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Based on observation, the facility failed to maintain the integrity of their building construction. This was evidenced by unsealed penetrations at in the walls and ceiling. This affected 1 of 2 smoke compartments which could result in the spread of smoke or fire to other locations in the facility and cause potential harm to patients and staff.
NFPA 101 2000 Edition
8.3.1* General. Where required by Chapters 12 through 42, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke.
8.3.2* Continuity. Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling,
including interstitial spaces.
Exception: A smoke barrier required for an occupied space below an interstitial space shall not be required to extend through the interstitial space, provided that the construction assembly forming the bottom of the interstitial space provides resistance to the passage of smoke equal to that provided by the smoke barrier.

Findings:

During a facility tour with Maintenance Staff and Fire Chief on December 12, 2011, the building construction was observed.

1. At 2:06 p.m., there was an approximate 3/4 inch unsealed penetration around an approximate 6 inch pipe in the ceiling above bed 2 in Room 4018.

2. At 2:18 p.m., there were two approximate 1/2 inch unsealed penetrations between the dresser near beds 5 and 6 in Room 4026.

3. At 2:21 p.m., there was an approximate 1 inch unsealed penetration in the ceiling above bed 2 in Room 4106.

Based on observation and interview, the facility failed to maintain their corridor doors. This was evidenced by a corridor door that failed to latch. This affected 1 of 2 smoke compartments, and could result in a delay to contain smoke or fire to a room.

Findings:

During a facility tour with Maintenance Staff and Fire Chief on December 12, 2011, the doors in the facility were observed.

At 2:25 p.m., there was a corridor door near Room 4104 that failed to close and latch. The door closed approximately 12 inches from the door frame.

Based on observation and interview, the facility failed to maintain their exit signs. This was evidenced by the facility's failure to display exit signs that were readily visible. This affected 2 of 2 smoke compartments and could result in a delay in evacuation due to limited exit sign visibility.

Findings:

During a facility tour with the Maintenance Staff on December 12, 2011, the exit signs were observed.

At 2:04 p.m., there was an Exit sign decal near Room 4107 that failed to self illuminate to provide direction for egress.

Based on observation and interview, the facility failed to protect its hazardous area enclosures. This was evidenced by rooms which contained combustible storage that posed a degree of hazard greater than that normal to the general occupancy of the building, and were not equipped with a self-closing mechanism on the door. This deficient practice affected 2 of 2 smoke compartments within the facility, and could result in the spread of smoke and/or fire.

Findings:

During a tour of the facility with Maintenance Staff and Fire Chief on December 12, 2011, the hazardous area enclosures were observed.

1. At 4:09 p.m., there was no self closing mechanism to the door to the activity Room 4019. The room contained combustible material and was over 50 square feet in a non-sprinklered room.

2. At 4:12 p.m., there was no self closing mechanism to the door to Room 4024. The room contained combustible material and was over 50 square feet in a non-sprinklered room.

Based on document review, the facility failed to conduct fire drills at unexpected times and conditions as evidenced by fire drills that were conducted at the same time. This effected 2 of 2 smoke compartments and could result in harm to patients and staff if staff are not trained at unexpected times.

Findings:

During document review with facility Maintenance Staff on December 12, 2011, the fire drill records were reviewed.

At 2:44 p.m., there were three of four fire drills that were conducted at approximately 1:00 A.M. for the NOC shift. The fire drill records provided the following: January 2, 2011, at 1:00 A.M., April 2, 2011, at 2:00 A.M., July 7, 2011, at 1:20 A.M., October 8, 2011, at 1:00 A.M.

Based on observation and interview, the facility failed to maintain their battery operated smoke detectors as evidenced by smoke detector failing to activate an audible alarm when tested and no smoke detectors. This failure could cause in a delay with a warning to patients and staff and cause potential harm in the event of a fire. This affected 2 of 2 smoke compartments.

Findings:

During a tour of the facility with Maintenance Staff and Fire Chief on December 12, 2011, the smoke detectors were observed and tested and a s staff person was interviewed.

1. At 1:55 p.m., there was no smoke detector in Room 4019 to warn patients and staff in the event of a fire.

2. At 2:03 p.m., there was no smoke detector in Room 4024 to warn patients and staff in the event of a fire.

3. At 2:14 p.m., there was a smoke detector in Room 4017 and near Bed 2 sounded a faint alarm when tested.

4. At 2:16 p.m., there were two smoke detectors near the entrance to Room 4106 that sounded a faint alarm when tested.

At 2:17 p.m., Staff 2 was interviewed and asked about the smoke alarms sounding a faint alarm. Staff 2 stated "the smoke alarms failed to meet the minimum decibels and need to be replaced".

Based on observation and interview, the facility failed to maintain the portable fire extinguishers as evidenced by extinguishers with inspection dates beyond 30 day intervals. This affected 2 of 2 smoke compartments which had the potential for fire extinguishers to fail and cause harm to patients and staff during a fire emergency.
NFPA 10 Standard for Portable Fire Extinguishers (1998 Edition), 4-3.1 Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire Extinguishers shall be inspected at more frequent intervals when circumstances require.

NFPA 10 Standard for Portable Fire Extinguishers (1998 Edition) 4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.

NFPA 10 Standard for Portable Fire Extinguishers (1998 Edition) 4-3.4.3 Records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or in an electronic system (e.g., bar coding) that provides a permanent record.

Findings:

During the facility tour with Maintenance Staff and Fire Chief on December 12, 2011, the fire extinguishers were observed.

At 2:08 p.m., there were 3 of 3 fire extinguishers in Wing 209 with a label attached that was dated May 11, 2011, and with an inspection date of December 11, 2011 (six months with no inspections).

At 2:11 p.m., Staff member 2 was interviewed about the inspection of the fire extinguishers and he stated "I inspected the fire extinguishers after I started with the department".