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Based on observation and staff interview, the facility failed to assure that corridor doors close tightly to prevent gaps, allowing the spread of smoke and fire. This affects 1 of 4 smoke zones. The facility has a capacity of 29 with a census of 12.

Findings include:

During the tour on 4/16/12 between 12:45 PM and 4:30 PM it is observed the self closer is not latching the door to the door frame to room 160 Electrical room.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Based on observation and staff interview the facility is not assuring that smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone. This deficient practice affects 2 of 4 smoke zones. This facility has a capacity of 29 and a census of 12.

Findings include:

During the tour on 4/16/12 between 12:45 PM and 4:30 PM it is observed there is an open wire chase in the smoke barrier wall by room 175.

Maintenance Staff A was 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

Based on observation and staff interview, the facility fails to assure that barrier doors provide a suitable means for keeping the smoke doors tightly closed. This deficient practice fails to prevent the spread of fire and smoke, affecting 4 of 4 smoke zones. The facility has a capacity of 29 with a census of 12.

Findings include:

During the tour on 4/16/12 between 12:45 PM and 4:30 PM it is observed the panic hardware is sticking and not releasing once the door hardware is pushed in, located at the smoke barrier doors by the Boiler room and by the Maintenance Office.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Requires doors in smoke barriers to be self-closing and have at least a 20-minute rating, 2000 NFPA 101, 19.3.7.6

Based on record review and staff interview, the facility is not conducting fire drills as required quarterly on each shift and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency and affects 4 of 4 smoke zones. The facility has a capacity of 29 with a census of 12.

Findings include:

During the tour on 4/16/12 between 12:45 PM and 4:30 PM it is observed that there is no fire scenario recorded on fire drills dated 5/31/11, 6/28/11, 11/19/11, 12/31/11, 2/27/12 and 3/31/12.

Maintenance Staff A was present and acknowledged 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 record review and staff interview, the facility failed to assure that the sensitivity testing of the smoke detectors was done at the appropriate time, failing to ensure that the smoke detectors will operate within the manufacturer's specifications for the building, affecting all 4 of 4 smoke zones. The facility has a capacity of 29 with a census of 12.

Findings include:

During the tour on 4/16/12 between 12:45 PM and 4:30 PM the following is observed:

--1) The last smoke detector sensitivity was conducted 1/22/10. The facility was due for sensitivity testing in Jan '12. The facility is 3 months past due for the smoke detector sensitivity test.
--2) There is a smoke detector within direct air flow of a ventilation duct in patient room 129. The detector is 22" from the edge of the ventilation duct and 36" from the center of the duct.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Smoke detector sensitivity shall be checked within one 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. 1999 NFPA 72, 7-3.2.1

Based on observation and staff interviews, the facility does not assure that the automatic fire sprinkler system is maintained properly. This deficient practice fails to prevent obstructions to spray patterns, affecting 1 of 4 smoke zones. The facility has a capacity of 29 and a census of 12.

Findings include:

Based on observation on 4/16/12 between 12:45 PM and 4:30 PM it is observed there is a gap around the sprinkler escutcheon in the Nursing Janitor closet.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. 1999 NFPA 13, 12.1

Based on observation and staff interview the facility failed to ensure that portable fire extinguishers are properly mounted. This deficient practice may prevent the portable fire extinguisher from being readily accessible due to difficulty in retrieving it from the mounting bracket, affecting 1 of 4 smoke zones. The facility has a capacity of 29 with a census of 12.

Findings include:

During the tour on 4/16/12 between 12:45 PM and 4:30 PM it is observed the K-type fire extinguisher is mounted higher than 5 ft from the top of the extinguisher in the Kitchen.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas. 1998 NFPA 10, 1-6.3

Based on observation and staff interview the facility failed to ensure that the means of egress are continuously maintained free of all obstructions or impediments, which would prevent full instant use of the means of egress in the case of a fire or other emergency. This deficiency affects 1 of 4 smoke zones. This facility has a capacity of 29 with a census of 12.

Findings include:

During the tour on 4/16/12 between 12:45 PM and 4:30 PM it is observed there is a metal shelf filled with combustible linens in the exit corridor and a 2nd metal rack with nursing supplies stored in the South nursing exit corridor.

Maintenance Staff A was present and acknowledged the finding.

NFPA standards: No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof. 2000 NFPA 101, 7.1.10.2.1

Based on observation and staff interview, the facility failed to assure that corridor doors close tightly to prevent gaps, allowing the spread of smoke and fire. This affects 1 of 4 smoke zones. The facility has a capacity of 29 with a census of 12.

Findings include:

During the tour on 4/16/12 between 12:45 PM and 4:30 PM it is observed the self closer is not latching the door to the door frame to room 160 Electrical room.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Based on observation and staff interview the facility is not assuring that smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone. This deficient practice affects 2 of 4 smoke zones. This facility has a capacity of 29 and a census of 12.

Findings include:

During the tour on 4/16/12 between 12:45 PM and 4:30 PM it is observed there is an open wire chase in the smoke barrier wall by room 175.

Maintenance Staff A was 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

Based on observation and staff interview, the facility fails to assure that barrier doors provide a suitable means for keeping the smoke doors tightly closed. This deficient practice fails to prevent the spread of fire and smoke, affecting 4 of 4 smoke zones. The facility has a capacity of 29 with a census of 12.

Findings include:

During the tour on 4/16/12 between 12:45 PM and 4:30 PM it is observed the panic hardware is sticking and not releasing once the door hardware is pushed in, located at the smoke barrier doors by the Boiler room and by the Maintenance Office.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Requires doors in smoke barriers to be self-closing and have at least a 20-minute rating, 2000 NFPA 101, 19.3.7.6

Based on record review and staff interview, the facility is not conducting fire drills as required quarterly on each shift and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency and affects 4 of 4 smoke zones. The facility has a capacity of 29 with a census of 12.

Findings include:

During the tour on 4/16/12 between 12:45 PM and 4:30 PM it is observed that there is no fire scenario recorded on fire drills dated 5/31/11, 6/28/11, 11/19/11, 12/31/11, 2/27/12 and 3/31/12.

Maintenance Staff A was present and acknowledged 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 record review and staff interview, the facility failed to assure that the sensitivity testing of the smoke detectors was done at the appropriate time, failing to ensure that the smoke detectors will operate within the manufacturer's specifications for the building, affecting all 4 of 4 smoke zones. The facility has a capacity of 29 with a census of 12.

Findings include:

During the tour on 4/16/12 between 12:45 PM and 4:30 PM the following is observed:

--1) The last smoke detector sensitivity was conducted 1/22/10. The facility was due for sensitivity testing in Jan '12. The facility is 3 months past due for the smoke detector sensitivity test.
--2) There is a smoke detector within direct air flow of a ventilation duct in patient room 129. The detector is 22" from the edge of the ventilation duct and 36" from the center of the duct.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Smoke detector sensitivity shall be checked within one 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. 1999 NFPA 72, 7-3.2.1

Based on observation and staff interviews, the facility does not assure that the automatic fire sprinkler system is maintained properly. This deficient practice fails to prevent obstructions to spray patterns, affecting 1 of 4 smoke zones. The facility has a capacity of 29 and a census of 12.

Findings include:

Based on observation on 4/16/12 between 12:45 PM and 4:30 PM it is observed there is a gap around the sprinkler escutcheon in the Nursing Janitor closet.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. 1999 NFPA 13, 12.1

Based on observation and staff interview the facility failed to ensure that portable fire extinguishers are properly mounted. This deficient practice may prevent the portable fire extinguisher from being readily accessible due to difficulty in retrieving it from the mounting bracket, affecting 1 of 4 smoke zones. The facility has a capacity of 29 with a census of 12.

Findings include:

During the tour on 4/16/12 between 12:45 PM and 4:30 PM it is observed the K-type fire extinguisher is mounted higher than 5 ft from the top of the extinguisher in the Kitchen.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas. 1998 NFPA 10, 1-6.3

Based on observation and staff interview the facility failed to ensure that the means of egress are continuously maintained free of all obstructions or impediments, which would prevent full instant use of the means of egress in the case of a fire or other emergency. This deficiency affects 1 of 4 smoke zones. This facility has a capacity of 29 with a census of 12.

Findings include:

During the tour on 4/16/12 between 12:45 PM and 4:30 PM it is observed there is a metal shelf filled with combustible linens in the exit corridor and a 2nd metal rack with nursing supplies stored in the South nursing exit corridor.

Maintenance Staff A was present and acknowledged the finding.

NFPA standards: No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof. 2000 NFPA 101, 7.1.10.2.1