged that the gaps are not sealed and would not resist the passage of fire or smoke. Staff C corrected the deficiency prior to completion of the tour.

Based upon observation, a review of records and staff interview, the facility fails to assure that not less than two exits, remote from each other, are provided from each fire section of the building as required by NFPA 101 18.2.4.1, 18.2.4.2, 18.2.4.3. The deficient practice does not provide a second exit in the event of an emergency, affecting 1 of 3 smoke zones. The facility has a capacity of 15 with a census of 1 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 04/13/2010, between 1:30 p.m. and 5:30 p.m., a review of records reveals that the Pharmacy, designated as "Smoke Compartment 3", does not have a second exit as required and shown in the facility's Code Plan dated 02/24/2010.

Staff A, B and C were present and acknowledged that the second exit does not currently exist. Staff B stated that materials are ordered and that the area will remain unoccupied until the second exit is complete.

Based on observation and staff interview, the facility fails to assure that oxygen cylinders are properly stored. The deficient practice does not assure that cylinders are protected in accordance with NFPA 99, affecting 1 of 3 smoke zones. The facility has a capacity of 15 with a census of 1 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 04/13/2009, between 1:30 p.m. and 5:30 p.m., it is observed that oxygen cylinders in the medical gas storage room are stored in mixed fashion in a single cart, with no separation or identification of empty and full cylinders.

Staff A and B were present and aware of the findings. Staff B immediately separated empty cylinders from full cylinders.

Based on a review of records and staff interview, the facility fails to conduct and properly document weekly testing of the generator in accordance with NFPA 99 and NFPA 110. The deficient practice reduces the reliability of the generator and affects 3 of 3 smoke zones. The facility has a capacity of 15 with a census of 1 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 04/13/2010, between 1:30 p.m. and 5:30 p.m., a review of records from February 2010 (initial opening for the facility) thru 04/13/2010 revealed no documented weekly inspection and testing of the facility's generator.

Staff A and B were present and aware of the findings. Staff A stated that the inspection and testing had been completed although not documented.