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Based on observation and staff interview, the facility is not providing appropriate construction standards as required by the life safety code. A rated ceiling assembly is not provided as required by the building's construction type, which would prevent containment of smoke and/or fire, affecting two of four smoke zones. This facility has a capacity of 25 and a census of 1 resident at the time of the survey.

FINDINGS INCLUDE:

During the tour on 9/21/2015 it is noted that:

1. At 12:40 PM (x2) ½ " unsealed penetrations in ceiling of mail room.
2. At 1:30 PM (x2) 2 " x1 " unsealed penetrations in ceiling of med room.

The maintenance director was present during the findings.

NFPA Standard: Floor-ceiling assemblies and walls used as fire barriers, including supporting construction, shall be of a design that has been tested to meet the conditions of acceptance of NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials. Fire barriers shall be continuous in accordance with 8.2.2.2 per NFPA 101, 8.2.3.1.1. Space between wires and similar building service equipment that pass through fire barriers shall be protected by filling the space with a material that is capable of maintaining the fire resistance of the fire barrier or shall be protected by an approved device that is designed for the specific purpose 2000 NFPA 101, 8.2.3.2.4.2

Based on observation and staff interview the facility is not ensuring that room doors latch properly. This deficient practice of not ensuring that room doors latch properly prevents the ability of the facility to properly confine fire and smoke products and to properly defend occupants in place, affecting two of four smoke zones. This facility has a capacity of 25 and a census of 1 resident at the time of the survey.

Findings Include:

During the tour on 9/21/2015 it is noted that:

1. At 1:33 PM east fire rated corridor door failed to close and latch on drop test.

The maintenance director was present during the findings.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop down or plunger type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3.

Based on record review and staff interview, the facility is not conducting fire drills as required quarterly on each shift and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency, affecting four of four smoke zones. This facility has a capacity of 25 and a census of 1 resident at the time of the survey.

Findings Include:

During the tour on 9/21/2015 it is noted that:

1. At 11:37 AM no scenarios provided for fire drills.
2. At 11:30 AM fire drills conducted on 6/19/15 at 6:00 AM, 7/29/15 6:00 AM, 9/18/15 5:06 AM all conducted within an hour of each other.
3. At 11:31 AM no time recorded for drill conducted on 3/31/15.

The maintenance director was present during the findings.

NFPA Standard: Fire 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.
When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 2000 NFPA 101, 19.7.1.2.

Based on record review and staff interview, the facility failed to maintain and test smoke detectors for sensitivity in accordance with NFPA 72, 7-3.2.1. This deficient practice may prevent the prompt initiating of smoke detectors alerting the residents and staff to smoke products due to the devices being out of calibration, affecting four of four smoke zones. This facility has a capacity of 25 and a census of 1 resident at the time of the survey.
Findings Include:

During the tour on 9/21/2015 it is noted that:


1. At 12:20 PM smoke detector sensitivity testing overdue.

The maintenance director was present during the findings.

NFPA Standard: Smoke detector sensitivity shall be checked within one year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed. 1999 NFPA 72, 7-3.2.1.

Based on observation, staff interview and record review, the facility failed to clean the kitchen range hood, grease removal devices, fans, ducts, and other appurtenances at intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. The deficient practice provides fuel for cooking equipment to ignite, affecting one of four smoke zones. This facility has a capacity of 25 and a census of 1 resident at the time of the survey.

Findings Include:
During the tour on 9/21/2015 it is noted that:
1. At 12:30 PM range hood duct cleaning documentation not available during the time of inspection.

The maintenance director was present during the findings.
NFPA Standard: Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s). 1998 NFPA 96, 8-3.1

Based on observation, record review and interview, the facility could not provide documentation that curtains and decorations were flame resistant. This deficient practice has the potential of allowing rapid flame spread, affecting one of four smoke zones. This facility has a capacity of 25 and a census of 1 resident at the time of the survey.

Findings Include:

During the tour on 9/21/2015 it is noted that:

1. At 1:32 PM no flame spread index available on curtains hung in waiting room.

The maintenance director was present during the findings.

NFPA Standard: Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films. 2000 NFPA 101, 10.3.1.

Based on observation, staff interview and record review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice may prevent the emergency power supply from being available at the time of a power loss, affecting four of four smoke zones. This facility has a capacity of 25 and a census of 1 resident at the time of the survey.

Findings Include:

During the tour on 9/21/2015 it is noted that:

1. At 11:09 AM no remote generator emergency stop available.
2. At 12:11 AM no generator malfunction policy available.

The maintenance director was present during the findings.

NFPA Standard: Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10 second interval specified in 3 4.1.1.8 and 3 4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
(b) Inspection and Testing.
1.* Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
2. Test Conditions. The scheduled test under load conditions shall include a complete simulated cold start and automatic and manual transfer of all essential electrical system loads.
3. Test Personnel. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures. 1999 NFPA 99 3.4.4.1.

Based on observation and staff interview, the facility fails to assure that all electrical wiring and equipment is installed and maintained in accordance with the requirements NFPA 70. This deficient practice increases the risk of an electrical fire, affecting one of four smoke zones. This facility has a capacity of 25 and a census of 1 resident at the time of the survey.

FINDINGS INCLUDE:
During the tour on 9/21/2015 it is noted that:

1. At 2:00 PM light fixture in O2 storage room missing knockout exposing energized wiring.
2. At 2:01 PM open elbow in conduit in O2 storage room missing knockout exposing energized wiring.

The maintenance director was present during the findings.
NFPA standard: All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 379-22, Exception. 1999 NFPA 70, 370-28(3)(c).

Based on observation and staff interview, the facility is not providing appropriate construction standards as required by the life safety code. A rated ceiling assembly is not provided as required by the building's construction type, which would prevent containment of smoke and/or fire, affecting two of four smoke zones. This facility has a capacity of 25 and a census of 1 resident at the time of the survey.

FINDINGS INCLUDE:

During the tour on 9/21/2015 it is noted that:

1. At 12:40 PM (x2) ½ " unsealed penetrations in ceiling of mail room.
2. At 1:30 PM (x2) 2 " x1 " unsealed penetrations in ceiling of med room.

The maintenance director was present during the findings.

NFPA Standard: Floor-ceiling assemblies and walls used as fire barriers, including supporting construction, shall be of a design that has been tested to meet the conditions of acceptance of NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials. Fire barriers shall be continuous in accordance with 8.2.2.2 per NFPA 101, 8.2.3.1.1. Space between wires and similar building service equipment that pass through fire barriers shall be protected by filling the space with a material that is capable of maintaining the fire resistance of the fire barrier or shall be protected by an approved device that is designed for the specific purpose 2000 NFPA 101, 8.2.3.2.4.2

Based on observation and staff interview the facility is not ensuring that room doors latch properly. This deficient practice of not ensuring that room doors latch properly prevents the ability of the facility to properly confine fire and smoke products and to properly defend occupants in place, affecting two of four smoke zones. This facility has a capacity of 25 and a census of 1 resident at the time of the survey.

Findings Include:

During the tour on 9/21/2015 it is noted that:

1. At 1:33 PM east fire rated corridor door failed to close and latch on drop test.

The maintenance director was present during the findings.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop down or plunger type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3.

Based on record review and staff interview, the facility is not conducting fire drills as required quarterly on each shift and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency, affecting four of four smoke zones. This facility has a capacity of 25 and a census of 1 resident at the time of the survey.

Findings Include:

During the tour on 9/21/2015 it is noted that:

1. At 11:37 AM no scenarios provided for fire drills.
2. At 11:30 AM fire drills conducted on 6/19/15 at 6:00 AM, 7/29/15 6:00 AM, 9/18/15 5:06 AM all conducted within an hour of each other.
3. At 11:31 AM no time recorded for drill conducted on 3/31/15.

The maintenance director was present during the findings.

NFPA Standard: Fire 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.
When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 2000 NFPA 101, 19.7.1.2.

Based on record review and staff interview, the facility failed to maintain and test smoke detectors for sensitivity in accordance with NFPA 72, 7-3.2.1. This deficient practice may prevent the prompt initiating of smoke detectors alerting the residents and staff to smoke products due to the devices being out of calibration, affecting four of four smoke zones. This facility has a capacity of 25 and a census of 1 resident at the time of the survey.
Findings Include:

During the tour on 9/21/2015 it is noted that:


1. At 12:20 PM smoke detector sensitivity testing overdue.

The maintenance director was present during the findings.

NFPA Standard: Smoke detector sensitivity shall be checked within one year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed. 1999 NFPA 72, 7-3.2.1.

Based on observation, staff interview and record review, the facility failed to clean the kitchen range hood, grease removal devices, fans, ducts, and other appurtenances at intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. The deficient practice provides fuel for cooking equipment to ignite, affecting one of four smoke zones. This facility has a capacity of 25 and a census of 1 resident at the time of the survey.

Findings Include:
During the tour on 9/21/2015 it is noted that:
1. At 12:30 PM range hood duct cleaning documentation not available during the time of inspection.

The maintenance director was present during the findings.
NFPA Standard: Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s). 1998 NFPA 96, 8-3.1

Based on observation, record review and interview, the facility could not provide documentation that curtains and decorations were flame resistant. This deficient practice has the potential of allowing rapid flame spread, affecting one of four smoke zones. This facility has a capacity of 25 and a census of 1 resident at the time of the survey.

Findings Include:

During the tour on 9/21/2015 it is noted that:

1. At 1:32 PM no flame spread index available on curtains hung in waiting room.

The maintenance director was present during the findings.

NFPA Standard: Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films. 2000 NFPA 101, 10.3.1.

Based on observation, staff interview and record review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice may prevent the emergency power supply from being available at the time of a power loss, affecting four of four smoke zones. This facility has a capacity of 25 and a census of 1 resident at the time of the survey.

Findings Include:

During the tour on 9/21/2015 it is noted that:

1. At 11:09 AM no remote generator emergency stop available.
2. At 12:11 AM no generator malfunction policy available.

The maintenance director was present during the findings.

NFPA Standard: Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10 second interval specified in 3 4.1.1.8 and 3 4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
(b) Inspection and Testing.
1.* Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
2. Test Conditions. The scheduled test under load conditions shall include a complete simulated cold start and automatic and manual transfer of all essential electrical system loads.
3. Test Personnel. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures. 1999 NFPA 99 3.4.4.1.

Based on observation and staff interview, the facility fails to assure that all electrical wiring and equipment is installed and maintained in accordance with the requirements NFPA 70. This deficient practice increases the risk of an electrical fire, affecting one of four smoke zones. This facility has a capacity of 25 and a census of 1 resident at the time of the survey.

FINDINGS INCLUDE:
During the tour on 9/21/2015 it is noted that:

1. At 2:00 PM light fixture in O2 storage room missing knockout exposing energized wiring.
2. At 2:01 PM open elbow in conduit in O2 storage room missing knockout exposing energized wiring.

The maintenance director was present during the findings.
NFPA standard: All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 379-22, Exception. 1999 NFPA 70, 370-28(3)(c).