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Based on observation and interview the facility does not assure all smoke barrier walls provided, inspected, and continuously maintained in accordance with 8.3. This deficient practice would not allow the patients to evacuate to a protect in place/defend in place smoke zone, affecting 4 of 4 smoke zones. This facility has a capacity of 19 and a census of 3 at the time of the survey.

FINDINGS INCLUDE:

On 03/08/10 at 11:30 a.m. through 03/10/10 at 11:30 a.m., the following was observed:

--1. Smoke barrier had multiple openings and penetrations where electrical conduit, piping, etc... passes through, above the ceiling level and on the 1A wall-side, on the 1st floor. Some of the openings and penetrations had been repaired by mixed fire-stopping materials.
--2. Smoke barrier had multiple openings and penetrations where electrical conduit, piping, etc... passes through, above the ceiling level and on the 1B wall-side, on the 1st floor. Some of the openings and penetrations had been repaired by mixed fire-stopping materials.
--3. Smoke barrier had multiple openings and penetrations where electrical conduit, piping, etc... passes through, above the ceiling level and on the 2A wall-side, on the 2nd floor. Some of the openings and penetrations had been repaired by mixed fire-stopping materials.
--4. Smoke barrier had multiple openings and penetrations where electrical conduit, piping, etc... passes through, above the ceiling level and on the 2B wall-side, on the 2nd floor. Some of the openings and penetrations had been repaired by mixed fire-stopping materials.

The Staff A was present and confirmed the findings. The Staff A interview expressed disappointment that all smoke barrier walls had been expected to have acceptable condition; he had not been aware that this was a requirement prior to the survey when the concern was raised about the appearance of inappropriate mixing of fire-stopping material that was present. Staff A presented the surveyor with a portion of the required manufacturer documentation that showed the fire rating values for one of the fire-stopping materials that was present in the smoke barrier assemblies; he expressed that each deficient location will be repaired accordingly.

Based on observation and interview the facility does not assure that required emergency lighting is provided in the facility and that it is inspected, tested, and continuously maintained, This deficient practice would affect all patients and would leave the protected areas in darkness when the emergency generator malfunctioned or failed to operate in the event of a power outage, affecting 2 of 4 smoke zones. The facility has a capacity of 19 and a census of 3 at the time of the survey.

FINDINGS INCLUDE:

On 03/08/10 at 11:30 a.m. through 03/10/10 at 11:30 a.m., the following was observed:

--1. Available documentation did not indicate whether each of the required auxiliary emergency lighting units had been tested annually for 90 minutes in 2009-2010, for each of the OR's in the 2A smoke zone; and, for each of the pharmacies, in the 2B smoke zone.
--2. Available documentation did not indicate whether each of the required auxiliary emergency lighting units had been tested monthly for 30 seconds, in 2009-2010, for each of the OR's in the 2A smoke zone; and, for each of the pharmacies, in the 2B smoke zone.
--3. There was no additional auxiliary emergency lighting provided in the pharmacy where drugs are mixed, in the 2A smoke zone, on the 2nd floor.

Staff A was present and aware of these findings. Staff A interview revealed that he had not been aware that this was a requirement prior to the survey; and that appropriate testing would be performed and he'd create and maintain the testing document; and, that an additional auxiliary emergency lighting would be installed.

Based on observation and interview the facility does not assure all required fire alarm system components are installed in accordance with NFPA 72, for 16 of the total quantity of smoke detectors. This deficient practice would effectively contaminate and deteriorate the smoke detectors, and would activate nuisance alarms and false alarms that would register on the fire alarm control panel, affecting 4 of 4 smoke zones. The facility has a capacity of 19 and a census of 3 at the time of the survey.

FINDINGS INCLUDE:

On 03/08/10 at 11:30 a.m. through 03/10/10 at 11:30 a.m., the following was observed:

--1. One smoke detector has been installed too close within the direct air-flow of the ceiling air vent, in the Myelography room, in the suite S1, in smoke zone 1A, on first floor.
--2. Seven smoke detectors have been installed too close within the direct air-flow of the ceiling air vents, in the waiting room, near S2 in the smoke zone 1B, on first floor.
3. Ten smoke detectors have been installed too close within the direct air-flow of the ceiling air vents, in smoke zone 2A, on second floor.
4. Five smoke detectors have been installed too close within the direct air-flow of the ceiling air vents, in smoke zone 2B, on second floor.

Staff A was present and aware of these findings. Staff A interview revealed that he had not been aware that this was a requirement prior to the survey; and that the appropriate smoke detector relocation would be performed; and, that he'd had to performed frequent cleaning for several smoke detectors when "trouble signals" were registered on the fire alarm control panel.

Based on observation and interview the facility does not assure a fire watch procedure and policy is written and available for implementation when the automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, for 12 of 12 months of records reviewed, for 2009 through 2010. This deficient practice would allow the facility to be exposed to uncontrolled fires when they occurred and without appropriately prepared staff response, affecting 4 of 4 smoke zones. The facility has a capacity of 19 and a census of 3 at the time of the survey.
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FINDINGS INCLUDE:

On 03/08/10 at 11:30 a.m. through 03/10/10 at 11:30 a.m., the following was observed:

--1. A written fire watch policy for the automatic sprinkler system and procedures were not present when the records were reviewed.

Staff A was present and aware of these findings. Staff A interview revealed that he had not been aware that this was a requirement prior to the survey and that he will create this document.

Based on observation and interview the facility does not assure a fire watch procedure and policy is written and available for implementation when fire alarm system is out of service for more than 4 hours in a 24-hour period, for 12 of 12 months of records reviewed, for 2009-2010. This deficient practice would allow facility exposure to undetected smoke and/or fire without an automatic detection compensatory provision when it occurred, and without appropriately prepared staff response, affecting 4 of 4 smoke zones. The facility has a capacity of 19 and a census of 3 at the time of the survey.

FINDINGS INCLUDE:

On 03/08/10 at 11:30 a.m. through 03/10/10 at 11:30 a.m., the following was observed:

--1. A written fire watch policy for the fire alarm system and procedures were not available when the records were reviewed.

Staff A was present and aware of these findings. Staff A interview revealed he had not been aware that this was a requirement prior to the survey and that he will create this document.

Based on observation and staff interview the facility does not assure alcohol-base/alcohol-gel hand sanitizer containers are installed properly. This deficient practice would allow the alcohol-base hand sanitizer (ABHS) product to come into contact with ignition sources and result in a fire, affecting 2 of 4 smoke zones. The facility has a capacity of 19 and a census of 3 at the time of the survey.

FINDINGS INCLUDE:

On 03/08/10 at 11:30 a.m. through 03/10/10 at 11:30 a.m., the following was observed:

--1. Alcohol-base hand cleaner dispenser has been installed in close proximity to wall electrical light switches, in all patient rooms, in the 1A smoke zone, on the 1st floor.
--2. Alcohol-base hand cleaner dispenser has been installed in close proximity to wall electrical light switches, in all patient rooms, in the 1B smoke zone, on the 1st floor.

Staff A was present and aware of these findings. Staff A interview revealed that the facility had installed the dispensers for the increased concern with the germ-spread and cross-contamination. He had not been aware that this was a requirement prior to the survey, and that another auditing agency had approved the ABHS location. He expressed ideas on how to remedy the deficient practice.