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Based on observation and interview, the facility failed to provide separation from other occupancies in accordance with National Fire Protection Association (NFPA) standards. The deficient practice affected three (3) of six (6) smoke compartments, staff, and all residents. The facility had the capacity for 25 beds with a census of five (5) on the day of survey.

The findings include:

1. Observation, during the building inspection tour on 12/28/2022 at 12:53 PM, revealed an eight (8) by 16 inch hole in the two (2) hour fire wall providing separation between the Long-Term Acute Care Hospital and the Skilled Nursing Facility. Interview, on 12/28/2022 at 12:54 PM with the Chief Operating Officer, revealed the facility was unaware of the penetration.
2. Observation, during the building inspection tour on 12/28/2022 at 01:06 PM, revealed a one (1) inch hole and unsealed duct work penetrating the two (2) hour fire wall located above the multi-purpose room double doors providing separation between the Long-Term Acute Care Hospital and the Skilled Nursing Facility. Interview, on 12/28/2022 at 01:07 PM with the Chief Operating Officer, revealed the facility was unaware of the penetrations.
3. Observation, during the building inspection tour on 12/28/2022 at 01:42 PM, revealed an eight (8) by eight (8) inch hole and an unsealed pipe penetration in the two (2) hour fire wall providing separation between the Long-Term Acute Care Hospital and the Outpatient Waiting Area. Interview, on 12/28/2022 at 01:43 PM with the Chief Operating Officer, revealed the facility was unaware of the penetrations.

The findings were verified by the Chief Operating Officer at the time of observation and the Administrator at the exit conference on 12/28/2022.

Actual NFPA Standard: NFPA 101 Life Safety Code (2012)

Based on observation and interview, it was determined the facility failed to maintain discharge from exits in accordance with National Fire Protection Association (NFPA) standards. The deficient practice had the potential to affect one (1) of six (6) smoke compartments, staff, and 16 residents.

The findings include:

Observation, during the building inspection tour on 12/28/2022 at 01:29 PM, revealed the exit discharge outside the emergency exit by the Administrators Office did not have an all-weather travel surface to the public way. A four (4) foot by four (4) foot concrete pad was located outside changing to grass between the concrete pad and the public way.

Interview, on 12/28/2022 at 12:54 PM with the Chief Operating Officer, revealed the facility was unaware of the requirements for maintaining exit discharges.

The finding was verified by the Chief Operating Officer at the time of observation and the Administrator at the exit conference on 12/28/2022.

Reference: NFPA 101 (2012 edition)

7.1.6.2 Changes in Elevation. Abrupt changes in elevation of walking surfaces shall not exceed 1/4 in. (6.3 mm). Changes in elevation exceeding 1/4 in. (6.3 mm), but not exceeding 1/2 in. (13 mm), shall be beveled with a slope of 1 in 2. Changes in
elevation exceeding 1/2 in. (13 mm) shall be considered a change in level and shall be subject to the requirements of 7.1.7.
7.1.6.3 Level. Walking surfaces shall comply with all of the following:
(1) Walking surfaces shall be nominally level.
(2) The slope of a walking surface in the direction of travel shall not exceed 1 in 20, unless the ramp requirements of 7.2.5 are met.
(3) The slope perpendicular to the direction of travel shall not exceed 1 in 48.

Discharge from Exits Exit discharge is arranged in accor

Based on observation and interview, it was determined the facility failed to ensure smoke barriers could restrict the transfer of smoke in accordance with National Fire Protection Association (NFPA) Standards. The deficient practice affected two (2) of six (6) smoke compartments, staff and 16 residents. The facility had the capacity of 25 beds with a census of five (5) on the day of survey.

The findings include:

Observation, during the building inspection tour on 12/28/2022 at 12:49 PM, revealed the smoke barrier wall located above the cross-corridor doors by room 145A had five (5) unsealed penetrations around wires.

Interview, on 12/28/2022 at 12:50 PM with the Chief Operating Officer, revealed the facility was not aware of the penetrations.

The finding was verified by the Chief Operating Officer at the time of observation and the Administrator at the exit conference on 12/28/2022.

Actual NFPA Standard: NFPA 101, 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1-2-hour fire resistance rating, unless otherwise permitted by one of the following:
(1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply:
(a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c).
(b) Not less than two separate smoke compartments shall be provided on each floor.
(2)%Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating,
and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier.

8.5.6.2 Penetrations for cables, cable tr

Based on observation and interview, the facility failed to locate the annunciator panel in an area that was readily observed by staff in accordance with National Fire Protection Association (NFPA) standards. The deficient practice had the potential to affect six (6) of six (6) smoke compartments, staff, and all residents. The facility had the capacity for 25 beds with a census of five (5) on the day of survey.

Findings include:

Observation, during the building inspection tour on 12/28/2022 at 03:16 PM, revealed the facility failed to install an annunciator panel for both generators to alert staff of alarm conditions with the generators.

Interview, on 12/28/2022 at 03:17 PM with the Chief Operating Officer, revealed the facility was not aware of the requirements for generator annunciator panels.

The finding was verified by the Chief Operating Officer at the time of observation and the Administrator at the exit conference on 12/28/2022.

Actual NFPA Standard: NFPA 99 (2012) 6.4.1.1.17 Alarm Annunciator. A remote annunciator that is storage battery powered shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see 700.12 of NFPA 70, National
Electrical Code). The annunciator shall be hard-wired to indicate alarm conditions of the emergency or auxiliary power source as follows:
(1) Individual visual signals shall indicate the following:
(a) When the emergency or auxiliary power source is operating to supply power to load
(b) When the battery charger is malfunctioning
(2) Individual visual signals plus a common audible signal to warn of an engine generator alarm condition shall indicate the following:
(a) Low lubricating oil pressure
(b) Low water temperature (below that require