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Based on observation, it was determined the one half hour fire resistance of the corridor walls was compromised at two of two locations due to unsealed penetrations of the corridor walls. Failure to properly seal penetrations of corridor walls had 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 corridor wall to the other. The failed practice had the potential to affect eight of eight patients on census on 02/23/11 and all staff and visitors. The findings follow:

A. On a tour of the facility on 02/24/11 at 0900 with the Assistant Director of Maintenance, unsealed penetrations of the corridor wall was observed at the following locations:
1) Above the ceiling at the entrance to Medical Records, one penetration of the corridor wall was not sealed with a fire rated material.
2) Above the ceiling at the smoke barrier doors near the Visitors Lounge, two penetrations of the corridor wall was not sealed with a fire rated material.
B. The Assistant Director of Maintenance verified the above unsealed penetrations at the time they were observed.

Based on observation, it was determined the one hour fire resistance of smoke barrier walls was compromised at four of four locations due to unsealed penetrations of the smoke barrier walls. Failure to properly seal penetrations of smoke barrier walls had 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 eight of eight patients on census on 02/23/11 and all staff and visitors. The findings follow:

A. On a tour of the facility on 02/24/11 at 0900 with the Assistant 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 entrance to the Patient Wing, one penetration of the smoke barrier wall was not sealed with a fire rated material.
2) Above the ceiling at the smoke barrier doors at the near the Visitors Lounge, three penetrations of the smoke barrier wall were not sealed with a fire rated material.
3) Above the ceiling at the smoke barrier doors near the Dietary Department, two penetrations of the smoke barrier wall were not sealed with a fire rated material.
4) Above the ceiling at the smoke barrier doors near the Business Office, one penetration of the smoke barrier wall was not sealed with a fire rated material.
B. The Assistant 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 prevented the facility from ensuring the reliability of the dampers to close in the event of a fire or smoke. The failed practice had the potential to affect eight of eight patients on census on 02/23/11 and all staff and visitors. The findings follow:

In an interview conducted on 02/24/11 at 0850 the Assistant 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 in the six years of his employment at the facility.

(Reference NFPA 90A, Section 3-4.7)

Based on observation, it was determined the one half hour fire resistance of the corridor walls was compromised at two of two locations due to unsealed penetrations of the corridor walls. Failure to properly seal penetrations of corridor walls had 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 corridor wall to the other. The failed practice had the potential to affect eight of eight patients on census on 02/23/11 and all staff and visitors. The findings follow:

A. On a tour of the facility on 02/24/11 at 0900 with the Assistant Director of Maintenance, unsealed penetrations of the corridor wall was observed at the following locations:
1) Above the ceiling at the entrance to Medical Records, one penetration of the corridor wall was not sealed with a fire rated material.
2) Above the ceiling at the smoke barrier doors near the Visitors Lounge, two penetrations of the corridor wall was not sealed with a fire rated material.
B. The Assistant Director of Maintenance verified the above unsealed penetrations at the time they were observed.

Based on observation, it was determined the one hour fire resistance of smoke barrier walls was compromised at four of four locations due to unsealed penetrations of the smoke barrier walls. Failure to properly seal penetrations of smoke barrier walls had 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 eight of eight patients on census on 02/23/11 and all staff and visitors. The findings follow:

A. On a tour of the facility on 02/24/11 at 0900 with the Assistant 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 entrance to the Patient Wing, one penetration of the smoke barrier wall was not sealed with a fire rated material.
2) Above the ceiling at the smoke barrier doors at the near the Visitors Lounge, three penetrations of the smoke barrier wall were not sealed with a fire rated material.
3) Above the ceiling at the smoke barrier doors near the Dietary Department, two penetrations of the smoke barrier wall were not sealed with a fire rated material.
4) Above the ceiling at the smoke barrier doors near the Business Office, one penetration of the smoke barrier wall was not sealed with a fire rated material.
B. The Assistant 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 prevented the facility from ensuring the reliability of the dampers to close in the event of a fire or smoke. The failed practice had the potential to affect eight of eight patients on census on 02/23/11 and all staff and visitors. The findings follow:

In an interview conducted on 02/24/11 at 0850 the Assistant 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 in the six years of his employment at the facility.

(Reference NFPA 90A, Section 3-4.7)