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Based on observations, the facility failed to properly protect corridors from use areas as
directed by NFPA 101 Chapter 19.3.6.2.2. This condition affected 100 % of the residents and staff.

Findings include:

On April 20, 2011 at 3:00 p.m., the maintenance person and surveyor found holes in the corridor walls. The holes were found randomly on every floor and varied in size from small gaps around wires to large holes. Most the holes were above the lay-in ceiling but a large (1 foot x 3 foot) air transfer grill was installed in the corridor wall separating the corridor from the elevator equipment room.

19.3.6.2.1*
Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than one-half (1/2) hour.


19.3.6.2.2*
Corridor walls shall form a barrier to limit the transfer of smoke.

This deficiency was cited during the last survey performed in 2007.

Based on observations, the facility failed to properly protect corridor openings.

This condition had the potential to affect 100 % of the residents and staff.

Findings include:

On April 20, 2011 at 3:10 p.m., the maintenance person and the surveyor found roller latches installed in numerous areas throughout the building.

This deficiency was originally cited during the 2007 survey and has not been completely corrected.

Based on observations and testing, the facility
failed to insure automatic closing of the smoke
barrier doors. This condition affected 100%
of the residents and staff.

Findings include:

On April 20, 2011 at 12:11 p.m., the maintenance person and the surveyor found the found the following problems:

1) The fire and smoke barrier doors located throughout the building were held open by magnetic devices that would not release when the fire alarm was initiated.

2) All three (3) doors to the stairwell on the second (2nd) floor had magnetic locks that would not release upon initiation of the fire alarm.

3) On the first (1st) floor, the stairwell doors by medical records and admissions were locked by magnetic devices that did not release when the fire alarm was initiated.

Based on observations, the facility
failed to properly maintain the door openings in
the smoke barrier walls. This condition affected 100%
of the residents and staff as the dining room was
affected by the deficiency.

Findings Include:

On April 20, 2011 at 3:50 p.m., the maintenance
person and surveyor found the smoke barrier doors
to be held open by magnetic holders that did not
release when the fire alarm was initiated. Additionally,
the door to the kitchen which is part of the smoke barrier
wall, lacked an automatic door closer

Based on observations, the facility failed to
properly protect hazardous areas. This
condition had the potential to affect 50%
of the residents and staff.

Findings include:

On April 20, 2011 between 2:00 p.m. and 4:00 p.m.,
the maintenance person, and surveyor found
the following hazardous to be improperly protected:

1) The elevator equipment room lacked an automatic door
closer, had unsealed penetrations, lacked a 45 minute (min) fire rated
door, and had an air transfer grill built into the wall.

2) The boiler room had unsealed wall penetrations the walls
and lacked a 45 min fire rated door.

3) The mechanical room on the first (1st) floor had unsealed penetrations,
lacked a 45 min fire rated door, and lacked an automatic door closer.

4) Rooms #201, #223, #226, #227, #229, #230, #231, #301 and medical records lacked an automatic door closer, had unsealed penetrations above the lay in ceiling and lacked a 45 min rated door.

Based on interviews and observation, the facility
failed to properly maintain exit egress as per
NFPA 101 chapter 19 .2.2.2.4 and NPFA 101
chapter 7.1.9 This condition had the potential to affect
30% of the residents and staff .

Findings include:

On April 20, 2011 at 11:15 a.m., the maintenance person
and surveyor found the two (2) sets of exit or exit access doors on the second (2nd) floor and the door to the stairwell located in the senior care unit on the second (2nd) floor to have double keyed dead bolt locks installed. The locks were not locked at the time of survey and the maintenance person said they were never locked. Census for the senior care unit was three (3) on the day of survey.

This deficiency was cited during the last survey in 2007

7.1.9 Impediments to Egress.
Any device or alarm installed to restrict the improper use of a means of egress shall be designed and installed so that it cannot, even in case of failure, impede or prevent emergency use of such means of egress unless otherwise provided in 7.2.1.6 and Chapters 18, 19, 22, and 23.

19.2.2.2.4
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.

Based on observation, the facility
failed to provide clear and unobstructed
corridors. This condition affected 100%
of the residents and 50% of the staff .

Findings include:

On February 15, 2011 at 11:00 a.m., the maintenance person
and surveyor found the following corridors to be blocked:

1) The corridor in the senior care unit on the second (2nd) floor had a
Shred-It container located in the hallway.

2) The corridor on the second (2nd) floor in the therapy department
was blocked with chairs, a coat rack, and parallel bars
used to assist in walking.

3) The corridor on the third (3rd) floor near the nurse's station was
blocked with two (2) Shred-It containers and a copying machine.

4) The East Hall Corridor on the second (2nd) floor was blocked with
a desk, file cabinet, and a table.

5) The West Stairwell on the first (1st) floor had eight (8) chairs and five(5) Shred-It containters stored near the exit discharge door.

6) The East Stairwell on the third (3rd) floor was blocked by two (2) backboards and a screen.

7) The West Stairwell on the third (3rd) floor was blocked with two (2) backboards.

Based on observations and testing, the facility failed to provide emergency lighting for at least one and a half (1.5) hours. This condition affected 100% of the residents and staff.

Findings include:

On April 20, 2011 at 11:30 a.m., the generator would not start therefore there was no emergency lighting or power in the building. The maintenance person was unable to get the generator started until 1:11 p.m.

Based on observations, the facility failed to
provide properly displayed exit signs as
required by NFPA 101 7.10.2. This condition
affected 100% of the residents and 50 % of the staff.

Findings include:

On April 20, 2011 at 1:30 a.m., the maintenance
person and surveyor found the area in front of the
elevators on the second (2nd) floor, and the old operating room
on the third (3rd) floor to lack proper exit signage. The path
of exit was not clearly marked.

7.10.2* Directional Signs.

A sign complying with 7.10.3 with a directional indicator
showing the direction of travel shall be placed in every
location where the direction of travel to reach the nearest
exit is not apparent.

Based on interviews and record review, the
facility failed to properly perform fire drills
quarterly for each shift. This condition
affected 100% of the residents and staff.

Findings include:

On April 20, 2011 at 12:06 p.m., the maintenance
person and chief operating officer (hereafter referred to as the C.O.O.) stated that the facility had not performed audible alarms from 6:00 a.m. to 9:00 p.m. since 2008 due to problems resetting the fire alarm panel. The facility's code red drill report form (fire drill reports) indicated that the fire alarm system was being activated routinely
and that the system was operational.

See attached copies of the fire drills.

Based on interviews, the facility failed to provide armed forces Notification for the fire alarm system as required by NFPA 101, Chapter 19 3.4.3.2 and NFPA 101 Chapter 9.6.4.
The condition affected 100% of the residents and staff assigned to the building.

Findings include:

On April 20, 2011 at 12:00 p.m., while preparing to test the fire alarm system, a call was made to the off-site emergency forces notifcation provider. The reason for the call was to place the fire alarm system in test mode so that the system could be tested without notifying fire department. The service provider informed the maintenance person and surveyor that ADT had not had a contract to provide emergency forces notification since 2008. The C. O.O. was asked if she knew of another monitoring company and she stated she did not.

Part 1

Based on interviews and record review, the facility failed to properly maintain the fire alarm system. This condition affected100% of the residents and staff. NFPA 101 9.6.1.4 and NFPA 72 Table 7-3.2.

Findings include:

On April 20, 2011 at 11:40 a.m., the maintenance person could not produce documentation showing that the fire alarm system had received an annual inspection in the last year. The maintenance person stated there hadn't been an annual inspection in the last three (3) or four (4) years.

This deficiency was cited during the last survey in 2007.


Part 2

Based on testing, the facility failed to properly maintain the fire alarm system. This condition affected100% of the residents and staff.

Findings include:

On April 20, 2011 at 12:11 p.m., the fire alarm system was found to be inoperable. The maintenance person attempted to activate the system by activating a manual station located at the main entrance at 12:11 p.m., but the system did not activate in any way. At 12:15 p.m., the manual station at the boiler room was activated but the system did not respond in any way. At 12:19 p.m., the manual station at the north hall exit door in the second (2nd) floor was activated and the system still did not respond. While reviewing documents, the maintenance person stated at 11:35 a.m., that the system had been giving them trouble since 2008 and this was confirmed by the C.O.O. in an interview conducted at 12:06 p.m.

No annual inspection for the fire alarm system could be produced for the last year and the maintenance person stated at 11:35 a.m., that no annual inspection had been performed in three (3) of four (4) years. At 1:21 p.m., interim life safety measures were initiated by maintenance and the C.O.O. At 4:55 p.m., an allegation of compliance was accepted, all interim life safety measures appeared to be in place, and the Immediate Jeopardy was abated.

This situation was considered to be immediately dangerous to life and health.

No harm had occurred but there was potential for more than minimum harm.

Based on record review the facility failed to properly
maintain and test the smoke detectors as required by
NFPA 101 section 9.6.1.3 and NFPA 72 section 7-3.2.1.

The condition affected 100% of the residents and
the staff in the building.

Findings include:

On April 20, 2011 at 11:40 a.m. the maintenance person could not provide any documentation showing that the smoke detectors had ever received sensitivity testing.

This deficiency was cited during the last survey in 2007 and a new fire alarm panel was supposed to be installed by 5-4-07.

7-3.2.1*
Detector sensitivity shall be checked within one (1) 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 five (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.

To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:

(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction

Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.

Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.

Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.

The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Based on observations, the facility failed
to properly maintain fire extinguishers as per
NFPA 10 chapter 4 - 4.1. and 4-3.1 This deficiency
had the potential to affect 100% of the residents and staff.

Findings include:

On April 20, 2011 at 11:15 a.m., the maintenance
person and surveyor found that none of the fire extinguishers
in the building had received an annual inspection since December 2009. Also, no monthly inspections of the extinguishers had been performed since December 2009.

4-4.1 Frequency.
Fire extinguishers shall be subjected to maintenance at intervals of not more than one (1) year, at the time of hydrostatic test, or when specifically indicated by an inspection.

4-3.1* Frequency.
Fire extinguishers shall be inspected when
initially placed in service and thereafter at
approximately 30-day intervals. Fire
extinguishers shall be inspected at more
frequent intervals when circumstances require.

Part 1:

Based on document review, the facility failed to properly maintain the kitchen hood suppression system as per NFPA 17 A 5-3.1 and NFPA 96 8-3.1. This condition had the potential to affect 100%of the residents and staff as the kitchen was open to the dining room.

Findings include:

On April 20, 2011 at 10:35 a.m., the facility was unable to produce documentation that the hood system had been cleaned or inspected since May 2008.

5-3.1*
A trained person who has undergone the instructions necessary to perform the maintenance and recharge service reliably and has the applicable manufacturer's listed installation and maintenance manual and service bulletins shall service the wet chemical fire extinguishing system six (6) months apart as outlined in 5-3.1.1.

8-3.1
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) acceptable to the authority having jurisdiction in accordance with Table 8-3.1.

Table 8-3.1 Exhaust System Inspection Schedule

Type or Volume of Cooking Frequency Frequency

Systems serving solid fuel cooking operations Monthly

Systems serving high-volume cooking
operations such as 24-hour cooking,
charbroiling or wok cooking Quarterly

Systems serving moderate-volume
cooking operations Semiannually

Systems serving low-volume cooking
operations, suchas churches, day camps,
seasonal businesses, or senior Annually
centers


Part 11:

Based on observations, the facility failed to properly protect the kitchen as directed by
NFPA 10 2-3.2 This deficiency had the potential to affect 10% of the staff.

Findings include:

On April 20, 2011 at 10:37 a.m., the facility was found to be lacking a K-class fire
extinguisher in the kitchen.


NFPA 10 2-3.2
Fire extinguishers provided for the protection of cooking appliances that use combustible cooking media (vegetable or animal oils and fats) shall be listed and labeled for Class K fires.

Based on observations, the facility failed to properly protect smoke barrier wall
penetrations. The condition affected 100 % of the residents and staff in the facility.

Findings include:

On April 20, 2011 at 1:00 p.m., the maintenance person and surveyor found three (3) of three (3) smoke barrier walls to have unsealed penetrations. The penetrations were mostly around newly installed wires and along the wall/ceiling junction. Additrionally, the maintenance person could not identify the smoke barrier wall(s) on the first (1st) floor.

This deficiency was cited during the last survey in 2007.

Based on observations and testing, the facility failed to provide an adequate Essential Electrical System as prescribed in NFPA 99 3-4.1.1.8. This condition affected 100% of the residents and staff.

Findings include:

On April 20, 2011 at 11:30 a.m., the maintenance person, could not get the emergency generator to start until 1:11 p.m. The generator failed to start when tried
at 11:57 a.m., and again at 12:27 p.m. Without an operable generator, there is no alternate power source for the essential electrical system in the building. The maintenance person stated at 12:30 p.m., that the generator had been giving him problems since mid March. He also stated that he told the C.O.O. about the problem but nothing had been done to correct the problem. Record review indicated no weekly inspections in April of 2011 and no monthly load tests in March 2011 or December 2010.The maintenance person could not produce documentation that an annual inspection had been done on the generator in the last year and the maintenance person stated at 11:40 a.m., he was not aware of an annual inspection being done in three (3) or four (4) years. The facility was notified of the jeopardy at 2:44 p.m., but the jeopardy was abated at 1:11 p.m., when the generator was repaired and put back into service.

This represented an Immediate Jeopardy to resident health and safety.
No harm had occurred but there was potential for more than minimum harm.

3-4.1.1.2
Essential electrical systems shall have a minimum of two (2) independent sources of power: a normal source generally supplying the entire electrical system and one (1) or more alternate sources for use when the normal source is interrupted.

3-4.1.1.8 + Load Pickup.
The generator set(s) shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. [110: 3-4.1]

Part 1

Based on record review, the facility failed
to properly inspect the generator as required
by NFPA 110 6-4.1 and NFPA 110 figure A-6-3.1.
This condition affected 100% of the residents and staff.

Findings include:

On April 20, 2011 at 11:40 a.m., the documentation
provided by the maintenance person indicated
lapses in the weekly inspections and monthly load
tests. No documentation of weekly inspections
could be produced for the month April 2011. No
documentation of monthly load tests could be
produced for March 2011 or December 2010


Part 2

This standard is not met as evidenced by;

Based on document review, the facility failed
to properly maintain the emergency generator
as per NFPA 110 A-6-3.1.

This condition had the potential to affect 100%
of the maintenance and staff.

Findings include:

On April 20, 2011 at 11:40 a.m., the maintenance
person could not produce documentation showing
that the generator had received an annual inspection.
The maintenance person stated the generator had not
received an annual inspection in three (3) of four (4) years due to a
lack of money.

Based on observations, the facility failed to properly protect corridors from use areas as
directed by NFPA 101 Chapter 19.3.6.2.2. This condition affected 100 % of the residents and staff.

Findings include:

On April 20, 2011 at 3:00 p.m., the maintenance person and surveyor found holes in the corridor walls. The holes were found randomly on every floor and varied in size from small gaps around wires to large holes. Most the holes were above the lay-in ceiling but a large (1 foot x 3 foot) air transfer grill was installed in the corridor wall separating the corridor from the elevator equipment room.

19.3.6.2.1*
Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than one-half (1/2) hour.


19.3.6.2.2*
Corridor walls shall form a barrier to limit the transfer of smoke.

This deficiency was cited during the last survey performed in 2007.

Based on observations, the facility failed to properly protect corridor openings.

This condition had the potential to affect 100 % of the residents and staff.

Findings include:

On April 20, 2011 at 3:10 p.m., the maintenance person and the surveyor found roller latches installed in numerous areas throughout the building.

This deficiency was originally cited during the 2007 survey and has not been completely corrected.

Based on observations and testing, the facility
failed to insure automatic closing of the smoke
barrier doors. This condition affected 100%
of the residents and staff.

Findings include:

On April 20, 2011 at 12:11 p.m., the maintenance person and the surveyor found the found the following problems:

1) The fire and smoke barrier doors located throughout the building were held open by magnetic devices that would not release when the fire alarm was initiated.

2) All three (3) doors to the stairwell on the second (2nd) floor had magnetic locks that would not release upon initiation of the fire alarm.

3) On the first (1st) floor, the stairwell doors by medical records and admissions were locked by magnetic devices that did not release when the fire alarm was initiated.

Based on observations, the facility
failed to properly maintain the door openings in
the smoke barrier walls. This condition affected 100%
of the residents and staff as the dining room was
affected by the deficiency.

Findings Include:

On April 20, 2011 at 3:50 p.m., the maintenance
person and surveyor found the smoke barrier doors
to be held open by magnetic holders that did not
release when the fire alarm was initiated. Additionally,
the door to the kitchen which is part of the smoke barrier
wall, lacked an automatic door closer

Based on observations, the facility failed to
properly protect hazardous areas. This
condition had the potential to affect 50%
of the residents and staff.

Findings include:

On April 20, 2011 between 2:00 p.m. and 4:00 p.m.,
the maintenance person, and surveyor found
the following hazardous to be improperly protected:

1) The elevator equipment room lacked an automatic door
closer, had unsealed penetrations, lacked a 45 minute (min) fire rated
door, and had an air transfer grill built into the wall.

2) The boiler room had unsealed wall penetrations the walls
and lacked a 45 min fire rated door.

3) The mechanical room on the first (1st) floor had unsealed penetrations,
lacked a 45 min fire rated door, and lacked an automatic door closer.

4) Rooms #201, #223, #226, #227, #229, #230, #231, #301 and medical records lacked an automatic door closer, had unsealed penetrations above the lay in ceiling and lacked a 45 min rated door.

Based on interviews and observation, the facility
failed to properly maintain exit egress as per
NFPA 101 chapter 19 .2.2.2.4 and NPFA 101
chapter 7.1.9 This condition had the potential to affect
30% of the residents and staff .

Findings include:

On April 20, 2011 at 11:15 a.m., the maintenance person
and surveyor found the two (2) sets of exit or exit access doors on the second (2nd) floor and the door to the stairwell located in the senior care unit on the second (2nd) floor to have double keyed dead bolt locks installed. The locks were not locked at the time of survey and the maintenance person said they were never locked. Census for the senior care unit was three (3) on the day of survey.

This deficiency was cited during the last survey in 2007

7.1.9 Impediments to Egress.
Any device or alarm installed to restrict the improper use of a means of egress shall be designed and installed so that it cannot, even in case of failure, impede or prevent emergency use of such means of egress unless otherwise provided in 7.2.1.6 and Chapters 18, 19, 22, and 23.

19.2.2.2.4
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.

Based on observation, the facility
failed to provide clear and unobstructed
corridors. This condition affected 100%
of the residents and 50% of the staff .

Findings include:

On February 15, 2011 at 11:00 a.m., the maintenance person
and surveyor found the following corridors to be blocked:

1) The corridor in the senior care unit on the second (2nd) floor had a
Shred-It container located in the hallway.

2) The corridor on the second (2nd) floor in the therapy department
was blocked with chairs, a coat rack, and parallel bars
used to assist in walking.

3) The corridor on the third (3rd) floor near the nurse's station was
blocked with two (2) Shred-It containers and a copying machine.

4) The East Hall Corridor on the second (2nd) floor was blocked with
a desk, file cabinet, and a table.

5) The West Stairwell on the first (1st) floor had eight (8) chairs and five(5) Shred-It containters stored near the exit discharge door.

6) The East Stairwell on the third (3rd) floor was blocked by two (2) backboards and a screen.

7) The West Stairwell on the third (3rd) floor was blocked with two (2) backboards.

Based on observations and testing, the facility failed to provide emergency lighting for at least one and a half (1.5) hours. This condition affected 100% of the residents and staff.

Findings include:

On April 20, 2011 at 11:30 a.m., the generator would not start therefore there was no emergency lighting or power in the building. The maintenance person was unable to get the generator started until 1:11 p.m.

Based on observations, the facility failed to
provide properly displayed exit signs as
required by NFPA 101 7.10.2. This condition
affected 100% of the residents and 50 % of the staff.

Findings include:

On April 20, 2011 at 1:30 a.m., the maintenance
person and surveyor found the area in front of the
elevators on the second (2nd) floor, and the old operating room
on the third (3rd) floor to lack proper exit signage. The path
of exit was not clearly marked.

7.10.2* Directional Signs.

A sign complying with 7.10.3 with a directional indicator
showing the direction of travel shall be placed in every
location where the direction of travel to reach the nearest
exit is not apparent.

Based on interviews and record review, the
facility failed to properly perform fire drills
quarterly for each shift. This condition
affected 100% of the residents and staff.

Findings include:

On April 20, 2011 at 12:06 p.m., the maintenance
person and chief operating officer (hereafter referred to as the C.O.O.) stated that the facility had not performed audible alarms from 6:00 a.m. to 9:00 p.m. since 2008 due to problems resetting the fire alarm panel. The facility's code red drill report form (fire drill reports) indicated that the fire alarm system was being activated routinely
and that the system was operational.

See attached copies of the fire drills.

Based on interviews, the facility failed to provide armed forces Notification for the fire alarm system as required by NFPA 101, Chapter 19 3.4.3.2 and NFPA 101 Chapter 9.6.4.
The condition affected 100% of the residents and staff assigned to the building.

Findings include:

On April 20, 2011 at 12:00 p.m., while preparing to test the fire alarm system, a call was made to the off-site emergency forces notifcation provider. The reason for the call was to place the fire alarm system in test mode so that the system could be tested without notifying fire department. The service provider informed the maintenance person and surveyor that ADT had not had a contract to provide emergency forces notification since 2008. The C. O.O. was asked if she knew of another monitoring company and she stated she did not.

Part 1

Based on interviews and record review, the facility failed to properly maintain the fire alarm system. This condition affected100% of the residents and staff. NFPA 101 9.6.1.4 and NFPA 72 Table 7-3.2.

Findings include:

On April 20, 2011 at 11:40 a.m., the maintenance person could not produce documentation showing that the fire alarm system had received an annual inspection in the last year. The maintenance person stated there hadn't been an annual inspection in the last three (3) or four (4) years.

This deficiency was cited during the last survey in 2007.


Part 2

Based on testing, the facility failed to properly maintain the fire alarm system. This condition affected100% of the residents and staff.

Findings include:

On April 20, 2011 at 12:11 p.m., the fire alarm system was found to be inoperable. The maintenance person attempted to activate the system by activating a manual station located at the main entrance at 12:11 p.m., but the system did not activate in any way. At 12:15 p.m., the manual station at the boiler room was activated but the system did not respond in any way. At 12:19 p.m., the manual station at the north hall exit door in the second (2nd) floor was activated and the system still did not respond. While reviewing documents, the maintenance person stated at 11:35 a.m., that the system had been giving them trouble since 2008 and this was confirmed by the C.O.O. in an interview conducted at 12:06 p.m.

No annual inspection for the fire alarm system could be produced for the last year and the maintenance person stated at 11:35 a.m., that no annual inspection had been performed in three (3) of four (4) years. At 1:21 p.m., interim life safety measures were initiated by maintenance and the C.O.O. At 4:55 p.m., an allegation of compliance was accepted, all interim life safety measures appeared to be in place, and the Immediate Jeopardy was abated.

This situation was considered to be immediately dangerous to life and health.

No harm had occurred but there was potential for more than minimum harm.

Based on record review the facility failed to properly
maintain and test the smoke detectors as required by
NFPA 101 section 9.6.1.3 and NFPA 72 section 7-3.2.1.

The condition affected 100% of the residents and
the staff in the building.

Findings include:

On April 20, 2011 at 11:40 a.m. the maintenance person could not provide any documentation showing that the smoke detectors had ever received sensitivity testing.

This deficiency was cited during the last survey in 2007 and a new fire alarm panel was supposed to be installed by 5-4-07.

7-3.2.1*
Detector sensitivity shall be checked within one (1) 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 five (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.

To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:

(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction

Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.

Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.

Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.

The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Based on observations, the facility failed
to properly maintain fire extinguishers as per
NFPA 10 chapter 4 - 4.1. and 4-3.1 This deficiency
had the potential to affect 100% of the residents and staff.

Findings include:

On April 20, 2011 at 11:15 a.m., the maintenance
person and surveyor found that none of the fire extinguishers
in the building had received an annual inspection since December 2009. Also, no monthly inspections of the extinguishers had been performed since December 2009.

4-4.1 Frequency.
Fire extinguishers shall be subjected to maintenance at intervals of not more than one (1) year, at the time of hydrostatic test, or when specifically indicated by an inspection.

4-3.1* Frequency.
Fire extinguishers shall be inspected when
initially placed in service and thereafter at
approximately 30-day intervals. Fire
extinguishers shall be inspected at more
frequent intervals when circumstances require.

Part 1:

Based on document review, the facility failed to properly maintain the kitchen hood suppression system as per NFPA 17 A 5-3.1 and NFPA 96 8-3.1. This condition had the potential to affect 100%of the residents and staff as the kitchen was open to the dining room.

Findings include:

On April 20, 2011 at 10:35 a.m., the facility was unable to produce documentation that the hood system had been cleaned or inspected since May 2008.

5-3.1*
A trained person who has undergone the instructions necessary to perform the maintenance and recharge service reliably and has the applicable manufacturer's listed installation and maintenance manual and service bulletins shall service the wet chemical fire extinguishing system six (6) months apart as outlined in 5-3.1.1.

8-3.1
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) acceptable to the authority having jurisdiction in accordance with Table 8-3.1.

Table 8-3.1 Exhaust System Inspection Schedule

Type or Volume of Cooking Frequency Frequency

Systems serving solid fuel cooking operations Monthly

Systems serving high-volume cooking
operations such as 24-hour cooking,
charbroiling or wok cooking Quarterly

Systems serving moderate-volume
cooking operations Semiannually

Systems serving low-volume cooking
operations, suchas churches, day camps,
seasonal businesses, or senior Annually
centers


Part 11:

Based on observations, the facility failed to properly protect the kitchen as directed by
NFPA 10 2-3.2 This deficiency had the potential to affect 10% of the staff.

Findings include:

On April 20, 2011 at 10:37 a.m., the facility was found to be lacking a K-class fire
extinguisher in the kitchen.


NFPA 10 2-3.2
Fire extinguishers provided for the protection of cooking appliances that use combustible cooking media (vegetable or animal oils and fats) shall be listed and labeled for Class K fires.

Based on observations, the facility failed to properly protect smoke barrier wall
penetrations. The condition affected 100 % of the residents and staff in the facility.

Findings include:

On April 20, 2011 at 1:00 p.m., the maintenance person and surveyor found three (3) of three (3) smoke barrier walls to have unsealed penetrations. The penetrations were mostly around newly installed wires and along the wall/ceiling junction. Additrionally, the maintenance person could not identify the smoke barrier wall(s) on the first (1st) floor.

This deficiency was cited during the last survey in 2007.

Based on observations and testing, the facility failed to provide an adequate Essential Electrical System as prescribed in NFPA 99 3-4.1.1.8. This condition affected 100% of the residents and staff.

Findings include:

On April 20, 2011 at 11:30 a.m., the maintenance person, could not get the emergency generator to start until 1:11 p.m. The generator failed to start when tried
at 11:57 a.m., and again at 12:27 p.m. Without an operable generator, there is no alternate power source for the essential electrical system in the building. The maintenance person stated at 12:30 p.m., that the generator had been giving him problems since mid March. He also stated that he told the C.O.O. about the problem but nothing had been done to correct the problem. Record review indicated no weekly inspections in April of 2011 and no monthly load tests in March 2011 or December 2010.The maintenance person could not produce documentation that an annual inspection had been done on the generator in the last year and the maintenance person stated at 11:40 a.m., he was not aware of an annual inspection being done in three (3) or four (4) years. The facility was notified of the jeopardy at 2:44 p.m., but the jeopardy was abated at 1:11 p.m., when the generator was repaired and put back into service.

This represented an Immediate Jeopardy to resident health and safety.
No harm had occurred but there was potential for more than minimum harm.

3-4.1.1.2
Essential electrical systems shall have a minimum of two (2) independent sources of power: a normal source generally supplying the entire electrical system and one (1) or more alternate sources for use when the normal source is interrupted.

3-4.1.1.8 + Load Pickup.
The generator set(s) shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. [110: 3-4.1]

Part 1

Based on record review, the facility failed
to properly inspect the generator as required
by NFPA 110 6-4.1 and NFPA 110 figure A-6-3.1.
This condition affected 100% of the residents and staff.

Findings include:

On April 20, 2011 at 11:40 a.m., the documentation
provided by the maintenance person indicated
lapses in the weekly inspections and monthly load
tests. No documentation of weekly inspections
could be produced for the month April 2011. No
documentation of monthly load tests could be
produced for March 2011 or December 2010


Part 2

This standard is not met as evidenced by;

Based on document review, the facility failed
to properly maintain the emergency generator
as per NFPA 110 A-6-3.1.

This condition had the potential to affect 100%
of the maintenance and staff.

Findings include:

On April 20, 2011 at 11:40 a.m., the maintenance
person could not produce documentation showing
that the generator had received an annual inspection.
The maintenance person stated the generator had not
received an annual inspection in three (3) of four (4) years due to a
lack of money.