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Based on observation and staff interview the facility fails to maintain the integrity of the building construction by allowing penetrations in the ceiling assembly to remain opened. This deficient practice would allow fire products to spread to the attic area, affecting all residents in all three smoke zones. The facility has a capacity of 25 with a census of 5.

Findings include:

During the tour conducted on July 29, 2015 the following is observed:

1. At 10:21 a.m. the custodian room by tub room has a penetration into the ceiling where a small bundle of wires go into the attic space.

2. At 10:48 a.m. a ceiling tile is broken outside room 107.

3. At 10:50 a.m. above both smoke barriers there are multiple penetrations through the wall.

Purchasing Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: One story is permitted with complete sprinkler coverage and one hour rated ceilings for all parts of a facility composed of wood frame construction, type V (111). 2000 NFPA 101, table 19.1.6.2

Review of the following NFPA Standard revealed: Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. The fire protection rating for opening protectives shall be as follows:

(1) 2 hour fire barrier 11/2 hour fire protection rating
(2) 1 hour fire barrier 1 hour fire protection rating where used for vertical openings or exit enclosures, or 3/4 hour fire protection rating where used for other than vertical openings or exit enclosures, unless a lesser fire protection rating is specified by Chapter 7 or Chapters 11 through 42

Exception No. 1: Where the fire barrier specified in 8.2.3.2.3.1(2) is provided as a result of a requirement that corridor walls or smoke barriers be of 1 hour fire resistance rated construction, the opening protectives shall be permitted to have not less than a 20 minute fire protection rating when tested in accordance with NFPA 252, Standard Methods of Fire Tests of Door Assemblies, without the hose stream test.

Exception No. 2: The requirement of 8.2.3.2.3.1(2) shall not apply where special requirements for doors in 1 hour fire resistance rated corridor walls and 1 hour fire resistance rated smoke barriers are specified in Chapters 18 through 21.

Exception No. 3: Existing doors having a 3/4 hour fire protection rating shall be permitted to continue to be used in vertical openings and in exit enclosures in lieu of the 1 hour rating required by 8.2.3.2.3.1(2). (3) 1/2 hour fire barrier 20 minute fire protection rating.

Exception: Twenty minute fire protection rated doors shall be exempt from the hose stream test of NFPA 252, Standard Methods of Fire Tests of Door Assemblies. 2000, NFPA 101, 8.2.3.2.3.1

Based on observation and staff interview the facility fails to maintain one of the barriers to at least one half hour fire resistance and ensure that all penetrations are properly sealed. This deficient practice would prevent containment of fire and smoke, affecting 16 residents in one of three smoke zones. The facility has a capacity of 25 with a census of 5.

Findings include:

During the tour conducted on July 29, 2015 the following is observed:

1. At 10:41 a.m. the east wall of extended care has a penetration around conduit above the ceiling tile.

Purchasing Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: 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

Review of the following NFPA Standard revealed: 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 records review and staff interview the facility failed to ensure that battery powered emergency lighting devices are tested and documented. This deficient practice could result in the lack of lighting during an interruption of power and does not ensure that the light is tested as required, affecting all residents in all three smoke zones. The facility has a capacity of 25 with a census of 5.

Findings include:

During record review and tour on July 29, 2015 the following is observed:

1. There are no records indicating that the battery powered emergency lighting devices are being tested annually for 90 minutes or monthly for 30 seconds.

2. At 9:56 a.m. the emergency light in physical therapy room did not illuminate when tested.

3. At 10:08 a.m. the emergency light in medication room did not illuminate when tested.

Purchasing Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 and 1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 2000 NFPA 101, 7.9.3

Based on record review and staff interview, the facility is not conducting fire drills as required 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, affecting all residents in all three smoke zones. The facility has a capacity of 25 with a census of 5.

Findings include:

During record review on July 29, 2015 the following is observed:

1. Review of fire drill records for the last 5 quarters revealed that no fire drills have been performed during the second shift.

2. Review of the facility's fire drill records for the last 5 quarters revealed that no drill scenarios were used for drills events conducted.


Purchasing Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 2000 NFPA 101, 19.7.1.2

Based on observation and staff interviews, the facility failed to assure that the sprinkler system is installed in accordance with the NFPA 13. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting all residents in all three smoke zones. The facility has a capacity of 25 with a census of 5.

Findings include:

During record review of the annual sprinkler report on July 29, 2015 the following has not been corrected:

1. Room 112 has one sprinkler head that appears to need the hanger adjusted up.

2. Four sprinkler heads in the lab appear to be loaded.

3. Fire room needs to have one sprinkler head added.

4. No quarterly sprinkler inspection testing reports were available.


Purchasing Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. 2000 NFPA 101, 9.7.1.1

Review of the following NFPA Standard revealed: The distance from sprinklers to walls shall not exceed one-half of the allowable distance between sprinklers as indicated in Tables 5-6.2.2(a) through (d). The distance from the wall to the sprinkler shall be measured perpendicular to the wall. Where walls are angled or irregular, the maximum horizontal distance between a sprinkler and any point of floor area protected by that sprinkler shall not exceed 0.75 times the allowable distance permitted between sprinklers, provided the maximum perpendicular distance is not exceeded.

Exception: *Within small rooms as defined in 1-4.2, sprinklers shall be permitted to be located not more than 9 ft. (2.7 m) from any single wall. Sprinkler spacing limitations of 5-6.3 and area limitations of Table 5-6.2.2(a) shall not be exceeded. 1999 NFPA 13, 5-6.3.2.1

Based on record review and staff interview the facility fails to assure fire extinguishers are inspected monthly in accordance with NFPA 10. This deficiency practice fails to ensure that a fire extinguisher will be in proper working condition when needed in the event of a fire emergency, affecting all residents in all three smoke zones. The facility has a capacity of 25 with a census of 5.

Findings include:

During the tour conducted on July 29, 2015 the following is observed:

1. Fire extinguishers throughout the facility are missing monthly check documentation.

2. At 10:54 a.m. it is noted that there is no kitchen class K fire extinguisher available in the facility.

Purchasing Director was present and acknowledged the findings.

Record review of the following NFPA Standard revealed: Fire extinguishers shall be inspected when placed in service and thereafter at approximately 30-day intervals per 1998 NFPA 10, 4-3.1

Review of the following NFPA Standard revealed: Portable fire extinguishers shall be maintained in a fully charged and operable condition, and kept in their designated places at all times when they are not being used. 1998 NFPA 10, 1-6.2

Review of the following NFPA Standard revealed: 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

Review of the following NFPA Standard revealed: Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer ' s instructions. 1998 NFPA 10, 1-6.7

Based on observation and staff interview the facility fails to ensure that all means of egress are free of all obstructions or impediments to a full instant use. This deficient practice could impede occupants from exiting in the event of a fire or other emergency situation, affecting all residents in two of three smoke zones. The facility has a capacity of 25 with a census of 5.

Findings include:

During the tour conducted on July 29, 2015 the following is observed:

1. At 9:42 a.m. the north exit egress corridor is obstructed by a floor machine, wheelchair, racking material, and phone books.

Purchasing Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1

Review of the following NFPA Standard revealed: No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress from, or visibility thereof. 2000 NFPA 101, 7.1.10.2.1

Review of the following NFPA Standard revealed: Exits shall terminate directly at a public way or an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. 2000 NFPA 101, 7.7.1

Based on observation and staff interview, the facility fails to assure that all electrical wiring and equipment is installed and maintained in accordance with the requirements NFPA 70. This deficient practice increases the risk of an electrical fire. The deficient practice could affect all residents in one of three smoke zones. The facility has a capacity of 25 with a census of 5.

Findings include:

During the tour conducted on July 29, 2015 the following is observed:

1. At 9:58 a.m. a daisy chained set of power strips is located in the therapy office.

2. At 10:04 a.m. two extension cords are being used as permanent wiring located in the boiler room.


Purchasing Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction. 2000 NFPA 101, 9.1.2

Review of the following NFPA Standard revealed: Unless specifically permitted, flexible cords and cable shall not be used as a substitute for fixed wiring of a structure. 1999 NFPA 70, 4000-8

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) through (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 the facility fails to maintain the integrity of the building construction by allowing penetrations in the ceiling assembly to remain opened. This deficient practice would allow fire products to spread to the attic area, affecting all residents in all three smoke zones. The facility has a capacity of 25 with a census of 5.

Findings include:

During the tour conducted on July 29, 2015 the following is observed:

1. At 10:21 a.m. the custodian room by tub room has a penetration into the ceiling where a small bundle of wires go into the attic space.

2. At 10:48 a.m. a ceiling tile is broken outside room 107.

3. At 10:50 a.m. above both smoke barriers there are multiple penetrations through the wall.

Purchasing Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: One story is permitted with complete sprinkler coverage and one hour rated ceilings for all parts of a facility composed of wood frame construction, type V (111). 2000 NFPA 101, table 19.1.6.2

Review of the following NFPA Standard revealed: Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. The fire protection rating for opening protectives shall be as follows:

(1) 2 hour fire barrier 11/2 hour fire protection rating
(2) 1 hour fire barrier 1 hour fire protection rating where used for vertical openings or exit enclosures, or 3/4 hour fire protection rating where used for other than vertical openings or exit enclosures, unless a lesser fire protection rating is specified by Chapter 7 or Chapters 11 through 42

Exception No. 1: Where the fire barrier specified in 8.2.3.2.3.1(2) is provided as a result of a requirement that corridor walls or smoke barriers be of 1 hour fire resistance rated construction, the opening protectives shall be permitted to have not less than a 20 minute fire protection rating when tested in accordance with NFPA 252, Standard Methods of Fire Tests of Door Assemblies, without the hose stream test.

Exception No. 2: The requirement of 8.2.3.2.3.1(2) shall not apply where special requirements for doors in 1 hour fire resistance rated corridor walls and 1 hour fire resistance rated smoke barriers are specified in Chapters 18 through 21.

Exception No. 3: Existing doors having a 3/4 hour fire protection rating shall be permitted to continue to be used in vertical openings and in exit enclosures in lieu of the 1 hour rating required by 8.2.3.2.3.1(2). (3) 1/2 hour fire barrier 20 minute fire protection rating.

Exception: Twenty minute fire protection rated doors shall be exempt from the hose stream test of NFPA 252, Standard Methods of Fire Tests of Door Assemblies. 2000, NFPA 101, 8.2.3.2.3.1

Based on observation and staff interview the facility fails to maintain one of the barriers to at least one half hour fire resistance and ensure that all penetrations are properly sealed. This deficient practice would prevent containment of fire and smoke, affecting 16 residents in one of three smoke zones. The facility has a capacity of 25 with a census of 5.

Findings include:

During the tour conducted on July 29, 2015 the following is observed:

1. At 10:41 a.m. the east wall of extended care has a penetration around conduit above the ceiling tile.

Purchasing Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: 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

Review of the following NFPA Standard revealed: 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 records review and staff interview the facility failed to ensure that battery powered emergency lighting devices are tested and documented. This deficient practice could result in the lack of lighting during an interruption of power and does not ensure that the light is tested as required, affecting all residents in all three smoke zones. The facility has a capacity of 25 with a census of 5.

Findings include:

During record review and tour on July 29, 2015 the following is observed:

1. There are no records indicating that the battery powered emergency lighting devices are being tested annually for 90 minutes or monthly for 30 seconds.

2. At 9:56 a.m. the emergency light in physical therapy room did not illuminate when tested.

3. At 10:08 a.m. the emergency light in medication room did not illuminate when tested.

Purchasing Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 and 1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 2000 NFPA 101, 7.9.3

Based on record review and staff interview, the facility is not conducting fire drills as required 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, affecting all residents in all three smoke zones. The facility has a capacity of 25 with a census of 5.

Findings include:

During record review on July 29, 2015 the following is observed:

1. Review of fire drill records for the last 5 quarters revealed that no fire drills have been performed during the second shift.

2. Review of the facility's fire drill records for the last 5 quarters revealed that no drill scenarios were used for drills events conducted.


Purchasing Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 2000 NFPA 101, 19.7.1.2

Based on observation and staff interviews, the facility failed to assure that the sprinkler system is installed in accordance with the NFPA 13. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting all residents in all three smoke zones. The facility has a capacity of 25 with a census of 5.

Findings include:

During record review of the annual sprinkler report on July 29, 2015 the following has not been corrected:

1. Room 112 has one sprinkler head that appears to need the hanger adjusted up.

2. Four sprinkler heads in the lab appear to be loaded.

3. Fire room needs to have one sprinkler head added.

4. No quarterly sprinkler inspection testing reports were available.


Purchasing Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. 2000 NFPA 101, 9.7.1.1

Review of the following NFPA Standard revealed: The distance from sprinklers to walls shall not exceed one-half of the allowable distance between sprinklers as indicated in Tables 5-6.2.2(a) through (d). The distance from the wall to the sprinkler shall be measured perpendicular to the wall. Where walls are angled or irregular, the maximum horizontal distance between a sprinkler and any point of floor area protected by that sprinkler shall not exceed 0.75 times the allowable distance permitted between sprinklers, provided the maximum perpendicular distance is not exceeded.

Exception: *Within small rooms as defined in 1-4.2, sprinklers shall be permitted to be located not more than 9 ft. (2.7 m) from any single wall. Sprinkler spacing limitations of 5-6.3 and area limitations of Table 5-6.2.2(a) shall not be exceeded. 1999 NFPA 13, 5-6.3.2.1

Based on record review and staff interview the facility fails to assure fire extinguishers are inspected monthly in accordance with NFPA 10. This deficiency practice fails to ensure that a fire extinguisher will be in proper working condition when needed in the event of a fire emergency, affecting all residents in all three smoke zones. The facility has a capacity of 25 with a census of 5.

Findings include:

During the tour conducted on July 29, 2015 the following is observed:

1. Fire extinguishers throughout the facility are missing monthly check documentation.

2. At 10:54 a.m. it is noted that there is no kitchen class K fire extinguisher available in the facility.

Purchasing Director was present and acknowledged the findings.

Record review of the following NFPA Standard revealed: Fire extinguishers shall be inspected when placed in service and thereafter at approximately 30-day intervals per 1998 NFPA 10, 4-3.1

Review of the following NFPA Standard revealed: Portable fire extinguishers shall be maintained in a fully charged and operable condition, and kept in their designated places at all times when they are not being used. 1998 NFPA 10, 1-6.2

Review of the following NFPA Standard revealed: 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

Review of the following NFPA Standard revealed: Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer ' s instructions. 1998 NFPA 10, 1-6.7

Based on observation and staff interview the facility fails to ensure that all means of egress are free of all obstructions or impediments to a full instant use. This deficient practice could impede occupants from exiting in the event of a fire or other emergency situation, affecting all residents in two of three smoke zones. The facility has a capacity of 25 with a census of 5.

Findings include:

During the tour conducted on July 29, 2015 the following is observed:

1. At 9:42 a.m. the north exit egress corridor is obstructed by a floor machine, wheelchair, racking material, and phone books.

Purchasing Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1

Review of the following NFPA Standard revealed: No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress from, or visibility thereof. 2000 NFPA 101, 7.1.10.2.1

Review of the following NFPA Standard revealed: Exits shall terminate directly at a public way or an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. 2000 NFPA 101, 7.7.1

Based on observation and staff interview, the facility fails to assure that all electrical wiring and equipment is installed and maintained in accordance with the requirements NFPA 70. This deficient practice increases the risk of an electrical fire. The deficient practice could affect all residents in one of three smoke zones. The facility has a capacity of 25 with a census of 5.

Findings include:

During the tour conducted on July 29, 2015 the following is observed:

1. At 9:58 a.m. a daisy chained set of power strips is located in the therapy office.

2. At 10:04 a.m. two extension cords are being used as permanent wiring located in the boiler room.


Purchasing Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction. 2000 NFPA 101, 9.1.2

Review of the following NFPA Standard revealed: Unless specifically permitted, flexible cords and cable shall not be used as a substitute for fixed wiring of a structure. 1999 NFPA 70, 4000-8

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) through (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