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Based on interview and observation, the facility failed to maintain the building free of penetrations, as evidenced by a cut out of the smoke barrier wall that was covered over with plastic and blue painters tape. This deficient condition affected one of two smoke compartments and could result in the passage of smoke from one part of the facility to another in the event of a fire.

Findings:

During a tour of the facility with maintenance staff, on 9/27/11, the facility walls and ceilings were observed. At 9:30 a.m., by the nursing station, there were six tiles missing from the ceiling and a 4"X 4" penetration in the smoke barrier wall above the fire doors. The openings were closed with plastic held up by blue painters tape.
During an interview, staff stated that the work had been completed by that the tiles for the ceiling had not been replaced and that the opening had not been sealed.

Based on observation and document review, the facility failed to maintain the portable fire extinguishers as evidenced by the fire extinguisher in the laundry area that was obstructed. This deficient condition affected 1 of 2 smoke compartments and could result in a delay of access of the extinguisher in the event of a fire.

NFPA 10 Standard for Portable Fire Extinguishers, 1998 edition
1-6.6 Fire extinguishers shall not be obstructed or obscured from view.
Exception: In large rooms, and in certain locations where visual obstruction cannot be completely avoided, means shall be provided to indicate the location.
4-3.2 Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or "hefting"
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

Findings:

During a tour of the facility with a staff member on 9/27/11, the facility fire extinguishers were observed. At 9:38 a.m., the fire extinguisher in the laundry area was mounted approximately 4 feet off the floor and was blocked by the dryer and a laundry basket full of clothes that was placed on top of the dryer.

Based on observation, and staff interview, the facility failed to maintain the generator as evidenced by no alarm annunciator panel to notify the facility in the event a generator malfunction. This deficient practice affected two of two smoke compartments and could result in the malfunctioning of the generator in the event of a primary emergency power loss without staff knowledge.

NFPA 99, Health Care Facilities, 1999 Edition
3-4.1.1.15 Alarm Annunciator. A remote annunciator, 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 NFPA 70, National Electrical code, Section 700-12.)

The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:

(a) Individual visual signals shall indicate the following:
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed

Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15 (a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]


Findings:

During a tour of the facility with a staff member on 9/27/11, the generator was observed. At 11:10 a.m., no remote annunciator panel was observed in the facility.

Upon interview with maintenance staff, staff stated that there was an annunciator panel in the facility but that they could not locate the panel. Staff e-mailed photos of the annunciator panel when it was located. Staff confirmed that the panel is not located in a regular work area. The annunciator panel is located in the basement of the building next to Koret and is not in a 24 hour manned area. The annunciator panel does not have the capability to communicate with staff outside of the immediate area.

Based on interview and observation, the facility failed to maintain the building free of penetrations, as evidenced by a cut out of the smoke barrier wall that was covered over with plastic and blue painters tape. This deficient condition affected one of two smoke compartments and could result in the passage of smoke from one part of the facility to another in the event of a fire.

Findings:

During a tour of the facility with maintenance staff, on 9/27/11, the facility walls and ceilings were observed. At 9:30 a.m., by the nursing station, there were six tiles missing from the ceiling and a 4"X 4" penetration in the smoke barrier wall above the fire doors. The openings were closed with plastic held up by blue painters tape.
During an interview, staff stated that the work had been completed by that the tiles for the ceiling had not been replaced and that the opening had not been sealed.

Based on observation and document review, the facility failed to maintain the portable fire extinguishers as evidenced by the fire extinguisher in the laundry area that was obstructed. This deficient condition affected 1 of 2 smoke compartments and could result in a delay of access of the extinguisher in the event of a fire.

NFPA 10 Standard for Portable Fire Extinguishers, 1998 edition
1-6.6 Fire extinguishers shall not be obstructed or obscured from view.
Exception: In large rooms, and in certain locations where visual obstruction cannot be completely avoided, means shall be provided to indicate the location.
4-3.2 Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or "hefting"
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

Findings:

During a tour of the facility with a staff member on 9/27/11, the facility fire extinguishers were observed. At 9:38 a.m., the fire extinguisher in the laundry area was mounted approximately 4 feet off the floor and was blocked by the dryer and a laundry basket full of clothes that was placed on top of the dryer.

Based on observation, and staff interview, the facility failed to maintain the generator as evidenced by no alarm annunciator panel to notify the facility in the event a generator malfunction. This deficient practice affected two of two smoke compartments and could result in the malfunctioning of the generator in the event of a primary emergency power loss without staff knowledge.

NFPA 99, Health Care Facilities, 1999 Edition
3-4.1.1.15 Alarm Annunciator. A remote annunciator, 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 NFPA 70, National Electrical code, Section 700-12.)

The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:

(a) Individual visual signals shall indicate the following:
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed

Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15 (a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]


Findings:

During a tour of the facility with a staff member on 9/27/11, the generator was observed. At 11:10 a.m., no remote annunciator panel was observed in the facility.

Upon interview with maintenance staff, staff stated that there was an annunciator panel in the facility but that they could not locate the panel. Staff e-mailed photos of the annunciator panel when it was located. Staff confirmed that the panel is not located in a regular work area. The annunciator panel is located in the basement of the building next to Koret and is not in a 24 hour manned area. The annunciator panel does not have the capability to communicate with staff outside of the immediate area.