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Based on record review and staff interview, the facility fails to assure interior finish for rooms is of a Class A, Class B or Class C flame spread rating. This deficient practice would allow for flames to spread more rapidly across the surfat of the exposed wall treatment, affecting 1 of 5 smoke zones. The facility has a capacity of 25 with a census of 11.

FINDINGS INCLUDE:

During the tour on 5/5/10 between 11:00am and 3:00pm it is observed there is no documentation for the flame spread rating on the paneling in the Administrators basement office.

Staff A is aware of the finding. Staff A stated paneling was removed from other offices after the last KRS fire marshal survey.

Based on observation and staff interview the facility fails to maintain two of three smoke barriers to at least one half hour fire resistance and ensure that all penetrations area properly sealed. This deficient practice would prevent containment of fire and smoke, affecting 3 of 5 smoke zones. This facility has a capacity of 25 and a census of 11.

FINDINGS INCLUDE:

During the tour on 5/5/10 between 11:00am and 3:00pm the following is observed:

--1) There is a penetration around a conduit in the North smoke barrier wall, nurse desk side of wall.
--2) There is an open wire chase in the Solarium smoke barrier wall in the Solarium.

Staff A is aware of the findings and stated a contractor had done work in the Solarium smoke wall.

Based on observation and staff interview, the facility fails to assure barrier doors provide a suitable means for keeping the smoke doors smoke tight. This deficient practice fails to prevent the spread of fire and smoke, affecting 3 of 5 smoke zones. The facility has a capacity of 25 with a census of 11.

FINDINGS INCLUDE:

During the tour on 5/5/10 between 11:00am and 3:00pm it is observed there is a smoke barrier door that is not latching with the provided latching hardware to the North corridor.

Staff A is aware of the finding and stated the door had been functioning when previously checked.

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 spread into adjacent areas, affecting 3 of 5 smoke zones. The facility has a capacity of 25 and a census of 7.

FINDINGS INCLUDE:

During the tour on 5/5/10 between 11:00am and 3:00pm the following is observed:

--1) There is an open wire chase and a gap around three conduits in the basement Cleaning closet.
--2) There is a gap around the sprinkler pipe in the Dry food storage where combustibles are also stored.
--3) The self closing device is not latching to the door frame to the Dry food storage where combustibles are stored.
--4) Room 118 is over 50 sq feet in size, stores combustibles and there is no self closure on the door.
--5) There is three open wire chases, a gap around the magnetic door holder and expandable foam insulation around a sprinkler pipe in Central Supply.
--6) There is an open ventilation duct between Laundry and Kitchen bathroom.
--7) There is an open hole around a pipe and an open wire chase in the Elevator Mechanical room.
--8) There is oil all over the floor of the Elevator Mechanical room.

Staff A is aware of the findings. Staff A stated that the elevator has been leaking oil for some time.

Based on observation and staff interview the facility failed to provide continuous illumination of floors and other walking surfaces within an exit to values of at least 1 ft-candle (10 lux) measured at the floor. Illumination of the means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use. This deficient practice does not insure that exit paths will be illuminated continuously and will delay egress in 2 of 5 smoke zones. The facility has a capacity of 25 and a census of 11.


FINDINGS INCLUDE:

During the tour on 5/5/10 between 11:00am and 3:00pm it is observed the overhead lighting for normal illumination can be turned off with a manual switch in the Treadmill exit stairwell and the West hall exit stairwell.

Staff A is aware of the finding, and was aware the exit stairwells could be left in darkness if lights are turned off.

Based on observation and staff interview the facility failed to provide adequate emergency lighting as required for corridor exiting and exit discharges. The deficient practice could leave the exit path and exit discharge paths without illumination during a disruption of normal power due to the switch being in the off position preventing the fixtures from illuminating in the event of an emergency. This deficiency has the potential of affecting 2 of 5 smoke zones. This facility has a capacity of 25 and a census of 11.

FINDINGS INCLUDE:

During the tour on 5/5/10 between 11:00am and 3:00pm it is observed the light fixtures located in the West stairwell and Treadmill stairway that are used for emergency lighting are connected to the generator and can be turned off with a manual switch.

Staff A is aware of the finding. Staff A noted the exit stairwell lights are connected to the generator.

Based on record review and staff interview the facility fails to assure that fire drills are held at unexpected times under varying conditions. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. The deficient practice could affect 5 of 5 smoke zones. The facility has a capacity of 2 and a census of 11.

FINDINGS INCLUDE:

During the tour on 5/5/10 between 11:00am and 4:00pm it is observed there are no times recorded for fire drills for the 2nd, 3rd and 4th quarter of 2009.

Staff A was present, observed the finding, and acknowledged the cited deficiency during the exit interview with the KSFM surveyor.

Based on observation, record review and staff interview, the facility failed to assure that the fire alarm system required for life safety is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. This deficiency fails to ensure that the fire alarm system control functions are working properly jeopardizing the safety of all building occupants. This deficiency would affect 2 of the 5 smoke zones. This facility has a capacity 25 with a census 11.

FINDINGS INCLUDE:

During the tour on 5/5/10 between 11:00am and 3:00pm it is observed there are two strobes that are not synchronized in the South exit corridor and the Solarium.

Staff A is aware of the finding.

Based on observation and staff interview the facility fails to insure that the automatic sprinkler system is installed in accordance with NFPA 13. The sprinkler system is missing a sprinkler. This deficient practice would not prevent a fire from spreading into the enclosed stairwell. This deficient practice affects 1 of 5 smoke zones. The facility has a capacity of 25 with a census of 11.

FINDINGS INCLUDE:

During the tour on 5/5/10 between 11:00am and 3:00pm it is observed there is no sprinkler protection in the Treadmill exit stairwell. The building is fully sprinkled other than this missing sprinkler.

Staff A is aware of the finding. Staff A stated he was aware there was no sprinkler in the stairwell.

Based on observation and staff interview the facility does not assure that the automatic fire sprinkler system is maintained properly. This deficient practice fails to ensure the fire suppression system will function properly in the event of a fire, affecting 1 of 5 smoke zones. The facility has a capacity of 25 with a census of 11.

FINDINGS INCLUDE:

During the tour on 5/5/10 between 11:00am and 3:00pm the following is observed:

--1) There is lint on sprinklers above the dryers in Laundry.
--2) There is an escutcheon ring missing in OB bath.
--3) There is a sprinkler with a different style in the North hall Linen closet than in the exit corridor. There are no other sprinklers of this type to check if the temperature rating is the same as in the corridor.

Staff A is present and aware of the findings

Based on observation and staff interview the facility fails to assure fire extinguishers are properly installed in accordance with NFPA 10. This deficient practice fails to ensure the extinguishers will be easily accessible in the event of an emergency, affecting 2 of 5 smoke zones. The facility has a capacity of 25 and a census of 11.

FINDINGS INCLUDE:

During the tour on 5/5/10 between 11:00am and 3:00pm the following is observed:

--1) There is a fire extinguisher sitting on the floor in Treadmill room.
--2) There is a fire extinguisher obstructed by surgical supply carts in the Surgical corridor.

Staff A is aware of the findings. Staff A stated staff have been told not to place items in front of fire extinguishers.

Based on observation and staff interview, the facility failed to assure that the smoking area has the proper container with a self-closing lid. This deficient practice fails to ensure that the ashtrays are not being dumped into trashcans with other combustibles, increasing the risk of fire, affecting 1 of 5 smoke zones. The facility has a capacity of 25 with a census of 11.

FINDINGS INCLUDE:

During the tour on 5/5/10 between 11:00am and 3:00pm it is observed there is no metal container with a self closing lid to empty ash trays into.

Staff A is aware of the finding Staff A was unaware a self closing container is required.

Based on observation and staff interview the facility failed to ensure that the means of egress are continuously maintained free of all obstructions or impediments, which would prevent full instant use of the means of egress in the case of a fire or other emergency. This deficiency affects 1 of 5 smoke zones. This facility has a capacity of 25 with a census of 11.

FINDINGS INCLUDE:

During the tour on 5/5/10 between 11:00am and 3:00pm it is observed there are four vending machines in the basement exit corridor.

Staff A is aware of the finding. Staff A stated the vending machines have been in this location for some time.

Based on observation and staff interview, the facility failed to assure that medical gas storage is protected in accordance with NFPA 99, including the storage of combustible items within the location of the oxygen storage area. This deficient practice fails to ensure the proper storage of combustible items, and could cause an empty cylinder to be retrieved in an emergency situation, affecting 1 of 5 smoke zones. The facility has a capacity of 25 with a census of 11.

FINDINGS INCLUDE:

During the tour on 5/5/10 between 11:00am and 3:00pm it is observed there is full and empty oxygen tanks that are not physically separated from each other, and no sign posted for full tanks and for empty tanks in the Surgical storage room.

Staff A was present, observed the finding, and acknowledged the cited deficiency during the exit interview with this KSFM surveyor.

Based on observation and staff interview the facility failed to ensure electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2., including the improper maintenance of and access to the electrical panel. This deficient practice fails to prevent the overheating of the panel and the facility's inability to access the panel in an emergency situation, affecting 2 of the 5 smoke zones. The facility has a capacity of 25 with a census of 11.

FINDINGS INCLUDE:

During the tour on 5/5/10 between 11:00am and 3:00pm the following is observed:

--1) There are three open electrical spaces in electrical panel in Warren Clinic Storage closet and one open space in electrical panel C in the Kitchen.
--2) There is an open junction box in the Surgery Air Handling room.

Staff A is aware of the findings, and stated that the open space in the electrical panel would be covered.

Based on record review and staff interview, the facility fails to assure interior finish for rooms is of a Class A, Class B or Class C flame spread rating. This deficient practice would allow for flames to spread more rapidly across the surfat of the exposed wall treatment, affecting 1 of 5 smoke zones. The facility has a capacity of 25 with a census of 11.

FINDINGS INCLUDE:

During the tour on 5/5/10 between 11:00am and 3:00pm it is observed there is no documentation for the flame spread rating on the paneling in the Administrators basement office.

Staff A is aware of the finding. Staff A stated paneling was removed from other offices after the last KRS fire marshal survey.

Based on observation and staff interview the facility fails to maintain two of three smoke barriers to at least one half hour fire resistance and ensure that all penetrations area properly sealed. This deficient practice would prevent containment of fire and smoke, affecting 3 of 5 smoke zones. This facility has a capacity of 25 and a census of 11.

FINDINGS INCLUDE:

During the tour on 5/5/10 between 11:00am and 3:00pm the following is observed:

--1) There is a penetration around a conduit in the North smoke barrier wall, nurse desk side of wall.
--2) There is an open wire chase in the Solarium smoke barrier wall in the Solarium.

Staff A is aware of the findings and stated a contractor had done work in the Solarium smoke wall.

Based on observation and staff interview, the facility fails to assure barrier doors provide a suitable means for keeping the smoke doors smoke tight. This deficient practice fails to prevent the spread of fire and smoke, affecting 3 of 5 smoke zones. The facility has a capacity of 25 with a census of 11.

FINDINGS INCLUDE:

During the tour on 5/5/10 between 11:00am and 3:00pm it is observed there is a smoke barrier door that is not latching with the provided latching hardware to the North corridor.

Staff A is aware of the finding and stated the door had been functioning when previously checked.

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 spread into adjacent areas, affecting 3 of 5 smoke zones. The facility has a capacity of 25 and a census of 7.

FINDINGS INCLUDE:

During the tour on 5/5/10 between 11:00am and 3:00pm the following is observed:

--1) There is an open wire chase and a gap around three conduits in the basement Cleaning closet.
--2) There is a gap around the sprinkler pipe in the Dry food storage where combustibles are also stored.
--3) The self closing device is not latching to the door frame to the Dry food storage where combustibles are stored.
--4) Room 118 is over 50 sq feet in size, stores combustibles and there is no self closure on the door.
--5) There is three open wire chases, a gap around the magnetic door holder and expandable foam insulation around a sprinkler pipe in Central Supply.
--6) There is an open ventilation duct between Laundry and Kitchen bathroom.
--7) There is an open hole around a pipe and an open wire chase in the Elevator Mechanical room.
--8) There is oil all over the floor of the Elevator Mechanical room.

Staff A is aware of the findings. Staff A stated that the elevator has been leaking oil for some time.

Based on observation and staff interview the facility failed to provide continuous illumination of floors and other walking surfaces within an exit to values of at least 1 ft-candle (10 lux) measured at the floor. Illumination of the means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use. This deficient practice does not insure that exit paths will be illuminated continuously and will delay egress in 2 of 5 smoke zones. The facility has a capacity of 25 and a census of 11.


FINDINGS INCLUDE:

During the tour on 5/5/10 between 11:00am and 3:00pm it is observed the overhead lighting for normal illumination can be turned off with a manual switch in the Treadmill exit stairwell and the West hall exit stairwell.

Staff A is aware of the finding, and was aware the exit stairwells could be left in darkness if lights are turned off.

Based on observation and staff interview the facility failed to provide adequate emergency lighting as required for corridor exiting and exit discharges. The deficient practice could leave the exit path and exit discharge paths without illumination during a disruption of normal power due to the switch being in the off position preventing the fixtures from illuminating in the event of an emergency. This deficiency has the potential of affecting 2 of 5 smoke zones. This facility has a capacity of 25 and a census of 11.

FINDINGS INCLUDE:

During the tour on 5/5/10 between 11:00am and 3:00pm it is observed the light fixtures located in the West stairwell and Treadmill stairway that are used for emergency lighting are connected to the generator and can be turned off with a manual switch.

Staff A is aware of the finding. Staff A noted the exit stairwell lights are connected to the generator.

Based on record review and staff interview the facility fails to assure that fire drills are held at unexpected times under varying conditions. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. The deficient practice could affect 5 of 5 smoke zones. The facility has a capacity of 2 and a census of 11.

FINDINGS INCLUDE:

During the tour on 5/5/10 between 11:00am and 4:00pm it is observed there are no times recorded for fire drills for the 2nd, 3rd and 4th quarter of 2009.

Staff A was present, observed the finding, and acknowledged the cited deficiency during the exit interview with the KSFM surveyor.

Based on observation, record review and staff interview, the facility failed to assure that the fire alarm system required for life safety is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. This deficiency fails to ensure that the fire alarm system control functions are working properly jeopardizing the safety of all building occupants. This deficiency would affect 2 of the 5 smoke zones. This facility has a capacity 25 with a census 11.

FINDINGS INCLUDE:

During the tour on 5/5/10 between 11:00am and 3:00pm it is observed there are two strobes that are not synchronized in the South exit corridor and the Solarium.

Staff A is aware of the finding.

Based on observation and staff interview the facility fails to insure that the automatic sprinkler system is installed in accordance with NFPA 13. The sprinkler system is missing a sprinkler. This deficient practice would not prevent a fire from spreading into the enclosed stairwell. This deficient practice affects 1 of 5 smoke zones. The facility has a capacity of 25 with a census of 11.

FINDINGS INCLUDE:

During the tour on 5/5/10 between 11:00am and 3:00pm it is observed there is no sprinkler protection in the Treadmill exit stairwell. The building is fully sprinkled other than this missing sprinkler.

Staff A is aware of the finding. Staff A stated he was aware there was no sprinkler in the stairwell.

Based on observation and staff interview the facility does not assure that the automatic fire sprinkler system is maintained properly. This deficient practice fails to ensure the fire suppression system will function properly in the event of a fire, affecting 1 of 5 smoke zones. The facility has a capacity of 25 with a census of 11.

FINDINGS INCLUDE:

During the tour on 5/5/10 between 11:00am and 3:00pm the following is observed:

--1) There is lint on sprinklers above the dryers in Laundry.
--2) There is an escutcheon ring missing in OB bath.
--3) There is a sprinkler with a different style in the North hall Linen closet than in the exit corridor. There are no other sprinklers of this type to check if the temperature rating is the same as in the corridor.

Staff A is present and aware of the findings

Based on observation and staff interview the facility fails to assure fire extinguishers are properly installed in accordance with NFPA 10. This deficient practice fails to ensure the extinguishers will be easily accessible in the event of an emergency, affecting 2 of 5 smoke zones. The facility has a capacity of 25 and a census of 11.

FINDINGS INCLUDE:

During the tour on 5/5/10 between 11:00am and 3:00pm the following is observed:

--1) There is a fire extinguisher sitting on the floor in Treadmill room.
--2) There is a fire extinguisher obstructed by surgical supply carts in the Surgical corridor.

Staff A is aware of the findings. Staff A stated staff have been told not to place items in front of fire extinguishers.

Based on observation and staff interview, the facility failed to assure that the smoking area has the proper container with a self-closing lid. This deficient practice fails to ensure that the ashtrays are not being dumped into trashcans with other combustibles, increasing the risk of fire, affecting 1 of 5 smoke zones. The facility has a capacity of 25 with a census of 11.

FINDINGS INCLUDE:

During the tour on 5/5/10 between 11:00am and 3:00pm it is observed there is no metal container with a self closing lid to empty ash trays into.

Staff A is aware of the finding Staff A was unaware a self closing container is required.

Based on observation and staff interview the facility failed to ensure that the means of egress are continuously maintained free of all obstructions or impediments, which would prevent full instant use of the means of egress in the case of a fire or other emergency. This deficiency affects 1 of 5 smoke zones. This facility has a capacity of 25 with a census of 11.

FINDINGS INCLUDE:

During the tour on 5/5/10 between 11:00am and 3:00pm it is observed there are four vending machines in the basement exit corridor.

Staff A is aware of the finding. Staff A stated the vending machines have been in this location for some time.

Based on observation and staff interview, the facility failed to assure that medical gas storage is protected in accordance with NFPA 99, including the storage of combustible items within the location of the oxygen storage area. This deficient practice fails to ensure the proper storage of combustible items, and could cause an empty cylinder to be retrieved in an emergency situation, affecting 1 of 5 smoke zones. The facility has a capacity of 25 with a census of 11.

FINDINGS INCLUDE:

During the tour on 5/5/10 between 11:00am and 3:00pm it is observed there is full and empty oxygen tanks that are not physically separated from each other, and no sign posted for full tanks and for empty tanks in the Surgical storage room.

Staff A was present, observed the finding, and acknowledged the cited deficiency during the exit interview with this KSFM surveyor.

Based on observation and staff interview the facility failed to ensure electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2., including the improper maintenance of and access to the electrical panel. This deficient practice fails to prevent the overheating of the panel and the facility's inability to access the panel in an emergency situation, affecting 2 of the 5 smoke zones. The facility has a capacity of 25 with a census of 11.

FINDINGS INCLUDE:

During the tour on 5/5/10 between 11:00am and 3:00pm the following is observed:

--1) There are three open electrical spaces in electrical panel in Warren Clinic Storage closet and one open space in electrical panel C in the Kitchen.
--2) There is an open junction box in the Surgery Air Handling room.

Staff A is aware of the findings, and stated that the open space in the electrical panel would be covered.