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Based on observation and interview, it was determined the facility did not maintain penetrations for three of three (loacted near the elevators, Sleep Disorders Center and entrance to the facility) smoke barrier walls with a fire rated material to resist the passage of smoke. The failed practice had the potential to affect all patients, staff, and visitors due to the inability of the smoke barrier walls to prevent the passage of smoke and fire through the unsealed penetrations. The facility had a census of 24 patients on 009/22/14. The findings follow:

A. On a tour of the facility with the Maintenance Director, Interim Chief Executive Officer, Chief Nursing Officer, and Quality Coordinatoron 09/25/14 at 0915, unsealed penetrations of the smoke barrier were observed at the following locations:
1) One unsealed penetration above the ceiling at the fire rated doors located near the elevators.
2) Two unsealed penetrations above the ceiling at the fire rated doors located near the Sleep Disorders Center.
3) Two unsealed penetration above the ceiling at the fire rated doors located at the entrance to the facility.
B. The Maintenance Director verified the unsealed penetrations at the time of observation.

Based on observation and interview, it was determined the facility failed to ensure light fixtures in one (northeast exit) of two exit stairwells inspected were maintained to provide illumination for egress. The failed practice had the potential to affect 24 of 24 patients on 09/22/14 and all staff and visitors. The findings follow:

A. On a tour of the facility on 09/25/14 at 0915 with the Maintenance Director, Interim Chief Executive Officer, Chief Nursing Officer, and Quality Coordinator, the light fixture located at the bottom landing, near the exit discharge door of the northeast exit stairwell, was not illuminated, and left the area in darkness.
B. The non-illuminating light fixture was verified by the Maintenance Director at the time of observation.

Based on fire drill documentation review and interview it was determined the facility failed to conduct five of eight quarterly fire drills from July 2013 through June 2014. Failure to perform quarterly fire drills prevented the facility from ensuring staff are trained and prepared to respond to fire emergencies with required procedures in a prompt and orderly manner to protect patients from fire and smoke. The failed practice had the potential to affect all patients, staff and visitors and 24 of 24 patients on 09/22/14. The findings follow:

A. Review of the fire drill documentation provided 09/23/14 at 1230 revealed there was no evidence the facility participated in building fire drills as follows:
1) In the third quarter of 2013, the first and second shifts.
2) In the fourth quarter of 2013, the second shift.
3) In the first quarter of 2014, the second shift.
4) In the second quarter of 2014, the second shift.
B. In an interview on 09/23/14 at 1315, the Quality Coordinator verified there was no further fire drill documentation was available for review.

Based on Fire Alarm System inspection documentation review and interview, it was determined the facility failed to ensure the fire alarm system was inspected annually as required. The failed practice had the potential to affect the health and safety of patients, staff, and visitors because the reliability of the fire alarm system devices to alert building occupants and the fire department of a fire emergency was not assured. The facility had a census of 24 patients on 09/22/14. The findings follow:

A. Review of the Fire Alarm System Testing Report on 09/23/14 at 1100 revealed the most recent annual inspection of the fire alarm system occurred on 12/12/11.
B. In an interview on 09/23/14 at 1145, the Maintenance Director verified there was no further documentation available for review.

Based on Work Order review and interview it was determined the facility failed to inspect fire and smoke dampers every 4 years (or every six years under CMS Waiver per Survey & Certification Letter 10-04-LSC dated October 30, 2009). Failure to inspect fire and smoke dampers prevents the facility from ensuring the reliability of the dampers to close in the event of a fire or smoke event. The failed practice had the potential to affect 24 of 24 patients on 09/22/14 and all staff and visitors. The findings follow:

A. Review of Work Order #3169 on 09/23/14 at 1050 revealed the most recent damper inspection was completed on 04/08/01.
B. In an interview on 09/23/14 at 1145, the Maintenance Director verified there was no further documentation of fire and smoke damper inspection available for review.

(Reference NFPA 90A, Section 3-4.7)