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Based on observations and staff interview, the facility failed to ensure two electrical rooms maintained a one hour fire rated construction in accordance with the code at 8.4.1. This affected all staff and patients. The census was 21 at the time of the survey.

Findings include:

A tour was conducted on 08/11/10 between 2:10 PM-3:36 PM with Staff A, B, C, and S. Two electrical rooms on the second floor were observed with penetrations around conduit and wiring.

The first electrical/data room was located across the hall from Room 215. This room was observed with two conduits containing wiring that were observed penetrating the ceiling of this room. The conduit was approximately three inches in diameter, contained wiring, and was open around the wiring. The door to this room was observed open to the corridor when first observed. Staff S stated the door should be kept closed.

The second electrical room was located in the inner corridor near the respirator clean/soiled rooms. This room was observed with two conduits, approximately 3 inches in diameter, in the ceiling of the room. These conduits were observed open, which would allow passage of smoke into the ceiling.

Both rooms were identified as one hour fire-rated rooms by Staff S and according to facility floor plans.

Based on staff interview and fire drill records review, the facility failed to conduct fire drills for the third quarter. This affects all staff, visitors, and patients. The current census is 21.

Findings include:

On 08/11/10, a review of fire drills was conducted. The facility lacked documentation of fire drills this past year for the third quarter. This was verified with staff S on 08/11/10 at 1:30 PM.

Based on observations and review of fire extinguisher/halon extinguisher tags, the facility failed to ensure two portable fire extinguishers and one halon extinguisher were inspected monthly and serviced annually in accordance with the NFPA 10 code at 4-3.1, 4-4.1, and 4-5.1.1. This affected all staff, visitors, and patients in the facility. This involved the second floor and basement of the facility. The census at the time of the survey was 21.

Findings include:

A tour of the facility was conducted on 08/11/10 between 2:10 PM and 3:36 PM. Two portable fire extinguishers and one halon extinguisher were observed with tags that lacked evidence facility staff checked the fire extinguishers on a monthly basis or ensured the halon extinguisher was serviced annually. The halon extinguisher was observed in the mechanical room located in the hallway near the high observation unit. This extinguisher was observed with an inspection tag by an outside service company dated October 2008. The back of the tag lacked evidence of monthly inspections by staff. Staff S verified this halon extinguisher had not been inspected annually for 2009 and had not been visualized monthly as required by the code.
A fire extinguisher located in the basement hallway outside the kitchen/cafeteria and the east wing stairwell on the first floor was observed with an inspection tag dated October 2009 by an outside service company. The back of the tag lacked evidence of monthly inspections by the facility since October 2009.

An interview with Staff S during tour, and Staff B on 08/12/10 at 8:40 AM, verified these extinguishers had not been maintained as required by the code.