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Based on schematic review and observation during tour of the facility and staff verification it was determined this facility failed to ensure the integrity of the two hour fire rated occupancy separation. This had the potential to affect all patients and visitors utilizing this unit. The patient census was 16 at the beginning of the survey.

Findings include:

Review of the unit schematics took place on 3/20/17. The schematics revealed the unit has a two hour fire rated barrier separating the healthcare occupancy from a business occupancy.

During facility tour on 3/22/17 between the hours of 1:36 PM to 3:34 PM with staff C, (maintenance manager), observation was made of penetrations through the two hour fire rated barrier above the ceiling tiles in the following areas:

1) Above the east entrance door, observation was made of two unsealed silver conduits around the annular space. Additionally, areas of fire caulking were noted to be separating leaving gaps in the protective caulking.

2) To the right of the east door near the center of the chase, observation was made of no fire sealant at the top of the drywall where it meets the upper deck. On the back side of the chase, observed from the exam room, four holes and an unsealed pipe were also noted.

3) Above the west entrance door, observation was made of two insulated pipes and a black pipe sealed with a pink type foam around the annular space that was identified by the maintenance manager as not being fire rated. Additionally, smaller penetrations were observed on the face of the two hour fire barrier.

These finding were verified by staff C during the tour of these rooms.

Based on observation and staff interview the facility failed to ensure exit signage was displayed to indicate the egress pathway for people to leave the kitchen area on the ground level of the facility. This deficient practice had the potential to affect any occupants / staff in the kitchen area. The patient census was 16 at the beginning of the survey.

Findings include:

Tour of the ground level kitchen area of the facility on 3/22/17 at 10:05 AM revealed a large open area with tables, convection ovens, portable carts and various food prep equipment. At one end of the room was a set of double doors that opened to an open storage area where observation was made of another set of double doors with an exit sign above them, and egress through those doors led to the outside of the building. Interview with Staff A and Staff C on 03/22/17 at 10:07 AM confirmed the absence of an exit sign above the double doors from the kitchen area.

Based on schematic review and observation during tour of the facility and staff verification it was determined this facility failed to ensure the integrity of the hazardous areas. This had the potential to affect all patients and visitors utilizing this unit. The patient census was 16 at the beginning of the survey.

Findings include:

Review of the unit schematics took place on 3/20/17. The schematics revealed the unit has a clean supply and soiled linen rooms with a one hour fire resistance rated fire/smoke barrier.

During facility tour on 3/22/17 between the hours of 1:36 PM to 3:34 PM with staff C (maintenance manager), observation was made of two hazardous rooms protected by an automatic sprinkler system, although penetrations were observed through the one hour fire rated barrier above the ceiling tiles in the following areas:

1) Within the soiled utility room on the north and south walls, observation was made of three unsealed conduits. Additionally, a fist size hole was observed in the ceiling.

2) Within the clean supply room an approximate half inch hole was observed in the north wall and a small opening was observed at the bottom of the duct passing through the east wall above the door.

These finding were verified by staff C during the tour of these rooms.

Based on interview with facility staff, it was determined the facility failed to ensure sensitivity testing was performed to all duct detectors according to the National Fire Protection Association (NFPA) 72. This had the potential to affect all patients and visitors utilizing this unit. The patient census was 16 at the beginning of the survey.

Findings include:

Review of the 10/27/16 smoke detector sensitivity test report took place on 3/21/17 and revealed some duct detectors were not sensitivity tested. Interview with staff C in the afternoon of the same day verified the duct detectors within each patient room were not sensitivity tested.

Based on observation and staff interview the facility failed to ensure a fire extinguisher was mounted properly and had monthly checks completed. This deficient practice had the potential to affect any occupant/ staff in the kitchen area. The patient census was 16 at the beginning of the survey.

Findings include:

Tour of the ground level kitchen area of the facility on 3/22/17 at 10:05 AM revealed a large open area with tables, convection ovens, portable carts and various food prep equipment. An observation was made of a portable fire extinguisher on a lower shelf of one of the work tables along the perimeter of the room, unsecured, and the attached tag was labeled for annual service in June 2016, but none of the monthly checks were documented on the tag.

Interview with Staff C at 10:15 AM confirmed the portable fire extinguisher was not secured and the tag had no monthly checks documented.

Based on schematic review and observation during tour of the facility and staff verification it was determined this facility failed to ensure the integrity of the smoke barrier. This had the potential to affect all patients and visitors utilizing this unit. The patient census was 16 at the beginning of the survey.

Findings include:

Review of the unit schematics took place on 3/20/17. The schematics revealed the unit is divided by a one hour fire resistance rated fire/smoke barrier.

During facility tour on 3/22/17 between the hours of 1:36 PM to 3:34 PM with staff C (maintenance manager), observation was made of penetrations through the smoke barrier above the ceiling tiles in the following areas:

1) Above the east double smoke barrier doors observation was made of one open end conduit with four red wires passing through.

2) Above the west double smoke barrier doors observation was made of a small opening in the fire caulking placed around a group of conduits.

These findings were verified by staff C during tour.

Based on record review and staff interview the facility failed to ensure fire drills were conducted on each shift at varying times and failed to ensure the transition time for the signal was documented. This deficient practice has the potential to affect any patient at the facility with a census of 16 patients.

Findings include:

Review of fire drill reports for 2016 revealed the facility had three daily staff shifts for the first half of 2016, but fire drills were completed irregularly. Review of drills for January 2016 revealed two dates, 1/01/16 at 11:00 PM and 1/30/16 at 1:40 PM, a single February 2016 drill was recorded 2/25/16 at 11:00 PM, two March 2016 drills were recorded, on 3/24/16 at 11:00 PM and 3/25/16 at 11:10 AM, two April 2016 drills were recorded, on 4/28/16 at 11:10 AM and 4/29/16 at 1:30 PM, one May 2016 drill, on 5/26/16 at 11:15 PM, one June 2016 drill, on 6/22/16, and one September 2016 drill, on 9/27/16 at 1:00 PM, and no other drills were documented for 2016.

An interview with Staff B on 3/21/17 at 9:30 AM revealed there was no additional drill documentation available for 2016. An e-mail communication from the maintenance department revealed the maintenance department had completed some of the drills, but no additional documentation was available for the drills.

Staff B confirmed the staff shifts had been three per day for the first half of the year, and then changed to two daily shifts, and the fire drills had not been conducted for each shift on a quarterly basis.

Review of the documentation revealed none of the recorded drills had a time noted for the transmission of the signal from the facility to the monitoring company Interview with Staff B on 3/21/17 at 9:31 AM confirmed no time for the transmission of the signal had been documented on the drill reports.

Based on record review and staff interview, the facility failed to ensure annual testing of the electrical receptacles. This deficient practice had the potential to affect any patient in the facility, with a census of 16 and a capacity of 32.

Findings include:

Review of the facility safety and preventative maintenance testing documentation revealed there was no annual testing of the electrical receptacles completed. In an interview on 3/21/17 at 9:40 AM Staff C confirmed there had been no annual testing of electrical receptacles completed.