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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 June 30, 2011 between 11:00 a.m. and 2:00 p.m., the maintenance person and surveyor found holes in the corridor walls above the suspended ceiling. The holes were found randomly on every floor and were typically small in size. Many of the holes had been improperly sealed with a packing material that did not give the proper fire rating.

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 1/2 hour.


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

Note: 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 June 30, 2011 at 11:00 a.m., the maintenance person and surveyor found numerous doors that opened to the corridor to be lacking a suitable means for keeping the door closed. Numerous rooms still had roller latches installed.

In other areas, the roller latches had been removed but an approved positive latching device had not been installed. Non- approved key operated deadbolts had been installed but that does not meet the requirement.

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 June 30, 2011 at 2:40 p.m., the maintenance person and the surveyor observed the following:

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 2nd floor had magnetic locks that would not release upon initiation of the fire alarm.
3) On the first floor, the stairwell doors by Medical Records and Admissions were locked closed 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 June 30, 2011 at 2:40 p.m., the maintenance person and surveyor found the smoke barrier doors to be held open by magnetic locks that did not release when the fire alarm was initiated. Additionally, the door to the kitchen which is part of the smoke barrier wall was held open by a wedge under the door.

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 June 30, 2011 between 10:00 a.m. and 12:00 p.m., the maintenance person, and surveyor found the following hazardous areas to be improperly protected;

1) The elevator equipment room had improperly sealed penetrations and lacked a 45 min. rated
door, and had an air grate built into the wall.
2) The mechanical room on the 1st floor had unsealed penetrations and lacked a 45 min rated door.
3) Rooms 223,225,226,228,229,230, and 301 and Medical Records lacked an automatic door closer, had unsealed penetrations above the suspended 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 NFPA 101 chapter 7.1.9. This condition had the potential to affect 30% of the residents and staff .

Findings Include:

On June 30, 2011 at 11:15 a.m., the maintenance person and surveyor found the two (2) sets of traffic control doors on the 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.


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 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. This condition affected 100% of the residents and staff assigned to the building.

Findings Include:

On June 30, 2011 at 2:30 p.m., the maintenance person stated that due to complications with the fire alarm system no monitoring of the system was being performed. A proposal for the monitoring was provided but no monitoring could be done until a new fire alarm panel was installed.

Part 1
Based on interviews and record review, the facility failed to properly maintain the fire alarm system. This condition affected 100% of the residents and staff. NFPA 101 9.6.1.4 and NFPA 72 Table 7-3.2.


Findings Include:

On June 30, 2011 at 1:42 p.m., the maintenance person could not produce documentation showing that the fire alarm system had received an annual inspection in the last year.


Part 2
Based on testing, the facility failed to properly maintain the fire alarm system. This condition affected 100% of the residents and staff.


Findings Include:

On June 30, 2011 at 2:35 p.m., the fire alarm system was found to have numerous problems. The manual stations on the third floor were totally inoperable. The manual station in the Boiler Room on the first floor did set off the horns and strobes when activated but the exit doors and smoke doors that were held open by magnetic devices did not release. The manual station on the 2nd floor South Hall set off the system when activated but the magnets on the doors did not release. The manual station on the 2nd floor East Hall released the magnets when pulled but some of the strobes and horns did not activate.

A fire watch was started immediately upon learning of the problems.

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

Findings Include:

On June 30, 2011 at 1:40 p.m., the maintenance person could not provide any documentation showing that the smoke detectors had ever received sensitivity testing.

7-3.2.1*
Detector sensitivity shall be checked within 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 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 protect smoke barrier wall penetrations. The condition affected 100 % of the residents and staff in the facility.

Findings Include:

On June 30, 2011 between 11:30 a.m. and 2:00 p.m., the maintenance person and surveyor found 3 of 3 smoke barrier walls checked to have unsealed penetrations. The penetrations were mostly around wires and along the top seam of the wall.

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 June 30, 2011 at 1:45 p.m., the maintenance person could not produce documentation showing that the generator had received an annual inspection. Additionally, the generator failed to crank and transfer load within the allotted 10 second time period.