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Based on observations, the facility had penetrations in the corridors that are not in compliance with NFPA Life Safety Code 101 (00) Sections 19.3.6.2 and 8.2.4.4.1 in resisting the passage of smoke. This deficient practice could affect the exiting of 8 of 16 patients, staff and visitors. In the event of a fire in this space, smoke and fire could spread into the corridor making it untenable.

Findings include:

On facility tour between 9:30 AM to 3:30 PM on 07/10/2012, it was observed that the facility had a 1 inch diameter penetration in the ceiling tile and a missing ceiling tile that are located near the 122 Nurses Station.

This deficient practice was verified by the facility Maintenance staff member (SM).

Based on observation and interview, the facility had a corridor door that did not meet the requirements of NFPA 101 LSC (00) Section 19.3.6.3.6. This deficient practice could affect the safety of all patients, staff and visitors, if smoke from a fire were allowed to enter the exit access corridors making it untenable.

Findings include:

On facility tour between 9:30 AM to 3:30 PM on 07/10/2012, it was observed that several unapproved door hold open devices "wedges" were located throughout the facility and that numerous doors were being held open by these unapproved door hold open devices.

This deficient practice was verified by the facility Maintenance staff member (SM).

Based on observation, the facility failed to maintain 1 of several smoke barrier walls construction that meet the requirements of NFPA 101 - 2000 edition, Sections 19-3.7.3 and 8.3. This deficient practice could affect 8 of 16 patients, staff and visitors by allowing smoke to propagate from one smoke compartment to another.

Findings include:

On facility tour between 9:30 AM to 3:30 PM on 07/10/2012, observation revealed, that there was a one inch gap around a set of wires creating a penetration through the smoke barrier wall located by Room 119.


This deficient practice was verified by the facility Maintenance staff member (SM).

Based on review of reports, records and interview, it was determined that the facility failed accurately document the facility's fire drills and also failed to conduct the required number of fire drill in the last 12-month period. This deficient practice could affect how staff react in the event of a fire. Improper reaction by staff would affect the safety of all patients, visitors and staff.

Findings include:

On facility tour between 9:30 AM to 3:30 PM on 07/10/2012, during a documentation review of the available fire drill reports, and an interview with the maintenance worker (SM), the following deficiencies were revealed:

1. The fire drill for January did not have a year annotated on the report,
2. The fire drill for April did not have a year annotated on the report, and
3. The facility failed to conduct a fire drill in the second quarter for the overnight shift.

This deficient practice was verified by the facility Maintenance staff member (SM).

Based on observation and staff interview, the facility failed to install and maintain the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1999 NFPA 72, Sections 2-3.4.5.1.2, 2-3.5.1. These deficient practices could adversely affect the functioning of the fire alarm system that could delay the timely notification and emergency actions for the facility thus negatively affecting all patients, staff, and visitors of the facility.


Findings include:


On facility tour between 9:30 AM to 3:30 PM on 07/10/2012, the following deficient conditions affecting the facility's fire alarm system were observed:

1. The facility failed to provide current documentation verifying that the annual test/inspection of the facility's fire alarm system has been conducted.

2. The smoke detector head located by Room 130 was installed within 36 inches of a HVAC vent.


This deficient practice was verified by the facility Maintenance staff member (SM).

Based on interview and review of available documentation, the facility has not been conducting sensitivity testing of the smoke detectors on the fire alarm system in accordance with NFPA 72 (99), Sec. 7-3.2.1. This deficient practice could affect all residents, visitors, and staff.

Findings include:

On facility tour between 9:30 AM to 3:30 PM on 07/10/2012, a review of the facility's available fire alarm test documentation revealed that the facility failed to conduct the required sensitivity test of each smoke detector. The last smoke detector sensitivity test was conducted on 12/08/2009.


This deficient practice was verified by the facility Maintenance staff member (SM).

Based on documentation review and interview with staff, the facility has failed to properly inspect and maintain the automatic sprinkler system in accordance with NFPA 101 LSC (00) section 19.7.6, 4.6.12. This deficient practice does not ensure that the fire sprinkler system is functioning properly and is fully operational in the event of a fire and could negatively affect all residents, staff and visitors.

Findings include:

On facility tour between 9:30 AM to 3:30 PM on 07/10/2012, during a review of the available fire sprinkler test and inspection documentation, observations revealed, and were confirmed by an interview with the Facility Maintenance staff member (SM), that the facility failed to provide current documentation for the annual fire sprinkler test/inspection verifying that the facility's fire sprinkler system has been tested and inspected annually.

This deficient practice was verified by the facility Maintenance staff member (SM).

Based on observation and interview with the staff the facility was using extension cords in place of permanent wiring that is not in accordance with NFPA 70 (99), National Electrical Code. This deficient practice could negatively affect all patients, staff and visitors.


Findings include:

On facility tour between 9:00 AM and 3:30 PM on 07/10/2012 observations revealed that the facility was using an extension cord in place of permanent wiring in Room 114 to power a television. The extension cord was also being pinched between a closet door and the metal door frame.

This deficient practice was verified by the facility Maintenance staff member (SM).

Based on observations, the facility had penetrations in the corridors that are not in compliance with NFPA Life Safety Code 101 (00) Sections 19.3.6.2 and 8.2.4.4.1 in resisting the passage of smoke. This deficient practice could affect the exiting of 8 of 16 patients, staff and visitors. In the event of a fire in this space, smoke and fire could spread into the corridor making it untenable.

Findings include:

On facility tour between 9:30 AM to 3:30 PM on 07/10/2012, it was observed that the facility had a 1 inch diameter penetration in the ceiling tile and a missing ceiling tile that are located near the 122 Nurses Station.

This deficient practice was verified by the facility Maintenance staff member (SM).

Based on observation and interview, the facility had a corridor door that did not meet the requirements of NFPA 101 LSC (00) Section 19.3.6.3.6. This deficient practice could affect the safety of all patients, staff and visitors, if smoke from a fire were allowed to enter the exit access corridors making it untenable.

Findings include:

On facility tour between 9:30 AM to 3:30 PM on 07/10/2012, it was observed that several unapproved door hold open devices "wedges" were located throughout the facility and that numerous doors were being held open by these unapproved door hold open devices.

This deficient practice was verified by the facility Maintenance staff member (SM).

Based on observation, the facility failed to maintain 1 of several smoke barrier walls construction that meet the requirements of NFPA 101 - 2000 edition, Sections 19-3.7.3 and 8.3. This deficient practice could affect 8 of 16 patients, staff and visitors by allowing smoke to propagate from one smoke compartment to another.

Findings include:

On facility tour between 9:30 AM to 3:30 PM on 07/10/2012, observation revealed, that there was a one inch gap around a set of wires creating a penetration through the smoke barrier wall located by Room 119.


This deficient practice was verified by the facility Maintenance staff member (SM).

Based on review of reports, records and interview, it was determined that the facility failed accurately document the facility's fire drills and also failed to conduct the required number of fire drill in the last 12-month period. This deficient practice could affect how staff react in the event of a fire. Improper reaction by staff would affect the safety of all patients, visitors and staff.

Findings include:

On facility tour between 9:30 AM to 3:30 PM on 07/10/2012, during a documentation review of the available fire drill reports, and an interview with the maintenance worker (SM), the following deficiencies were revealed:

1. The fire drill for January did not have a year annotated on the report,
2. The fire drill for April did not have a year annotated on the report, and
3. The facility failed to conduct a fire drill in the second quarter for the overnight shift.

This deficient practice was verified by the facility Maintenance staff member (SM).

Based on observation and staff interview, the facility failed to install and maintain the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1999 NFPA 72, Sections 2-3.4.5.1.2, 2-3.5.1. These deficient practices could adversely affect the functioning of the fire alarm system that could delay the timely notification and emergency actions for the facility thus negatively affecting all patients, staff, and visitors of the facility.


Findings include:


On facility tour between 9:30 AM to 3:30 PM on 07/10/2012, the following deficient conditions affecting the facility's fire alarm system were observed:

1. The facility failed to provide current documentation verifying that the annual test/inspection of the facility's fire alarm system has been conducted.

2. The smoke detector head located by Room 130 was installed within 36 inches of a HVAC vent.


This deficient practice was verified by the facility Maintenance staff member (SM).

Based on interview and review of available documentation, the facility has not been conducting sensitivity testing of the smoke detectors on the fire alarm system in accordance with NFPA 72 (99), Sec. 7-3.2.1. This deficient practice could affect all residents, visitors, and staff.

Findings include:

On facility tour between 9:30 AM to 3:30 PM on 07/10/2012, a review of the facility's available fire alarm test documentation revealed that the facility failed to conduct the required sensitivity test of each smoke detector. The last smoke detector sensitivity test was conducted on 12/08/2009.


This deficient practice was verified by the facility Maintenance staff member (SM).

Based on documentation review and interview with staff, the facility has failed to properly inspect and maintain the automatic sprinkler system in accordance with NFPA 101 LSC (00) section 19.7.6, 4.6.12. This deficient practice does not ensure that the fire sprinkler system is functioning properly and is fully operational in the event of a fire and could negatively affect all residents, staff and visitors.

Findings include:

On facility tour between 9:30 AM to 3:30 PM on 07/10/2012, during a review of the available fire sprinkler test and inspection documentation, observations revealed, and were confirmed by an interview with the Facility Maintenance staff member (SM), that the facility failed to provide current documentation for the annual fire sprinkler test/inspection verifying that the facility's fire sprinkler system has been tested and inspected annually.

This deficient practice was verified by the facility Maintenance staff member (SM).

Based on observation and interview with the staff the facility was using extension cords in place of permanent wiring that is not in accordance with NFPA 70 (99), National Electrical Code. This deficient practice could negatively affect all patients, staff and visitors.


Findings include:

On facility tour between 9:00 AM and 3:30 PM on 07/10/2012 observations revealed that the facility was using an extension cord in place of permanent wiring in Room 114 to power a television. The extension cord was also being pinched between a closet door and the metal door frame.

This deficient practice was verified by the facility Maintenance staff member (SM).