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Based on observation the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On March 20, 2012 the surveyor, accompanied by the Assistant Director of Nursing, observed that the following corridor doors would not tightly close when tested:

1. Staff Kitchen, rated door closing device will not close and positively latch the door when tested three of three times
2. Nurses station, staff door will not positively latch when tested three of three times
3. South West Administration rated hall way door on a closing device will not positively latch when tested three of three times

During the exit conference on March 20, 2012, the above findings were again acknowledged by the Vice President.

In time of a fire failing to protect patients from heat and smoke could cause harm to the patients.

Based on observation the facility did not maintain the integrity, smoke resistance, of doors in hazardous areas. And did not remove lint from the dryer.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.2.1 requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls and doors must be able to resist the passage of smoke. NFPA 80 "Fire Doors and Fire Windows" Chapter 2, Section 2-3.1.7 "The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. +/- 1/16 in for steel doors and shall not exceed 1/8 in. for wood doors. Chapter 19, Section 19.5.1.1, "Utilities shall comply with the provisions of Section 9.1. Section 9.1.1. "Equipment using gas and related gas piping shall be installed in accordance with NFPA 54 " National Fuel Gas Code" or NFPA 58 " Liquefied Petroleum Gas Code" , NFPA 54 Chapter 6, Section 6.4 "Clothes Dryers Section 6.4.5 (c) Type 2 Clothes Dryers shall be equipped or installed with lint controlling means. "

Findings include:

On March 20, 2012 the surveyor, accompanied by the Assistant Director of Nursing, observed the following hazardous area doors, and dryer:

1. Soiled laundry room rated door, with a closing device would not positively latch when tested three of three times
2. Medical records room rated door, with a closing device would not positively latch when tested three of three times
3. The dryer lint screen was covered with heavy lint and the back of the dryer area was covered with lint. There was no schedule of the cleaning times

During the exit conference on March 20, 2012, the above findings were again acknowledged by the Vice President.

Failing to prevent heat and smoke from spreading into the exit corridor will cause harm to patients.
Failing to insure proper cleaning of the lint could cause a fire and cause harm to the patients.

Based on observation the facility failed to document the monthly and annual testing of battery back up emergency lighting.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.2.9.1, "Emergency lighting shall be provided in accordance with Section 7.9". Section 7.9.3 " Periodic Testing of Emergency Lighting Equipment" " A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction."

Findings include:

On March 20, 2012, the surveyor accompanied by the Vice President, tested the emergency lighting unit located in the facility. The lighting unit was functional, but no documentation of monthly or annual testing were provided to the surveyor.

During the exit conference on March 20, 2012, the above findings were again acknowledged by the Vice President.

Failing to test and maintain emergency lighting units will cause harm to the patients.

Based on observation the facility failed to conduct the required fire drills.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.7.1.2 Fire exit drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions."

Findings include:

On March 20, 2012 the surveyor, accompanied by the Vice President, reviewed the facility's fire drill records. The surveyor noted there were no reports for the Third and Fourth quarter of 2011.

During the exit conference on March 20, 2012, the above findings were again acknowledged by the Vice President.

Failure to train and drill the staff on fire procedures could result in harm to the patients.

Based on observation and record review the facility failed to complete sensitivity testing on the facilities smoke detectors.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.1.1.1.1, "The requirements of this chapter apply to existing buildings or portions thereof currently occupied as health care. Existing health care facilities shall comply with the provisions of this chapter" Chapter 19, Section 19.3.4.1 "General" "Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.", Chapter 9, Section 9.6.1.4. A fire alarm system required for life safety shall be installed, tested and maintained in accordance with the applicable requirements of NFPA 70. National Electrical code, and NFPA 72, National fire Alarm Code. NFPA 101, Chapter 4, Section 4.6.12.3, " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 72 National Fire Alarm Code, Chapter 7 Inspection Testing, and Maintenance/Paragraph 7-3.2 "Testing shall be performed in accordance with the schedules in this chapter or more frequently where required by authority having jurisdiction. Section 7-3.2.1 "Detectors sensitivity shall be checked within 1 year after installation and every alternate year thereafter. Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced."

Findings include:

On March 20, 2012, the surveyor accompanied by the Vice President reviewed the fire alarm inspection report by Benson, dated July 22, 2009. The next sensitivity test was due on July 2011. The facility did not have the test completed.

During the exit conference on March 20, 2012, the above findings were again acknowledged by the Vice President

Failure to test and maintain the fire alarm systems smoke detectors could result in harm to the patients.

Based on observation the facility failed to maintain the sprinkler heads and assure that all parts of the sprinkler system were in accordance with the UL Listing, and the facility did not inspect, test and maintain the automatic sprinkler system.


NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.5.1 "Buildings containing health care facilities shall be protected throughout by and approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection,
Testing, and Maintenance of Water-Based Fire Protection systems. NFPA 25, Section 2-2.1.1 "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign material , paint, and physical damage and shall be installed in the proper orientation..." NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, Chapter 3, Section 3-2.7.2, "Escutcheon Plates used with a recessed or flushed sprinkler shall be part of a listed sprinkler assembly. NFPA 25, Standard for the Inspection, Testing , and Maintenance of Water-Based Fire Protection Systems.
" NFPA 25, Water Based Extinguishment Systems, requires monthly, quarterly and annual testing of automatic sprinkler systems.

Findings include:

On March 20, 2012, the surveyor, accompanied by the Vice President and the Assistant Director of Nursing, reviewed the automatic sprinkler records which indicated that the automatic sprinkler system was not inspected or tested, quarterly. To include the following sprinkler heads were not maintained in accordance with NFPA 25:

1. The facility has no documentation of third and fourth quarter 2011, inspector flow testing
2. Nurses station, two of four sprinkler assemblies lint and paint
3. Pharmacy, one of two sprinklers corroded
4. Staff kitchen, one of three sprinklers corroded

During the exit conference on March 20, 2012, the above findings were again acknowledged by the Vice President.

Failure to inspect, test, and maintain the sprinkler system could result in harm to the patients through the spread of smoke and fire.

Based on records review the facility failed to document the required testing of the emergency generator.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.7.6 " Maintenance and Testing (See 4.6.12) Section 4.6.12.2 " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 99 "HEALTH CARE FACILITIES". Chapter 3, Section 3-5.4.1.1 (a) and Section 3-4.4.1.1 (b) "Generator sets shall be tested twelve (12) times a year... Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Chapter 6, Section 6-4.1 "Level 1 and Level 2 EPSSs, including all appurtenant components shall be inspected weekly and shall be exercised under load at least monthly. NFPA 110, Chapter 6, Section 6-4.2 "Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes...
Chapter 3, Section 3-4.1.1.8. (Level/Type 1) "The generator sets shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power.
or Section 3-5.3.1 (Level/Type 2) "The emergency system shall be installed and connected to the alternate source of power specified in 3-4.1.1.2 and 3-4.1.1.3 so that all functions specified herein for the emergency system will be automatically restored to operation within 10 seconds after interruption of the normal source."

Findings Include:

On March 20, 2012, the surveyor, accompanied by the Vice President reviewed the generator test records. No documentation of weekly inspections or monthly tests were available for the year of 2011, the January 2012 load test was completed and documented however no weekly test. February 2012, no load test documentation. March 2012 the weekly and monthly documentation has been completed. The emergency generator was started at the time of survey.

During the exit conference on March 20, 2012, the above findings were again acknowledged by the Vice President.

Failure to test the emergency generator under load, inspect weekly, and document time from normal power to emergency power could result in harm to patients during emergency system failures.

Based on Observation the facility allowed the use of a multiple outlet adapter, power strips and did not use the wall outlet receptacles for appliances. The facility has a broken 110 outlet cover and a missing blank on a electrical panel.

NFPA 101, Life Safety Code, 2000, Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 1999 Edition. NFPA 99, Chapter 3, Section 3-3.2.1.2, "All Patient Care Areas," Section 3-3.2.1.2 (d) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1. Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70 "National Electrical Code." NEC, 1999, Article 410, Section 410-56 (e) Position of Receptacle Faces. "3. After installation, receptacle faces shall be flush with or project from faceplate of insulating material and shall project a minimum of 0.015 in. From metal faceplate. Faceplate shall be installed so as to completely cover the opening and seat against the mounting surface."

Findings include:

On March 20, 2012, the surveyor accompanied by the Assistant Director of Nursing, observed the following electrical deficiencies:

1. Electrical Room, SB panel missing blank
2. COO Office broken 110 outlet cover
3. Staff Kitchen, Two refrigerators plugged into a power strip

During the exit conference on March 20, 2012, the above findings were again acknowledged by the Vice President.

Failing to repair broken receptacles and face plates may contribute to starting a fire by allowing the electrical wiring to short when an electrical appliance is plugged in or removed from the receptacle. The use of multiple outlet adapters could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.