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Based on observation and interview, the facility failed to maintain one hour fire integrity of a soiled utility room in accordance with 19.3.2.1 and 9.6.2.11. This deficient practice presents a fire hazard due to the combustible nature of urine (ammonia) soaked linen, and a potential fire could affect any staff and patients in the southwest portion of the old (original structure) building. The facility census was 11.

This deficiency is uncorrected. For previous examples refer to the Statement of Deficiency dated 03/07/14.
Findings included:

1. Observation on 04/28/14 at 2:30 PM showed the one hour walls of an unsprinklered soiled utility room on the southwest end of the building (Senior Living Center) did not extend above the suspended ceiling to the roof deck. As constructed, the room currently does not meet the prescriptive requirements of the CMS-adopted 2000 existing Life Safety Code, (LSC) which requires a one-hour fire separation between hazardous enclosures and surrounding non-hazardous spaces. The Life Safety Code also requires hazardous rooms or spaces to be provided with an automatic fire detection system (smoke detector connected to the facility-wide notification system). The new room was in use at the time of the revisit, contained at least three large wheeled storage bins, each with several large bags of linen soiled with urine, feces and potentially infectious medical waste from all over the hospital.

2. During an interview on 04/29/14 at 9:50 AM, Staff S Director of Engineering, stated that the walls did not extend to the roof deck. He stated that the collection process for soiled linen was unchanged, i.e., bags of soiled linen are collected from all over the hospital and held there in the bins for pick-up by the linen contractor.