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Based on observation and staff interview, the facility failed to assure that the 2 hour wall separating the hospital from the clinic is properly sealed. This deficient practice of allowing improperly sealed penetrations in a 2 hour separation wall affects approximately emergency room patients and patients in surgery in one of four smoke zones in the facility. The facility has a capacity of 25 and a census of 16 at the time of survey.

Findings include:

During the survey on September 11, 2015 the following is observed:

1. At 11:25 AM it is observed that the 2 hour fire barrier on the ground floor between the hospital and the clinic has a penetration above the ceiling tile level west of the 1 ½ fire rated doors where 2 data cables penetrate the wall leaving a ¼ gap around the penetration.

2. At 11:40 AM it is observed that the 2 hour fire barrier on the ground floor level between the hospital and the clinic has penetrations above the ceiling level in the room next to the x-ray dark room a concrete block has been open for pipe and conduit run leaving an irregular opening in the barrier approximately 8 inches by 6 inches.

The Maintenance Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2 hour fire resistance rating and constructed of materials as required for the addition. Communicating openings in the fire barriers shall be permitted only in corridors and protected by approved self-closing fire doors. 2000 NFPA 101, 18/19.1.1.4.1 and 18/19.1.1.4.2

Review of the following NFPA Standard revealed: Occupied buildings shall meet the minimum construction requirements of the occupancy chapters and NFPA 220. Additions or connected structures of different construction types shall have the ratings and classification based on: separate buildings if a 2 hour or greater vertically aligned fire barrier wall in accordance with NFPA 221 exists between the buildings, or the least fire resistive type of construction of the connected portions. 2000 NFPA 101, 8.2.1

Review of the following NFPA Standard revealed: Locks, latches, surface-mounted top and bottom bolts, and fire exit hardware shall be secured to reinforcements in the doors with machine screws or shall be attached with through-bolts. Flush-mounted top and bottom bolts shall be secured to reinforcements in the doors with machine screws.

Exception: Locks and latches shall be attached to wood and plastic-covered composite doors or wood core doors with not less than No. 8, flat, threaded-to-the-head, wood screws or shall be attached with through-bolts. Fire exit hardware and surface-mounted top and bottom bolts shall be attached to wood and plastic-covered composite doors with through-bolts or with steel screws at locations specified in the door manufacturer ' s installation instructions. 1999 NFPA 80, 2-4.4.7

Based on observation and staff interview the facility is not ensuring that room doors latch properly and are free of impediments that prevent the door from closing. This deficient practice of not ensuring that room doors latch properly and are free of impediments prevents the ability of the facility to properly confine fire and smoke products and to properly defend occupants in place, affecting 25 patients in two of four smoke zones. The facility has a capacity of 25 and census of 16 at the time of the survey.

Findings include:

During the survey on September 14, 2015 the following is observed:

1. At 10:50 AM it is observed that the door from the 106 to the corridor is impeded from closing by a small waste container.

2. At 10:55 AM it is observed that the door from the linen closet near the nursery is not latching.

The Director of Nursing was present and acknowledged the findings.

Review of the following NFPA Standard revealed: 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 observation and staff interview the facility fails to maintain one of two smoke barriers to at least one half hour fire resistance. This deficient practice would prevent containment of fire and smoke, affecting 25 residents in two of three smoke zones. The facility has a capacity of 25 and census of 16 at the time of the survey.

Findings include:

During the survey on September 14, 2015at 10:30 AM the following is observed:

1. It is observed that the main level north smoke barrier is penetrated by data wire bundles in 2 places and where conduit passes through the barrier. This is observed above the ceiling tile level above the west leaf of the barrier doors leaving gaps ranging from ¼ inch to ½ inch.

2. It is observed from the south side of the main level north smoke barrier above the ceiling tile that this smoke barrier is penetrated where flexible conduit passes through the barrier leaving a ½ inch gap. This is west of the nurses ' station.

The Director of Nursing was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Requires smoke walls to have a fire resistance rating of at least a half hour and to be continuous from floor to roof deck and from outside wall to outside wall. 2000 NFPA 101, 19.3.7.3

Review of the following NFPA Standard revealed: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1

Based on observation and staff interview the facility failed to ensure proper separation of hazardous areas from other spaces. This deficient practice would allow for the spread of smoke and fire to travel into the adjacent areas, affecting the emergency room and surgery area in one of four smoke zones. The facility has a capacity of 25 with a census of 16 at the time of survey.

Findings include:

During the survey on September 11, 2015 at 11:50 AM it is observed that the east side of the boiler room has penetration around piping going into the clinic medication room. These penetrations are approximately ½ inch in size.

The Maintenance Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Review of the following NFPA Standard revealed: Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:

(1) Enclose the area with a fire barrier without windows that has a 1 hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42.
2000 NFPA 101, 8.4.1

Based on observation and staff interview, the facility failed to provide exit access that is arranged so that exits are readily accessible at all times. The deficient practice renders the exiting obstructed and impeded to a full instant use, affecting occupants in two of four smoke zones. The facility has a capacity of 25 and a census of 16 at the time of the survey.

Findings include:

During the survey on September 14, 2015 the following is observed:

1. At 10:30 AM it is observed that interior main level center east exit doors are equipped with two locking devices. 1 lock is a magnetic locking device and the other lock is a key operated dead bolt.

2. At 10:30 AM it is observed that exterior main level center east exit doors are equipped with a thumb turn dead bolt locking device.

3. At 1:10 PM it is observed that the ground level emergency room exit doors are equipped with key operated dead bolt.

The Director of Nursing was present and acknowledged the findings.

Review of the following NFPA Standard revealed: A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.

Exception No. 1:* Egress doors from individual living units and guest rooms of residential occupancies shall be permitted to be provided with devices that require not more than one additional releasing operation, provided that such device is operable from the inside without the use of a key or tool and is mounted at a height not exceeding 48 in. (122 cm) above the finished floor. Existing security devices shall be permitted to have two additional releasing operations. Existing security devices other than automatic latching devices shall not be located more than 60 in. (152 cm) above the finished floor. Automatic latching devices shall not be located more than 48 in. (122 cm) above the finished floor.

Exception No. 2: The minimum mounting height for the releasing mechanism shall not be applicable to existing installations. 2000 NFPA 101, 7.2.1.5.4

Review of the following NFPA Standard revealed: Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.

Exception No. 1: Door-locking arrangements without delayed egress shall be permitted in health care occupancies, or portions of health care occupancies, where the clinical needs of the patients require specialized security measures for their safety, provided that staff can readily unlock such doors at all times. (See 19.1.1.1.5 and 19.2.2.2.5)

Exception No. 2:* Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path.

Exception No. 3: Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted. 2000 NFPA 101, 19.2.2.2.4

Review of the following NFPA Standard revealed: Doors located in the means of egress that are permitted to be locked under other provisions of this chapter shall have adequate provisions made for the rapid removal of occupants by means such as remote control of locks, keying of all locks to keys carried by staff at all times, or other such reliable means available to the staff at all times. Only one such locking device shall be permitted on each door.

Exception No. 1: Locks in accordance with Exception Nos. 2 and 3 to 19.2.2.2.4.

Exception No. 2: More than one lock shall be permitted on each door subject to approval of the authority having jurisdiction. 2000 NFPA 101, 19.2.2.2.5

Based on observation and staff interview, the facility failed to provide the nursery room that can readily be unlocked during an emergency. This deficient practice of preventing this room from being readily unlocked will prevent speedy discovery of fire conditions, rescue and exiting, affecting the nursery residents in one of four smoke zones. This facility has a capacity of 25 and a census of 16 residents at the time of the survey.

Findings include:

During the survey on September 14, 2015 at10:55 AM it is observed that nursery has a locking device on the door. When staff was requested to demonstrate that a key was available to unlock this door the key was not presented.

The Director of Nursing was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Locks shall not be permitted on patient sleeping room doors.

Exception No. 1: Key-locking devices that restrict access to the room from the corridor and that are operable only by staff from the corridor side shall be permitted. Such devices shall not restrict egress from the room.

Exception No. 2: Door-locking arrangements shall be permitted in health care occupancies, or portions of health care occupancies, where the clinical needs of the patients require specialized security measures for their safety, provided that keys are carried by staff at all times. 2000 NFPA 101, 19.2.2.2.2

Based on observation and staff interview the facility failed to provide continuous illumination of floors and other walking surfaces within one of seven exit paths to values of at least 1 ft. candle (10 lux) measured at the floor. This deficient practice does not insure that exit paths will be illuminated continuously and will delay egress, affecting the occupants on the ground level in one of four smoke zones. The facility has a capacity of 25 and census of 16 at the time of the survey.

Findings include:

During the survey on September 14, 2015 at 1:00 PM it is observed that the ground level west exit door near dietary dry storage room is provided with a wall switch that allows the lighting fixtures in this exit to be turned off leaving the exiting path without illumination.

The Director of Nursing was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use. Artificial lighting shall be employed at such locations and for such periods of time as required to maintain the illumination to the minimum criteria values herein specified.

Exception: Automatic, motion sensor type lighting switches shall be permitted within the means of egress, provided that the switch controllers are equipped for fail safe operation, the illumination timers are set for a minimum 15 minute duration, and the motion sensor is activated by any occupant movement in the area served by the lighting units. 2000 NFPA 101, Section 7.8.1.2

Review of the following NFPA Standard revealed: The floors and other walking surfaces within an exit and within the portions of the exit access and exit discharge designated in 7.8.1.1 shall be illuminated to values of at least 1 ft. candle (10 lux) measured at the floor.

Exception No. 1: In assembly occupancies, the illumination of the floors of exit access shall be at least 0.2 ft. candle (2 lux) during periods of performances or projections involving directed light.

Exception No. 2:* This requirement shall not apply where operations or processes require low lighting levels. 2000 NFPA 101, Section 7.8.1.3

Based on record review and staff interview the facility failed to provide a written fire safety plan that addresses the evacuation of the smoke compartment. The deficient practice may prevent the staff in identifying the need to evacuate occupants beyond the compartment of origin to another smoke compartment, affecting all occupants in four of four smoke zones. The facility has a capacity of 25 and census of 16 at the time of the survey.

Findings include:

During the record review on September 11, 2015 at 1:40 PM it is observed that the written fire emergency plan does not clearly indicate that the requirement for evacuation of the smoke compartment. The policy presented states that relocation will be to a safe area.

The Maintenance Director and Director of Nursing were present and acknowledged the findings.

Review of the following NFPA Standard revealed: The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator ' s position or at the security center. The provisions of 19.7.1.2 through 19.7.2.3 shall apply. 2000 NFPA 101, Section 19.7.1.1

Review of the following NFPA Standard revealed: The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator ' s position or at the security center. The provisions of 19.7.1.2 through 19.7.2.3 shall apply. 2000 NFPA 101, Section 19.7.1.1

Review of the following NFPA Standard revealed: For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy ' s fire safety plan. 2000 NFPA 101, Section 19.7.2.1

Review of the following NFPA Standard revealed: A written health care occupancy fire safety plan shall provide for the following:

(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
2000 NFPA 101, Section 19.7.2.2

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 all occupants in four of four smoke zones. The facility has a capacity of 25 and census of 16 at the time of the survey.

Findings include:

During the survey on September 11, 2015 at 1:50 PM the following is observed:

1. Review of the facility ' s fire drill records for the previous 12 months revealed that the fire drills conducted on September 30, 2014 at 9:30 AM, October 16, 2014 at 4:00 PM, January 30, 2015 at 2:45 PM and March 31, 2015 at 8:35 AM did not transmit and alarm to the monitoring company when compared to the monitoring company ' s receiving log.

2. Review of the facility's fire drill records for the previous 12 months revealed that the facility is not using a coded announcement between the hours of 9:00 PM and 6:00 AM when conducting fire drills. The fire alarm system is also not being used for the fire drills at this time. No code phrase was described in the fire response plan.

The Director of Nursing was present and acknowledged the findings.

Review of the following NFPA Standard revealed: 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 interviews, the facility failed to assure that the sprinkler system is installed in accordance with NFPA 13 and maintained in accordance with NFPA 25. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting approximately 25 occupants in four of four smoke zones. The facility has a capacity of 25 and census of 16 at the time of the survey.

Findings include:

During the survey the following is observed:

1. On September 11, 2015 at 10:50 AM during record review it is observed that there is no record of weekly inspection of dry sprinkler system gauges.

2. On September 14, 2015 at 11:05 AM it is observed that the delivery room has 3 separate floor to ceiling closets that are equipped with sprinkler protected.

3. On September 14, 2015 at 12:40 PM a corroded head is observed in the ground level central supply water heater room.

The Maintenance Director and Director of Nursing were present and acknowledged the findings.

Review of the following NFPA Standard revealed: Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. 2000 NFPA 101, 4.6.12.1

Review of the following NFPA Standard revealed: 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. 2000 NFPA 101, 9.7.5

Review of the following NFPA Standard revealed: Gauges on dry, preaction, and deluge systems shall be inspected weekly to ensure that normal air and water pressures are being maintained.

Exception: Where air pressure supervision is connected to a constantly attended location, gauges shall be inspected monthly. 1998 NFPA 25, 2-2.4.2 and Table 2-1 Summary of Sprinkler System Inspection, Testing and Maintenance.

Review of the following NFPA Standard revealed: Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

Exception No. 1: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown. 1998 NFPA 25, 2-2.1.1

Review of the following NFPA Standard revealed: The requirements for spacing, location, and position
of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution

Exception No. 1: For locations permitting omission of sprinklers, see 5-13.1, 5-13.2, and 5-13.9.
Exception No. 2: When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.
Exception No. 3: Clearance between sprinklers and ceilings exceeding the maximum specified in 5-6.4.1, 5-7.4.1, 5-8.4.1, 5-9.4.1, 5-10.4.1, and 5-11.4.1 shall be permitted provided that tests or calculations demonstrate comparable sensitivity and performance of the sprinklers to those installed in conformance with these sections. 1999 NFPA 13, 5-1.1

Based on observation and staff interview, the facility failed to provide documentation proving that water heaters requiring a boiler inspection have been inspected and certified. Failure to comply with the State's inspection requirements could result in a hazardous condition due improper installation or the malfunction of a heat-producing appliance, affecting emergency room and surgery room occupant in one of four smoke zones. The facility has a capacity of 25 with a census of 16 at the time of survey.

Findings include:

During the survey on September 11, 2015 at 11:50 AM the boiler certificate expired August 31, 2013 for the west boiler identified as KS03950.

The Maintenance Director was present and acknowledged the findings.

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 in compliance with NFPA 96. The deficient practice provides fuel for cooking equipment to ignite, affecting emergency room and surgery room occupants in one of four smoke zones. The facility has a capacity of 25 residents with a census of 16 at the time of the survey.

Findings include:

During record review on September 11, 2015at 1:20 PM no documentation of kitchen hood cleaning since 2009 presented. The fire suppression system inspection report dated February 9, 2015 indicates the exhaust hood system needs cleaning.

The Maintenance Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Filters shall be equipped with a drip tray beneath their lower edges. The tray shall be kept to the minimum size needed to collect grease and shall be pitched to drain into an enclosed metal container having a capacity not exceeding 1 gal (3.785 L). 1998 NFPA 96, 3-2.6

Review of the following NFPA Standard revealed: Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction. 2000 NFPA 101, 9.2.3

Review of the following NFPA Standard revealed: 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 and staff interview the facility failed to provide a remote stop for the emergency generator power supply as required. The deficient practice may prevent the emergency power supply from being stopped at the time of a power loss, affecting all occupants in all smoke zones. This facility has capacity for 25 and a census of 16 at the time of the survey.

Findings include:

During the survey on September 11, 2015at11:50 AM it is observed that there is no remote stop for the generator located external to the weatherproof exterior generator enclosure.

Review of the following NFPA Standard revealed: Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems. 2000 NFPA 101, 7.9.2.3

Review of the following NFPA Standard revealed: Emergency generators, where required for compliance with this Code, shall be tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. 2000 NFPA 101, 9.1.3

Review of the following NFPA Standard revealed: All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building. 1999 NFPA 110, 3-5.5.6

Based on observation and staff interview, the facility failed to assure that the 2 hour wall separating the hospital from the clinic is properly sealed. This deficient practice of allowing improperly sealed penetrations in a 2 hour separation wall affects approximately emergency room patients and patients in surgery in one of four smoke zones in the facility. The facility has a capacity of 25 and a census of 16 at the time of survey.

Findings include:

During the survey on September 11, 2015 the following is observed:

1. At 11:25 AM it is observed that the 2 hour fire barrier on the ground floor between the hospital and the clinic has a penetration above the ceiling tile level west of the 1 ½ fire rated doors where 2 data cables penetrate the wall leaving a ¼ gap around the penetration.

2. At 11:40 AM it is observed that the 2 hour fire barrier on the ground floor level between the hospital and the clinic has penetrations above the ceiling level in the room next to the x-ray dark room a concrete block has been open for pipe and conduit run leaving an irregular opening in the barrier approximately 8 inches by 6 inches.

The Maintenance Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2 hour fire resistance rating and constructed of materials as required for the addition. Communicating openings in the fire barriers shall be permitted only in corridors and protected by approved self-closing fire doors. 2000 NFPA 101, 18/19.1.1.4.1 and 18/19.1.1.4.2

Review of the following NFPA Standard revealed: Occupied buildings shall meet the minimum construction requirements of the occupancy chapters and NFPA 220. Additions or connected structures of different construction types shall have the ratings and classification based on: separate buildings if a 2 hour or greater vertically aligned fire barrier wall in accordance with NFPA 221 exists between the buildings, or the least fire resistive type of construction of the connected portions. 2000 NFPA 101, 8.2.1

Review of the following NFPA Standard revealed: Locks, latches, surface-mounted top and bottom bolts, and fire exit hardware shall be secured to reinforcements in the doors with machine screws or shall be attached with through-bolts. Flush-mounted top and bottom bolts shall be secured to reinforcements in the doors with machine screws.

Exception: Locks and latches shall be attached to wood and plastic-covered composite doors or wood core doors with not less than No. 8, flat, threaded-to-the-head, wood screws or shall be attached with through-bolts. Fire exit hardware and surface-mounted top and bottom bolts shall be attached to wood and plastic-covered composite doors with through-bolts or with steel screws at locations specified in the door manufacturer ' s installation instructions. 1999 NFPA 80, 2-4.4.7

Based on observation and staff interview the facility is not ensuring that room doors latch properly and are free of impediments that prevent the door from closing. This deficient practice of not ensuring that room doors latch properly and are free of impediments prevents the ability of the facility to properly confine fire and smoke products and to properly defend occupants in place, affecting 25 patients in two of four smoke zones. The facility has a capacity of 25 and census of 16 at the time of the survey.

Findings include:

During the survey on September 14, 2015 the following is observed:

1. At 10:50 AM it is observed that the door from the 106 to the corridor is impeded from closing by a small waste container.

2. At 10:55 AM it is observed that the door from the linen closet near the nursery is not latching.

The Director of Nursing was present and acknowledged the findings.

Review of the following NFPA Standard revealed: 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 observation and staff interview the facility fails to maintain one of two smoke barriers to at least one half hour fire resistance. This deficient practice would prevent containment of fire and smoke, affecting 25 residents in two of three smoke zones. The facility has a capacity of 25 and census of 16 at the time of the survey.

Findings include:

During the survey on September 14, 2015at 10:30 AM the following is observed:

1. It is observed that the main level north smoke barrier is penetrated by data wire bundles in 2 places and where conduit passes through the barrier. This is observed above the ceiling tile level above the west leaf of the barrier doors leaving gaps ranging from ¼ inch to ½ inch.

2. It is observed from the south side of the main level north smoke barrier above the ceiling tile that this smoke barrier is penetrated where flexible conduit passes through the barrier leaving a ½ inch gap. This is west of the nurses ' station.

The Director of Nursing was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Requires smoke walls to have a fire resistance rating of at least a half hour and to be continuous from floor to roof deck and from outside wall to outside wall. 2000 NFPA 101, 19.3.7.3

Review of the following NFPA Standard revealed: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1

Based on observation and staff interview the facility failed to ensure proper separation of hazardous areas from other spaces. This deficient practice would allow for the spread of smoke and fire to travel into the adjacent areas, affecting the emergency room and surgery area in one of four smoke zones. The facility has a capacity of 25 with a census of 16 at the time of survey.

Findings include:

During the survey on September 11, 2015 at 11:50 AM it is observed that the east side of the boiler room has penetration around piping going into the clinic medication room. These penetrations are approximately ½ inch in size.

The Maintenance Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Review of the following NFPA Standard revealed: Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:

(1) Enclose the area with a fire barrier without windows that has a 1 hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42.
2000 NFPA 101, 8.4.1

Based on observation and staff interview, the facility failed to provide exit access that is arranged so that exits are readily accessible at all times. The deficient practice renders the exiting obstructed and impeded to a full instant use, affecting occupants in two of four smoke zones. The facility has a capacity of 25 and a census of 16 at the time of the survey.

Findings include:

During the survey on September 14, 2015 the following is observed:

1. At 10:30 AM it is observed that interior main level center east exit doors are equipped with two locking devices. 1 lock is a magnetic locking device and the other lock is a key operated dead bolt.

2. At 10:30 AM it is observed that exterior main level center east exit doors are equipped with a thumb turn dead bolt locking device.

3. At 1:10 PM it is observed that the ground level emergency room exit doors are equipped with key operated dead bolt.

The Director of Nursing was present and acknowledged the findings.

Review of the following NFPA Standard revealed: A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.

Exception No. 1:* Egress doors from individual living units and guest rooms of residential occupancies shall be permitted to be provided with devices that require not more than one additional releasing operation, provided that such device is operable from the inside without the use of a key or tool and is mounted at a height not exceeding 48 in. (122 cm) above the finished floor. Existing security devices shall be permitted to have two additional releasing operations. Existing security devices other than automatic latching devices shall not be located more than 60 in. (152 cm) above the finished floor. Automatic latching devices shall not be located more than 48 in. (122 cm) above the finished floor.

Exception No. 2: The minimum mounting height for the releasing mechanism shall not be applicable to existing installations. 2000 NFPA 101, 7.2.1.5.4

Review of the following NFPA Standard revealed: Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.

Exception No. 1: Door-locking arrangements without delayed egress shall be permitted in health care occupancies, or portions of health care occupancies, where the clinical needs of the patients require specialized security measures for their safety, provided that staff can readily unlock such doors at all times. (See 19.1.1.1.5 and 19.2.2.2.5)

Exception No. 2:* Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path.

Exception No. 3: Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted. 2000 NFPA 101, 19.2.2.2.4

Review of the following NFPA Standard revealed: Doors located in the means of egress that are permitted to be locked under other provisions of this chapter shall have adequate provisions made for the rapid removal of occupants by means such as remote control of locks, keying of all locks to keys carried by staff at all times, or other such reliable means available to the staff at all times. Only one such locking device shall be permitted on each door.

Exception No. 1: Locks in accordance with Exception Nos. 2 and 3 to 19.2.2.2.4.

Exception No. 2: More than one lock shall be permitted on each door subject to approval of the authority having jurisdiction. 2000 NFPA 101, 19.2.2.2.5

Based on observation and staff interview, the facility failed to provide the nursery room that can readily be unlocked during an emergency. This deficient practice of preventing this room from being readily unlocked will prevent speedy discovery of fire conditions, rescue and exiting, affecting the nursery residents in one of four smoke zones. This facility has a capacity of 25 and a census of 16 residents at the time of the survey.

Findings include:

During the survey on September 14, 2015 at10:55 AM it is observed that nursery has a locking device on the door. When staff was requested to demonstrate that a key was available to unlock this door the key was not presented.

The Director of Nursing was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Locks shall not be permitted on patient sleeping room doors.

Exception No. 1: Key-locking devices that restrict access to the room from the corridor and that are operable only by staff from the corridor side shall be permitted. Such devices shall not restrict egress from the room.

Exception No. 2: Door-locking arrangements shall be permitted in health care occupancies, or portions of health care occupancies, where the clinical needs of the patients require specialized security measures for their safety, provided that keys are carried by staff at all times. 2000 NFPA 101, 19.2.2.2.2

Based on observation and staff interview the facility failed to provide continuous illumination of floors and other walking surfaces within one of seven exit paths to values of at least 1 ft. candle (10 lux) measured at the floor. This deficient practice does not insure that exit paths will be illuminated continuously and will delay egress, affecting the occupants on the ground level in one of four smoke zones. The facility has a capacity of 25 and census of 16 at the time of the survey.

Findings include:

During the survey on September 14, 2015 at 1:00 PM it is observed that the ground level west exit door near dietary dry storage room is provided with a wall switch that allows the lighting fixtures in this exit to be turned off leaving the exiting path without illumination.

The Director of Nursing was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use. Artificial lighting shall be employed at such locations and for such periods of time as required to maintain the illumination to the minimum criteria values herein specified.

Exception: Automatic, motion sensor type lighting switches shall be permitted within the means of egress, provided that the switch controllers are equipped for fail safe operation, the illumination timers are set for a minimum 15 minute duration, and the motion sensor is activated by any occupant movement in the area served by the lighting units. 2000 NFPA 101, Section 7.8.1.2

Review of the following NFPA Standard revealed: The floors and other walking surfaces within an exit and within the portions of the exit access and exit discharge designated in 7.8.1.1 shall be illuminated to values of at least 1 ft. candle (10 lux) measured at the floor.

Exception No. 1: In assembly occupancies, the illumination of the floors of exit access shall be at least 0.2 ft. candle (2 lux) during periods of performances or projections involving directed light.

Exception No. 2:* This requirement shall not apply where operations or processes require low lighting levels. 2000 NFPA 101, Section 7.8.1.3

Based on record review and staff interview the facility failed to provide a written fire safety plan that addresses the evacuation of the smoke compartment. The deficient practice may prevent the staff in identifying the need to evacuate occupants beyond the compartment of origin to another smoke compartment, affecting all occupants in four of four smoke zones. The facility has a capacity of 25 and census of 16 at the time of the survey.

Findings include:

During the record review on September 11, 2015 at 1:40 PM it is observed that the written fire emergency plan does not clearly indicate that the requirement for evacuation of the smoke compartment. The policy presented states that relocation will be to a safe area.

The Maintenance Director and Director of Nursing were present and acknowledged the findings.

Review of the following NFPA Standard revealed: The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator ' s position or at the security center. The provisions of 19.7.1.2 through 19.7.2.3 shall apply. 2000 NFPA 101, Section 19.7.1.1

Review of the following NFPA Standard revealed: The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator ' s position or at the security center. The provisions of 19.7.1.2 through 19.7.2.3 shall apply. 2000 NFPA 101, Section 19.7.1.1

Review of the following NFPA Standard revealed: For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy ' s fire safety plan. 2000 NFPA 101, Section 19.7.2.1

Review of the following NFPA Standard revealed: A written health care occupancy fire safety plan shall provide for the following:

(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
2000 NFPA 101, Section 19.7.2.2

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 all occupants in four of four smoke zones. The facility has a capacity of 25 and census of 16 at the time of the survey.

Findings include:

During the survey on September 11, 2015 at 1:50 PM the following is observed:

1. Review of the facility ' s fire drill records for the previous 12 months revealed that the fire drills conducted on September 30, 2014 at 9:30 AM, October 16, 2014 at 4:00 PM, January 30, 2015 at 2:45 PM and March 31, 2015 at 8:35 AM did not transmit and alarm to the monitoring company when compared to the monitoring company ' s receiving log.

2. Review of the facility's fire drill records for the previous 12 months revealed that the facility is not using a coded announcement between the hours of 9:00 PM and 6:00 AM when conducting fire drills. The fire alarm system is also not being used for the fire drills at this time. No code phrase was described in the fire response plan.

The Director of Nursing was present and acknowledged the findings.

Review of the following NFPA Standard revealed: 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 interviews, the facility failed to assure that the sprinkler system is installed in accordance with NFPA 13 and maintained in accordance with NFPA 25. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting approximately 25 occupants in four of four smoke zones. The facility has a capacity of 25 and census of 16 at the time of the survey.

Findings include:

During the survey the following is observed:

1. On September 11, 2015 at 10:50 AM during record review it is observed that there is no record of weekly inspection of dry sprinkler system gauges.

2. On September 14, 2015 at 11:05 AM it is observed that the delivery room has 3 separate floor to ceiling closets that are equipped with sprinkler protected.

3. On September 14, 2015 at 12:40 PM a corroded head is observed in the ground level central supply water heater room.

The Maintenance Director and Director of Nursing were present and acknowledged the findings.

Review of the following NFPA Standard revealed: Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. 2000 NFPA 101, 4.6.12.1

Review of the following NFPA Standard revealed: 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. 2000 NFPA 101, 9.7.5

Review of the following NFPA Standard revealed: Gauges on dry, preaction, and deluge systems shall be inspected weekly to ensure that normal air and water pressures are being maintained.

Exception: Where air pressure supervision is connected to a constantly attended location, gauges shall be inspected monthly. 1998 NFPA 25, 2-2.4.2 and Table 2-1 Summary of Sprinkler System Inspection, Testing and Maintenance.

Review of the following NFPA Standard revealed: Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

Exception No. 1: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown. 1998 NFPA 25, 2-2.1.1

Review of the following NFPA Standard revealed: The requirements for spacing, location, and position
of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution

Exception No. 1: For locations permitting omission of sprinklers, see 5-13.1, 5-13.2, and 5-13.9.
Exception No. 2: When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.
Exception No. 3: Clearance between sprinklers and ceilings exceeding the maximum specified in 5-6.4.1, 5-7.4.1, 5-8.4.1, 5-9.4.1, 5-10.4.1, and 5-11.4.1 shall be permitted provided that tests or calculations demonstrate comparable sensitivity and performance of the sprinklers to those installed in conformance with these sections. 1999 NFPA 13, 5-1.1

Based on observation and staff interview, the facility failed to provide documentation proving that water heaters requiring a boiler inspection have been inspected and certified. Failure to comply with the State's inspection requirements could result in a hazardous condition due improper installation or the malfunction of a heat-producing appliance, affecting emergency room and surgery room occupant in one of four smoke zones. The facility has a capacity of 25 with a census of 16 at the time of survey.

Findings include:

During the survey on September 11, 2015 at 11:50 AM the boiler certificate expired August 31, 2013 for the west boiler identified as KS03950.

The Maintenance Director was present and acknowledged the findings.

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 in compliance with NFPA 96. The deficient practice provides fuel for cooking equipment to ignite, affecting emergency room and surgery room occupants in one of four smoke zones. The facility has a capacity of 25 residents with a census of 16 at the time of the survey.

Findings include:

During record review on September 11, 2015at 1:20 PM no documentation of kitchen hood cleaning since 2009 presented. The fire suppression system inspection report dated February 9, 2015 indicates the exhaust hood system needs cleaning.

The Maintenance Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Filters shall be equipped with a drip tray beneath their lower edges. The tray shall be kept to the minimum size needed to collect grease and shall be pitched to drain into an enclosed metal container having a capacity not exceeding 1 gal (3.785 L). 1998 NFPA 96, 3-2.6

Review of the following NFPA Standard revealed: Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction. 2000 NFPA 101, 9.2.3

Review of the following NFPA Standard revealed: 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 and staff interview the facility failed to provide a remote stop for the emergency generator power supply as required. The deficient practice may prevent the emergency power supply from being stopped at the time of a power loss, affecting all occupants in all smoke zones. This facility has capacity for 25 and a census of 16 at the time of the survey.

Findings include:

During the survey on September 11, 2015at11:50 AM it is observed that there is no remote stop for the generator located external to the weatherproof exterior generator enclosure.

Review of the following NFPA Standard revealed: Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems. 2000 NFPA 101, 7.9.2.3

Review of the following NFPA Standard revealed: Emergency generators, where required for compliance with this Code, shall be tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. 2000 NFPA 101, 9.1.3

Review of the following NFPA Standard revealed: All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building. 1999 NFPA 110, 3-5.5.6