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Based on observation and staff interview the facility is not ensuring that room doors latch properly. This deficient practice of not ensuring that room doors latch properly prevents the ability of the facility to properly confine fire and smoke products and to properly defend occupants in place, affecting one of five smoke zones on the 3nd floor and one of four smoke zones on the 3rd floor. The facility has 21 smoke zones on four floors total. The facility has a capacity of 69 with a census of 31 at the time of survey.

Findings Include:

During the tour on 04/04/2011 between 9:15 AM and 5:00 PM the following is observed:

1. The door to room 309 did not latch properly.

Staff B was present at the time of the findings. The door was repaired by staff at the time of the survey and the repairs were confirmed by the surveyor. .

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 interview the facility failed to ensure complete annual inspection and testing of the fire alarm system as required by NFPA 72. The absence of complete inspection and testing of the system could result in the system not functioning as required in the event of an emergency, affecting all patients, staff and visitors in all 21 smoke zones. The facility has a capacity of 69 with a census of 31.

Findings Include:

During the tour on 04/04/2011 between 9:15 AM and 5:00 PM the following is observed:

1. The batteries in the main fire alarm panel were dated to be replaced in October 2010.

Staff B was present and ordered batteries to be delivered by noon the day after the survey.

NFPA Standard: Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7 2.2. 1999 NFPA 72, 7 2.2.

NFPA Standard: A permanent record of all inspections, testing, and maintenance shall be maintained that includes periodic tests and applicable information, per 1999 NFPA 72, 7 5.2.2 and figure 7 5.2.2; A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70. 2000 NFPA 101, 9.6.1.4.

Based on record review, observation and staff interviews, the facility failed to assure that the sprinkler system is maintained and tested in accordance with the NFPA 13 and NFPA 25. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting 2 of 2 smoke zones on the 4th floor. This facility has a capacity of 69 and a census of 31 residents.

Findings Include:

During the survey on 04/04/2011 between 9:15 AM and 5:00 PM the following was observed:

1. The sprinkler system inspection report indicated a wrench for recessed sprinkler heads was missing from the spare head cabinet. This was confirmed by surveyor observation,

Staff B was present during the record review and survey and stated he thought it had been replaced. Staff B stated that they were due for another inspection in a few weeks and would contact the company to ensure that one was delivered and placed in the cabinet.

NFPA Standard: 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. 2000 NFPA 101, 4.6.12.1.

NFPA Standard: All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2000 NFPA 101, 9.7.5.

NFPA Standard: Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly. 1998 NFPA 25, 2-3.3.1.

NFPA Standard: Testing the waterflow alarms on wet pipe systems shall be accomplished by opening the inspector ' s test connection. Fire pumps shall not be turned off during testing unless all impairment procedures contained in Chapter 11 are followed.
Exception: Where freezing weather conditions or other circumstances prohibit use of the inspector ' s test connection, the bypass connection shall be permitted to be used. 1998 NFPA 25, 2-3.3.

NFPA Standard: A supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. The cabinet shall be so located that it will not be exposed to moisture, dust, corrosion, or a temperature exceeding 100?F (38?C).
Exception: Where dry sprinklers of different lengths are installed, spare dry sprinklers shall not be required, provided that a means of returning the system to service is furnished. 1998 NFPA 25, 2-4.1.4.

Based on observation and staff interview the facility is not ensuring that room doors latch properly. This deficient practice of not ensuring that room doors latch properly prevents the ability of the facility to properly confine fire and smoke products and to properly defend occupants in place, affecting one of five smoke zones on the 3nd floor and one of four smoke zones on the 3rd floor. The facility has 21 smoke zones on four floors total. The facility has a capacity of 69 with a census of 31 at the time of survey.

Findings Include:

During the tour on 04/04/2011 between 9:15 AM and 5:00 PM the following is observed:

1. The door to room 309 did not latch properly.

Staff B was present at the time of the findings. The door was repaired by staff at the time of the survey and the repairs were confirmed by the surveyor. .

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 interview the facility failed to ensure complete annual inspection and testing of the fire alarm system as required by NFPA 72. The absence of complete inspection and testing of the system could result in the system not functioning as required in the event of an emergency, affecting all patients, staff and visitors in all 21 smoke zones. The facility has a capacity of 69 with a census of 31.

Findings Include:

During the tour on 04/04/2011 between 9:15 AM and 5:00 PM the following is observed:

1. The batteries in the main fire alarm panel were dated to be replaced in October 2010.

Staff B was present and ordered batteries to be delivered by noon the day after the survey.

NFPA Standard: Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7 2.2. 1999 NFPA 72, 7 2.2.

NFPA Standard: A permanent record of all inspections, testing, and maintenance shall be maintained that includes periodic tests and applicable information, per 1999 NFPA 72, 7 5.2.2 and figure 7 5.2.2; A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70. 2000 NFPA 101, 9.6.1.4.

Based on record review, observation and staff interviews, the facility failed to assure that the sprinkler system is maintained and tested in accordance with the NFPA 13 and NFPA 25. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting 2 of 2 smoke zones on the 4th floor. This facility has a capacity of 69 and a census of 31 residents.

Findings Include:

During the survey on 04/04/2011 between 9:15 AM and 5:00 PM the following was observed:

1. The sprinkler system inspection report indicated a wrench for recessed sprinkler heads was missing from the spare head cabinet. This was confirmed by surveyor observation,

Staff B was present during the record review and survey and stated he thought it had been replaced. Staff B stated that they were due for another inspection in a few weeks and would contact the company to ensure that one was delivered and placed in the cabinet.

NFPA Standard: 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. 2000 NFPA 101, 4.6.12.1.

NFPA Standard: All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2000 NFPA 101, 9.7.5.

NFPA Standard: Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly. 1998 NFPA 25, 2-3.3.1.

NFPA Standard: Testing the waterflow alarms on wet pipe systems shall be accomplished by opening the inspector ' s test connection. Fire pumps shall not be turned off during testing unless all impairment procedures contained in Chapter 11 are followed.
Exception: Where freezing weather conditions or other circumstances prohibit use of the inspector ' s test connection, the bypass connection shall be permitted to be used. 1998 NFPA 25, 2-3.3.

NFPA Standard: A supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. The cabinet shall be so located that it will not be exposed to moisture, dust, corrosion, or a temperature exceeding 100?F (38?C).
Exception: Where dry sprinklers of different lengths are installed, spare dry sprinklers shall not be required, provided that a means of returning the system to service is furnished. 1998 NFPA 25, 2-4.1.4.