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Based on observation and interview, it was determined the ½ hour fire resistance rating of the corridor walls was compromised by unsealed penetrations of the walls at three (Maintenance Office, Kitchen, and Physical Therapy) of three locations. The failed practice had the potential to affect all patients, staff, and visitors due to the inability of the corridor walls to prevent the passage of smoke and fire through the unsealed penetrations. The facility had a census of 14 patients on 10/28/14. The findings follow:

A. On a tour of the facility with Maintenance Director on 10/30/14 at 0900, unsealed penetrations of the corridor walls were observed at the following locations:
1) One unsealed penetration above the ceiling near the doors to the Maintenance Office hallway.
2) One unsealed penetration above the ceiling above the entrance doors to the Kitchen.
3) Three unsealed penetrations above the ceiling near the entrance to Physical Therapy.
B. The Maintenance Director verified the unsealed penetrations at the time of each observation.

Based on observation and interview, it was determined the facility did not maintain penetrations for one (Emergency Department Nurse Station) of two 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 14 patients on 10/28/14. The findings follow:

A. On a tour of the facility with Maintenance Director on 10/30/14 at 0900, three unsealed penetrations of the smoke barrier were observed above the ceiling at the fire rated doors located near the Emergency Department Nurse Station.
B. The Maintenance Director verified the unsealed penetration at the time of the observation.

Based on Safety Manual review and interview it was determined the facility failed to inspect fire dampers annually. 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 14 of 14 patients on 10/28/14 and all staff and visitors. The findings follow:

A. In an interview on 10/28/14 at 1230, the Maintenance Director verified there was no documentation of fire damper inspection available for review.
B. Review of the Safety Manual on 10/29/14 at 1350 revealed Policy #1117 required "fire dampers will be inspected annually in accordance with the following procedures."

(Reference NFPA 90A, Section 3-4.7)

Based on Generator Log Book review and interview, it was determined the facility had not run the generator under load for 30 minutes each month from January 2014 through October 2014. The failed practice had the potential to affect the health and safety of all patients, visitors, and staff because the reliability of the generator to provide power to the facility in the event of the loss of normal power was not assured. The facility had a census of 14 patients on 10/28/14. The findings follow:

A. Review of the Generator Log Book on 10/28/14 at 1010 revealed the generator run time for each month from January 2014 through October 2014 had been documented for 15 minute run time instead of the required 30 minutes.
B. In an interview on 10/28/14 at 1230, the Maintenance Director verified the month generator run time was documented as 15 minutes and there was no further documentation available for review.