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Based on observation and staff interview, this facility is not assuring that one of three smoke barrier walls is free of penetrations that compromise the fire-resistance rating of the wall and allow the passage of smoke and fire to another smoke zone. This deficient practice affects all occupants including staff, visitors and residents in two of three smoke zones. This facility has a capacity of 25 with a census of 8 residents.

Findings include:

During the tour on 02/13/2012 beginning at 10:00 AM and ending at 4:30 PM it is observed that the 200 hall smoke barrier had two open low voltage penetrations above the ceiling tiles above the exit sign approximately one inch in diameter. According to the facility building diagram, this is a required smoke barrier. This affects all occupants in two of three smoke compartments. The facility has a capacity of 25 and a census of 8.

Maintenance Staff A was present and acknowledged the deficiency.

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

Based upon staff interview and a review of records, the facility fails to assure that fire drills are held at unexpected time under varying conditions. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of an emergency, affecting three of three smoke zones. The facility has a capacity of 25 with a census of 8.

FINDINGS INCLUDE:

During the tour on 2/13/2012 between 10:00 AM and 4:30 PM it is observed that:

1) Fire Drills have not been held at varying times and unexpected conditions evidenced by the fact that three of four 2nd shifts drills were held between 3:05 AP and 3:08 PM.
2) Fire Drills have not been held quarterly per shift as evidenced by the fact that there was not a drill recorded for a 4th quarter second shift fire drill.

Maintenance Staff A, B and Administrative Staff A were present and acknowledged the deficiencies. Staff indicated they thought the 4th quarter drill had been performed but apparently no record had been made.

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

The STANDARD is not met as evidenced by: Based on observation and staff interview, the facility does not prohibit the use of power strips and adapters as a substitute for adequate wiring. These deficient practices could create an electrical injury and fire hazards, affecting all occupants in one of three smoke zones. This facility has a capacity of 25 and a census of 8.

Findings include:

During tour on 02/13/12 between 10:00 AM and 4:30 PM it is observed that the lab had a three way adapter plugged into a two outlet wall receptacle. No items were plugged into the adapter at the time of the inspection.

Maintenance Staff A, B and Administrative Staff A were present and acknowledged the deficiency. The adapter was removed at the time of the inspection.

Record review of the following NFPA Standard revealed: In no case shall the load exceed the branch-circuit ampere rating. An individual branch circuit shall be permitted to supply any load for which it is rated. A branch circuit supplying two or more outlets or receptacles shall supply only the loads specified according to its size as specified in (a) thru (d) and as summarized in Section 210-24. A 15 or 20 ampere branch circuit shall be permitted to supply lighting units or other utilization equipment or a combination of both. The rating of any one cord- and plug-connected utilization equipment shall not exceed 80 percent of the branch-circuit ampere rating. The total rating of utilization equipment fastened in place, other than lighting fixtures, shall not exceed 50 percent of the branch-circuit ampere rating where lighting units, cord- and plug-connected utilization equipment not fastened in place, or both, are also supplied. 1999 NFPA 70, 210-23

Based on observation and staff interview, this facility is not assuring that one of three smoke barrier walls is free of penetrations that compromise the fire-resistance rating of the wall and allow the passage of smoke and fire to another smoke zone. This deficient practice affects all occupants including staff, visitors and residents in two of three smoke zones. This facility has a capacity of 25 with a census of 8 residents.

Findings include:

During the tour on 02/13/2012 beginning at 10:00 AM and ending at 4:30 PM it is observed that the 200 hall smoke barrier had two open low voltage penetrations above the ceiling tiles above the exit sign approximately one inch in diameter. According to the facility building diagram, this is a required smoke barrier. This affects all occupants in two of three smoke compartments. The facility has a capacity of 25 and a census of 8.

Maintenance Staff A was present and acknowledged the deficiency.

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

Based upon staff interview and a review of records, the facility fails to assure that fire drills are held at unexpected time under varying conditions. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of an emergency, affecting three of three smoke zones. The facility has a capacity of 25 with a census of 8.

FINDINGS INCLUDE:

During the tour on 2/13/2012 between 10:00 AM and 4:30 PM it is observed that:

1) Fire Drills have not been held at varying times and unexpected conditions evidenced by the fact that three of four 2nd shifts drills were held between 3:05 AP and 3:08 PM.
2) Fire Drills have not been held quarterly per shift as evidenced by the fact that there was not a drill recorded for a 4th quarter second shift fire drill.

Maintenance Staff A, B and Administrative Staff A were present and acknowledged the deficiencies. Staff indicated they thought the 4th quarter drill had been performed but apparently no record had been made.

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

The STANDARD is not met as evidenced by: Based on observation and staff interview, the facility does not prohibit the use of power strips and adapters as a substitute for adequate wiring. These deficient practices could create an electrical injury and fire hazards, affecting all occupants in one of three smoke zones. This facility has a capacity of 25 and a census of 8.

Findings include:

During tour on 02/13/12 between 10:00 AM and 4:30 PM it is observed that the lab had a three way adapter plugged into a two outlet wall receptacle. No items were plugged into the adapter at the time of the inspection.

Maintenance Staff A, B and Administrative Staff A were present and acknowledged the deficiency. The adapter was removed at the time of the inspection.

Record review of the following NFPA Standard revealed: In no case shall the load exceed the branch-circuit ampere rating. An individual branch circuit shall be permitted to supply any load for which it is rated. A branch circuit supplying two or more outlets or receptacles shall supply only the loads specified according to its size as specified in (a) thru (d) and as summarized in Section 210-24. A 15 or 20 ampere branch circuit shall be permitted to supply lighting units or other utilization equipment or a combination of both. The rating of any one cord- and plug-connected utilization equipment shall not exceed 80 percent of the branch-circuit ampere rating. The total rating of utilization equipment fastened in place, other than lighting fixtures, shall not exceed 50 percent of the branch-circuit ampere rating where lighting units, cord- and plug-connected utilization equipment not fastened in place, or both, are also supplied. 1999 NFPA 70, 210-23