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Based on observation and staff interview, the facility is not providing required construction standards in accordance with the Lfe Sfety Code, which would prevent containment of smoke and/or fire. This could affect occupants in 2 of 4 smoke zones. The facility has a capacity of 25 and a census of 8.

FINDINGS INCLUDE:

During the tour on 3/10/10 between 11:00am and 3:00pm it is observed that there is an open wire chase at the floor level in the Electrical room near the Nurse desk, and in the Telephone room.

Staff A was present and confirmed the finding and indicated the openings would be corrected.

Based on observation and staff interview, the facility fails to maintain smoke barriers to at least one half hour fire resistance on each side of wall and ensure that all penetrations area properly sealed. This deficient practice would prevent containment of fire and/or smoke, affecting occupants in 4 of 4 smoke zones. The facility has a capacity of 25 and a census of 8.

FINDINGS INCLUDE:

During the tour on 3/10/20 between 11:00am and 3:00pm the following is observed:

--1) There are penetrations through both sides of the North smoke barrier wall by the Nurse desk.
--2) There are penetrations in the South smoke barrier wall.
--3) There are penetrations through both sides of the Patient wing smoke barrier wall around newly installed ventilation duct. Work is still in progress.
--4) There are penetrations around conduits in the NW smoke barrier wall, Therapy side of wall.

Staff A is present and aware of the findings and is aware of the penetrations in the walls due to work in progress with the addition of the newly installed ventilation ducts.

Based on observation, record review and interview, the facility failed to assure smoke barrier doors are latching that are with provided with latching hardware. This deficient practice would result in allowing further advancement of fire and/or smoke products, affecting 3 of 4 smoke zones. The facility has a capacity of 25 with a census of 8.

FINDINGS INCLUDE:

During the tour on 3/10/10 between 11:00am and 3:00pm the following is observed:

--1) A smoke barrier door of the newer addition is not latching with the existing latching hardware by the Mens bathroom.
--2) A smoke barrier door is not latching with the existing latching hardware on the set of pink smoke doors.

Staff A was present and aware of the findings, noting this would be corrected immediately.

Based on observation and staff interview, the facility fails to assure storage rooms are properly separated from other areas of the facility, which fails to resist the passage of smoke. This affects occupants in 2 of 4 smoke zones. The facility has a capacity of 25 and a census of 8.

FINDINGS INCLUDE:

During the tour on 3/10/10 between 11:00am and 3:00pm the following is observed:

--1) The self closing door is not latching to the door frame to the Linen room across from room 106.
--2) The self closing door is not latching to the door frame to the Soiled Linen.
--3) The dutch doors to the Central supply room are not properly latching into the door frame. The upper leaf does not have a latching device, but it is equipped with a slide bolt that slides into the lower leaf of the dutch doors. The lower leaf does latch into the door frame.

Staff A was present and is aware of the findings. Staff A did note that the dutch doors need to be changed.

Based on observation and staff interview, the facility fails to assure smoke detectors are properly installed and maintained, possibly causing a delay in the activation of the smoke detection system. This could affect occupants in 1 of 4 smoke zones. The facility has a capacity of 25 and a census of 8.

FINDINGS INCLUDE:

During the tour on 3/10/10 between 11:00am and 3:00pm it is observed there is a smoke detector within direct air flow of a ventilation duct in the Physical Therapy corridor.

Staff A was present and confirmed the smoke detector was next to the ventilation duct.

Based on observation and record review, the facility fails to assure the kitchen hood system is being cleaned in accordance with the requirements set out in NFPA 96. This deficient practice fails to ensure that the cooking equipment is compliant in order to prevent a fire hazard, affecting occupant in 1 of 4 smoke zones. The facility has a capacity of 25 and a census of 8.

FINDINGS INCLUDE:

During the tour on 3/10/10 between 11:00am and 3:00pm it is observed during record review that the last kitchen hood flue cleaning was June 2008.

Staff A is aware of the finding and stated that the vendor who cleans the hood comes to the facility when in the area.

Based on observation, record review and staff interview, the facility failed to ensure that draperies and curtains are flame resistant in accordance with the provisions of NFPA 101, 10.3. This deficient practice fails to prevent the misuse of highly flammable curtains throughout the facility, affecting occupants in 1 of 4 smoke zones. The facility has a capacity of 25 with a census of 8.

FINDINGS INCLUDE:

During the tour on 3/10/10 between 11:00am and 3:00pm it is observed that there are six (6) sets of dividing/cubical curtains without 1/2 inch diagonal mesh at the top of the curtain.

Staff A is present and aware of the finding.

Based on observation and staff interview the facility failed to assure electrial equipment is installed and maintained in accordance with NFPA 70. This deficient practice could result in an electrical failure or fire, affecting occupants in 2 of 4 smoke zones. The facility has a capacity of 25 and a census of 8.

FINDINGS INCLUDE:

During the tour on 3/10/10 between 11:00am and 3:00pm the following is observed:

--1) There is an open junction box in the Air Handling room.

--2) There is a refrigerator and a freezer plugged into a power strip in the Lab.

Staff A confirmed the cover was missing and stated that an emergency light unit had been removed from the open junction box.

Based on observation and staff interview, the facility fails to assure alcohol based hand rub containers are not installed above or adjacent to an ignition source This deficient practice could result in a fire by failing to ensure that the ABHS does not come into contact with an ignition source, affecting occupants in 1 of 4 smoke compartments. The facility has a capacity of 25 and a census of 8.

FINDINGS INCLUDE:

During the tour on 3/10/10 between 11:00am and 3:00pm it is observed there is an alcohol hand gel container installed next to an electrical light switch in the Medication room.

Staff A was present and aware of the finding, and stated that this container was missed when all others had been removed.

Based on observation and staff interview, the facility is not providing required construction standards in accordance with the Lfe Sfety Code, which would prevent containment of smoke and/or fire. This could affect occupants in 2 of 4 smoke zones. The facility has a capacity of 25 and a census of 8.

FINDINGS INCLUDE:

During the tour on 3/10/10 between 11:00am and 3:00pm it is observed that there is an open wire chase at the floor level in the Electrical room near the Nurse desk, and in the Telephone room.

Staff A was present and confirmed the finding and indicated the openings would be corrected.

Based on observation and staff interview, the facility fails to maintain smoke barriers to at least one half hour fire resistance on each side of wall and ensure that all penetrations area properly sealed. This deficient practice would prevent containment of fire and/or smoke, affecting occupants in 4 of 4 smoke zones. The facility has a capacity of 25 and a census of 8.

FINDINGS INCLUDE:

During the tour on 3/10/20 between 11:00am and 3:00pm the following is observed:

--1) There are penetrations through both sides of the North smoke barrier wall by the Nurse desk.
--2) There are penetrations in the South smoke barrier wall.
--3) There are penetrations through both sides of the Patient wing smoke barrier wall around newly installed ventilation duct. Work is still in progress.
--4) There are penetrations around conduits in the NW smoke barrier wall, Therapy side of wall.

Staff A is present and aware of the findings and is aware of the penetrations in the walls due to work in progress with the addition of the newly installed ventilation ducts.

Based on observation, record review and interview, the facility failed to assure smoke barrier doors are latching that are with provided with latching hardware. This deficient practice would result in allowing further advancement of fire and/or smoke products, affecting 3 of 4 smoke zones. The facility has a capacity of 25 with a census of 8.

FINDINGS INCLUDE:

During the tour on 3/10/10 between 11:00am and 3:00pm the following is observed:

--1) A smoke barrier door of the newer addition is not latching with the existing latching hardware by the Mens bathroom.
--2) A smoke barrier door is not latching with the existing latching hardware on the set of pink smoke doors.

Staff A was present and aware of the findings, noting this would be corrected immediately.

Based on observation and staff interview, the facility fails to assure storage rooms are properly separated from other areas of the facility, which fails to resist the passage of smoke. This affects occupants in 2 of 4 smoke zones. The facility has a capacity of 25 and a census of 8.

FINDINGS INCLUDE:

During the tour on 3/10/10 between 11:00am and 3:00pm the following is observed:

--1) The self closing door is not latching to the door frame to the Linen room across from room 106.
--2) The self closing door is not latching to the door frame to the Soiled Linen.
--3) The dutch doors to the Central supply room are not properly latching into the door frame. The upper leaf does not have a latching device, but it is equipped with a slide bolt that slides into the lower leaf of the dutch doors. The lower leaf does latch into the door frame.

Staff A was present and is aware of the findings. Staff A did note that the dutch doors need to be changed.

Based on observation and staff interview, the facility fails to assure smoke detectors are properly installed and maintained, possibly causing a delay in the activation of the smoke detection system. This could affect occupants in 1 of 4 smoke zones. The facility has a capacity of 25 and a census of 8.

FINDINGS INCLUDE:

During the tour on 3/10/10 between 11:00am and 3:00pm it is observed there is a smoke detector within direct air flow of a ventilation duct in the Physical Therapy corridor.

Staff A was present and confirmed the smoke detector was next to the ventilation duct.

Based on observation and record review, the facility fails to assure the kitchen hood system is being cleaned in accordance with the requirements set out in NFPA 96. This deficient practice fails to ensure that the cooking equipment is compliant in order to prevent a fire hazard, affecting occupant in 1 of 4 smoke zones. The facility has a capacity of 25 and a census of 8.

FINDINGS INCLUDE:

During the tour on 3/10/10 between 11:00am and 3:00pm it is observed during record review that the last kitchen hood flue cleaning was June 2008.

Staff A is aware of the finding and stated that the vendor who cleans the hood comes to the facility when in the area.

Based on observation, record review and staff interview, the facility failed to ensure that draperies and curtains are flame resistant in accordance with the provisions of NFPA 101, 10.3. This deficient practice fails to prevent the misuse of highly flammable curtains throughout the facility, affecting occupants in 1 of 4 smoke zones. The facility has a capacity of 25 with a census of 8.

FINDINGS INCLUDE:

During the tour on 3/10/10 between 11:00am and 3:00pm it is observed that there are six (6) sets of dividing/cubical curtains without 1/2 inch diagonal mesh at the top of the curtain.

Staff A is present and aware of the finding.

Based on observation and staff interview the facility failed to assure electrial equipment is installed and maintained in accordance with NFPA 70. This deficient practice could result in an electrical failure or fire, affecting occupants in 2 of 4 smoke zones. The facility has a capacity of 25 and a census of 8.

FINDINGS INCLUDE:

During the tour on 3/10/10 between 11:00am and 3:00pm the following is observed:

--1) There is an open junction box in the Air Handling room.

--2) There is a refrigerator and a freezer plugged into a power strip in the Lab.

Staff A confirmed the cover was missing and stated that an emergency light unit had been removed from the open junction box.