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Based on observation and staff interview the facility fails to provide doors that are self-closing or automatically closing in a smoke barrier. The deficient practice of not providing self-closing or automatically closing doors in a smoke barrier would prevent the door from closing as required allowing smoke and fire product to spread beyond the smoke barrier more rapidly, affecting four of seven smoke zones. This facility has a capacity of 54 and census of 29.

Findings Include:

During the survey on 09/05/2012 between 9:00 AM and 3:15 PM the following is observed:

1. The smoke barrier door by the admissions office has an approximate 1/4 inch gap at the top of the door. The north door is sagging.

2. The smoke barrier doors by the CT Scanner area do not close completely.

Maintenance Staff A was present and acknowledged the findings.

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 observation and staff interview the facility failed to ensure proper separation of hazardous areas from other spaces. This deficient practice would allow for the spread of smoke and fire to travel into the adjacent area, affecting one of seven smoke zones. The facility has a capacity of 54 with a census of 29 at the time of survey.

Findings Include:

During the survey on 09/05/2012 between 9:00 AM and 3:15 PM the following is observed:

1. The door to electrical room 02 does not self latch and close completely.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1.

NFPA Standard: Protection from any area having a degree of hazard greater than that normal to the general occupancy of the
building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1 hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42. 2000 NFPA 101, 8.4.1.

Based on records review and staff interview the facility failed to ensure that battery powered emergency lighting is tested and documented. This deficient practice could result in the lights not operating for the minimum required time in the event of an emergency, affecting seven of seven smoke zones. The facility has a capacity of 54 and a census of 29 at the time of the survey.

Findings Include:

During the survey on 09/05/2012 between 9:00 AM and 3:15 PM the following is observed:

1. There was no documentation of emergency light tests for a period of January 2012 through August 2012.

Administrative Staff A and Maintenance Staff A were present and acknowledged the finding.

NFPA Standard: 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 and 7.10.9

Based on observation and interview, the facility fails to ensure that smoking materials are discarded properly. This deficient practice increases the risk of fire to one of seven smoke zones. The facility census is 54 with a capacity of 29.

Findings Include:

During the survey on 09/05/2012 between 9:00 AM and 3:15 PM the following is observed:

1. There is discarded smoking material in the trash receptacle.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Smoking. Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or
oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read
NO SMOKING or shall be posted with the international symbol for no smoking.
Exception: In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(2) Smoking by patients classified as not responsible shall be prohibited.
Exception: The requirement of 19.7.4(2) shall not apply where the patient is under direct supervision.
(3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available
to all areas where smoking is permitted. 2000 NFPA 101, Section 19.7.4.

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 all occupants from exiting in the event of a fire or other emergency situation, affecting two of seven smoke zones. This facility has a capacity of 54 and a census of 29 at the time of the survey.

Findings Include:

During the survey on 09/05/2012 between 9:00 AM and 3:15 PM the following is observed:

1. Two beds were being stored in the exit corridor by the CT Scanner area - the beds were at this location during the duration of the inspection.

2. Walkers, IV, and Vitals carts were being stored in the corridors throughout the 100 patient halls.

Maintenance Staff A was present and acknowledged the findings.

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

NFPA Standard: 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.

Based on observation and staff interview, the facility failed to assure the proper storage of oxygen tanks. This deficient practice does not assure that medical gas storage is protected in accordance with NFPA 99, affecting one of seven smoke zones. The facility has a capacity of 54 with a census of 29 residents.

Findings Include:

During the survey on 09/05/2012 between 9:00 AM and 3:15 PM the following is observed:

1. One portable oxygen cylinder is unsecured in the oxygen storage room 02.

Maintenance Staff A was present and acknowledged the finding. The cylinder was secured at time of discovery.

NFPA Standard: Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation. 1999 NFPA 99, 4.3.1.1.2

Based on observation and staff interview the facility fails to provide doors that are self-closing or automatically closing in a smoke barrier. The deficient practice of not providing self-closing or automatically closing doors in a smoke barrier would prevent the door from closing as required allowing smoke and fire product to spread beyond the smoke barrier more rapidly, affecting four of seven smoke zones. This facility has a capacity of 54 and census of 29.

Findings Include:

During the survey on 09/05/2012 between 9:00 AM and 3:15 PM the following is observed:

1. The smoke barrier door by the admissions office has an approximate 1/4 inch gap at the top of the door. The north door is sagging.

2. The smoke barrier doors by the CT Scanner area do not close completely.

Maintenance Staff A was present and acknowledged the findings.

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 observation and staff interview the facility failed to ensure proper separation of hazardous areas from other spaces. This deficient practice would allow for the spread of smoke and fire to travel into the adjacent area, affecting one of seven smoke zones. The facility has a capacity of 54 with a census of 29 at the time of survey.

Findings Include:

During the survey on 09/05/2012 between 9:00 AM and 3:15 PM the following is observed:

1. The door to electrical room 02 does not self latch and close completely.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1.

NFPA Standard: Protection from any area having a degree of hazard greater than that normal to the general occupancy of the
building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1 hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42. 2000 NFPA 101, 8.4.1.

Based on records review and staff interview the facility failed to ensure that battery powered emergency lighting is tested and documented. This deficient practice could result in the lights not operating for the minimum required time in the event of an emergency, affecting seven of seven smoke zones. The facility has a capacity of 54 and a census of 29 at the time of the survey.

Findings Include:

During the survey on 09/05/2012 between 9:00 AM and 3:15 PM the following is observed:

1. There was no documentation of emergency light tests for a period of January 2012 through August 2012.

Administrative Staff A and Maintenance Staff A were present and acknowledged the finding.

NFPA Standard: 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 and 7.10.9

Based on observation and interview, the facility fails to ensure that smoking materials are discarded properly. This deficient practice increases the risk of fire to one of seven smoke zones. The facility census is 54 with a capacity of 29.

Findings Include:

During the survey on 09/05/2012 between 9:00 AM and 3:15 PM the following is observed:

1. There is discarded smoking material in the trash receptacle.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Smoking. Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or
oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read
NO SMOKING or shall be posted with the international symbol for no smoking.
Exception: In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(2) Smoking by patients classified as not responsible shall be prohibited.
Exception: The requirement of 19.7.4(2) shall not apply where the patient is under direct supervision.
(3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available
to all areas where smoking is permitted. 2000 NFPA 101, Section 19.7.4.

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 all occupants from exiting in the event of a fire or other emergency situation, affecting two of seven smoke zones. This facility has a capacity of 54 and a census of 29 at the time of the survey.

Findings Include:

During the survey on 09/05/2012 between 9:00 AM and 3:15 PM the following is observed:

1. Two beds were being stored in the exit corridor by the CT Scanner area - the beds were at this location during the duration of the inspection.

2. Walkers, IV, and Vitals carts were being stored in the corridors throughout the 100 patient halls.

Maintenance Staff A was present and acknowledged the findings.

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

NFPA Standard: 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.

Based on observation and staff interview, the facility failed to assure the proper storage of oxygen tanks. This deficient practice does not assure that medical gas storage is protected in accordance with NFPA 99, affecting one of seven smoke zones. The facility has a capacity of 54 with a census of 29 residents.

Findings Include:

During the survey on 09/05/2012 between 9:00 AM and 3:15 PM the following is observed:

1. One portable oxygen cylinder is unsecured in the oxygen storage room 02.

Maintenance Staff A was present and acknowledged the finding. The cylinder was secured at time of discovery.

NFPA Standard: Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation. 1999 NFPA 99, 4.3.1.1.2