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Based on observation and interview the facility failed to assure that smoke walls were properly sealed. This deficient practice may cause fire/smoke to travel to adjacent smoke zones. This will affect 2 out of 15 smoke zones in the building. This facility has a capacity of 25 with a census of 9 residents at the time of the survey. Findings include:

During the tour on 8/10/11 from 9:00 AM to 2:00 PM it was found that the basement smoke wall above the corridor double doors has an open penetration where the internet cable and fire wire. Also expandable foam was used as a sealant in this area.

Staff M and S were present and acknowledged the finding.

NFPA Standard: 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

NFPA Standard: 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

Based on record review and interview the facility failed to assure that fire drills are completed on each shift per quarter of the year. This deficient practice may cause a delay in exiting if staff is not trained. This will affect all 15 smoke zones in the building. This facility has a capacity of 25 with a census of 9 residents at the time of the survey.

Findings include:

During the tour on 8/10/11 from 9:00 AM to 2:00 PM it was found that no fire drill was completed for the 1st shift of the 1st quarter of 2011.

Staff M and S were present and aware of the finding.

NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 19.7.1.2

Based on observation and interview the facility failed to assure that flammable paint is properly stored. This deficient practice may cause a fire. This will affect 1 out of 1 smoke zones in the energy center building. The hospital facility has a capacity of 25 with a census of 9 residents at the time of the survey.

Findings include:

During the tour on 8/10/11 from 9:00 AM to 2:00 PM it was found that 5 containers (5 gallons) marked "flammable" were stored in the boiler room.

Staff M and S were present and acknowledged the finding.

Standard: Dispensers shall not be installed in a corridor that is under 6 feet wide; the maximum dispenser capacity for rooms, corridors and areas open to the corridor is 1.2 liters (2.0 liters in suites of rooms); the minimum horizontal spacing shall be 4 feet; not more than 37.8 liters shall be mounted within a smoke compartment; storage of quantities greater than 5 gallons (18.9 liters) in a single smoke compartment shall meet the requirements of NFPA 30; dispensers installed directly over carpeted surfaces shall be permitted only in sprinklered smoke compartments; and the dispensers shall not be installed over or directly adjacent to an ignition source. Centers for Medicare & Medicaid Services, 42 CFR Parts 403, 416, 418, 460, 482, 483, and 485, [CMS-3145-IFC], RIN 0938-AN36, Medicare and Medicaid Programs; Fire Safety Requirements Federal Register, Vol. 70, No. 57, Friday, March 25, 2005 42 CFR 483.70 (a) (7)

Based on observation and interview the facility failed to assure that extension cords are not used for replacing permanent electrical wiring. This deficient practice may cause smoke/fire. This will affect 1 out of 1 smoke zones in the energy building. This facility has a capacity of 25 with a census of 9 residents at the time of the survey.

Findings include:

During the tour on 8/10/11 from 9:00 AM to 2:00 PM it was found that the water softener is powered with an extension cord.

Staff M and S were present and acknowledged the finding.

NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8

Based on observation and interview the facility failed to assure that smoke walls were properly sealed. This deficient practice may cause fire/smoke to travel to adjacent smoke zones. This will affect 2 out of 15 smoke zones in the building. This facility has a capacity of 25 with a census of 9 residents at the time of the survey. Findings include:

During the tour on 8/10/11 from 9:00 AM to 2:00 PM it was found that the basement smoke wall above the corridor double doors has an open penetration where the internet cable and fire wire. Also expandable foam was used as a sealant in this area.

Staff M and S were present and acknowledged the finding.

NFPA Standard: 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

NFPA Standard: 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

Based on record review and interview the facility failed to assure that fire drills are completed on each shift per quarter of the year. This deficient practice may cause a delay in exiting if staff is not trained. This will affect all 15 smoke zones in the building. This facility has a capacity of 25 with a census of 9 residents at the time of the survey.

Findings include:

During the tour on 8/10/11 from 9:00 AM to 2:00 PM it was found that no fire drill was completed for the 1st shift of the 1st quarter of 2011.

Staff M and S were present and aware of the finding.

NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 19.7.1.2

Based on observation and interview the facility failed to assure that flammable paint is properly stored. This deficient practice may cause a fire. This will affect 1 out of 1 smoke zones in the energy center building. The hospital facility has a capacity of 25 with a census of 9 residents at the time of the survey.

Findings include:

During the tour on 8/10/11 from 9:00 AM to 2:00 PM it was found that 5 containers (5 gallons) marked "flammable" were stored in the boiler room.

Staff M and S were present and acknowledged the finding.

Standard: Dispensers shall not be installed in a corridor that is under 6 feet wide; the maximum dispenser capacity for rooms, corridors and areas open to the corridor is 1.2 liters (2.0 liters in suites of rooms); the minimum horizontal spacing shall be 4 feet; not more than 37.8 liters shall be mounted within a smoke compartment; storage of quantities greater than 5 gallons (18.9 liters) in a single smoke compartment shall meet the requirements of NFPA 30; dispensers installed directly over carpeted surfaces shall be permitted only in sprinklered smoke compartments; and the dispensers shall not be installed over or directly adjacent to an ignition source. Centers for Medicare & Medicaid Services, 42 CFR Parts 403, 416, 418, 460, 482, 483, and 485, [CMS-3145-IFC], RIN 0938-AN36, Medicare and Medicaid Programs; Fire Safety Requirements Federal Register, Vol. 70, No. 57, Friday, March 25, 2005 42 CFR 483.70 (a) (7)

Based on observation and interview the facility failed to assure that extension cords are not used for replacing permanent electrical wiring. This deficient practice may cause smoke/fire. This will affect 1 out of 1 smoke zones in the energy building. This facility has a capacity of 25 with a census of 9 residents at the time of the survey.

Findings include:

During the tour on 8/10/11 from 9:00 AM to 2:00 PM it was found that the water softener is powered with an extension cord.

Staff M and S were present and acknowledged the finding.

NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8