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Based on observation the facility failed to maintain the two hour barrier. This deficient practice affects all occupants in one of the twelve smoke zones. The facility has a certified capacity of 25 with the current census of 4 residents.

Findings include:

Observation on 1/3/11 at 11:17 a.m., revealed a two inch hole around blue wires in the two smoke barrier that separated the Hospital from the Nursing Home. Maintenance Staff A confirmed this finding.

Based on observation, the facility is not ensuring that one door is free of impediments that would prevent the door from being closed. This deficient practice affects occupants in two of twelve smoke zones, as the doors would not prevent the spread of fire and smoke. This facility has a capacity of 25 and a census of 4 residents.

Findings include:


Observation on 1/3/11, revealed the North Dining Room door had a wedge or doorstop located at the base of the doors that could prevent the doors from being closed in an emergency. Maintenance Staff A verified the observations.


NFPA Standard: Doors in corridor walls shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed per 2000 NFPA 101, 19.3.6.3.1

Based on observation, this facility is not assuring that eight of ten 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 all occupants of the building. This facility has a capacity of 25 with a census of 4 residents.

Findings include:

Observation on 1/3/11, revealed the following penetrations in smoke barriers;

1. There was a two inch penetration around wires in the smoke barrier by the Maintenance Director Office.
2. There was a two inch penetration around orange wiring in the smoke barrier by Xray.
3. There was a one inch penetration around wiring and pipe in the smoke barrier by the Human Resource Office.
4. There was a four inch hole and one inch penetration around blue wiring in the smoke barrier by the Respiratory therapy room.
5. There was an open conduit in the smoke barrier by room #112.
6. There was a two inch hole in the smoke barrier of the Dialysis Wing.
7. There was a half inch penetration around blue wiring in the smoke barrier West of the Main Waiting area.
8. There was a two inch hole in the smoke barrier into Physical Therapy.

According to the facility layout, this was a required barrier. Administrative Staff A and Maintenance Staff A confirmed these observations.

NFPA standard: 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

Based on observation, the facility failed to maintain one smoke door to close and resist the passage of smoke. The smoke door affected two of the twelve smoke compartments in the building and all occupants in both smoke zones. The facility has 25 certified beds and at the time of the survey the census was 4.

Findings include:

Observation on 1/3/11, revealed the West leaf of the smoke doors into Physical Therapy did not close completely when tested. Maintenance Staff A confirmed these observations during the survey process.

NFPA standard: Requires doors in smoke barriers to be self-closing and resist the passage of smoke, 2000 NFPA 101, 19.3.7.6

Based on observation, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected one of twelve smoke compartments on the first floor, all of the basement level. This facility has a capacity of 25 and a census of 4 residents.

Findings include:

Observation of the Store Room in the Basement on 1/3/11 at 11:00 a.m., revealed open conduits with blue wiring throughout the room. Maintenance Staff A confirmed these observations.

Hazardous area with Sprinkler
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 closers and positive latches. 2000 NFPA 101, 19.3.2.1

Based on observation the facility failed to provide 5 doors out of the Kitchen readily accessible. This deficient practice affects all occupants in the Kitchen and Dining room area. The facility has a certified capacity of 25 with the current census of 4 residents.

Findings include:

Observation on 1/3/11 at 11:25 a.m., revealed three exit doors in Kitchen and two door in the Dining room had dead bolt locks on the doors along with door hardware that latch into the frame. Maintenance Staff A verified these findings.

A)
Based on record review and interview, the facility failed to document the emergency egress lighting monthly and annually. This deficient practice affects and all occupants of the facility. This facility has a capacity of 25 and a census of 4 residents.

Findings include:

Observation of the facility's maintenance records on 1/3/11, revealed the absence of documentation regarding the testing of the emergency battery lighting system. According to Maintenance Staff A, the lights were tested weekly and monthly, but there was no documentation to show that the monthly tests were conducted for 30 seconds or that an annual test was completed for 90 minutes under load.

NFPA standard: Requires a documented monthly test of battery-powered emergency lighting for at least 30 seconds, and an annual test for a duration of 1-1/2 hours. 2000 NFPA 101, 7.9.3


B)
Based on observation the facility failed to maintain all emergency lights. This deficient practice would affect all occupants in four area of the building. The facility has a capacity of 25 certified beds with the current census of 4 residents.

Findings include:

Observation on 1/3/11, revealed the following areas had emergency lights and when tested did not illuminate:

1. 2001 Heating and Ventilation Penthouse.
2. Basement of the Dialysis wing (1).
3. Mechanical Room of the Pool.
4. All lights in the Pool Area.

Maintenance Staff A verified these findings.

Based on observation and record review, the facility failed to provide a properly tested and maintained fire alarm system. All of the facility and occupants are directly affected by the deficient practice. The facility has 25 certified beds and at the time of the survey the census was 4.

Findings include:

A review of the inspection records for the fire alarm system on 01/03/11, revealed the last two completed inspection forms of the fire alarm system for the year 2010 documented the facility had only 4 smoke detectors and 2 strobe unit on the report. This is not accurate amount the facility actually has. Maintenance Staff A confirmed observations during the survey process.

NFPA standard: A permanent record of all inspections, testing, and maintenance shall be maintained that includes periodic tests and applicable information, per the 1999 edition of NFPA 72, table 7-3.2. and listed as required by NFPA 72, 7-5.2.2

A)
Based on record review, the facility failed to maintain the sprinkler system in accordance with the National Fire Protection Association (NFPA), Standard 25, by ensuring the 5 year Flow test had been performed. This deficient practice affects all occupants in the building. The facility has a capacity of 25 with the census of 4 residents.

Findings include:

Record review on 1/3/11, revealed documentation indicated the last time the 5 year Flow test had been preformed was May 2004. The facility could not find documentation the test had been performed. Maintenance Staff A verified this 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 performance and protection as designed. NFPA 13, 12.1

B)
Based on observation and interview, this facility is not maintaining the sprinkler system in accordance with the 1998 edition of National Fire Protection Association (NFPA) 25, and the 1999 edition of National Fire Protection Association (NFPA) 13 by ensuring sprinkler heads are replaced when they are not free of foreign materials. This can affect the operation of the heads by obstructing spray patterns, delaying the response time or preventing the operation of the heads that can compromise the effectiveness of the fire suppression system. This deficient practice can place all occupants at risk in the event of a fire. The census was 4 with a capacity of 25.

Findings include:

Observation on 1/3/11, revealed a missing sprinkler head escutcheon outside of the Clinic waiting area in the corridor and paint on a sprinkler head west of the Main Nursing Station. This was verified with Maintenance Staff A.

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. NFPA 13, 12.1

NFPA Standard: The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor. NFPA 25, 1-4.4

NFPA Standard: Sprinklers shall be inspected restoring heat in areas subject to freezing temperatures where water-filled piping is installed; and replacing worn or missing fire hose or nozzles. NFPA 25, 1-11.3 from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. NFPA 25, 2-2.1.1

NFPA Standard: Corrective maintenance includes, but is not limited to, replacing loaded, corroded, or painted sprinklers; replacing missing or loose pipe hangers; cleaning clogged fire pump impellers; replacing valve seats and gaskets;

A)
Based on record review, the facility failed to provide a commercial cooking suppression system that is tested and maintained as required. The facility kitchen area is located in one of twelve smoke compartments in the building. The facility has 25 certified beds and at the time of the survey the facility census was 4.

Findings include:

Record review on 01/03/11, revealed that the kitchen suppression system had not been inspected on a six month interval as required. The last two inspection were dated December 2010 and December 2009. Maintenance Staff A confirmed observations during the survey process.



NFPA Standard: Require inspection and servicing at least every six months by properly trained and qualified persons. 1998 NFPA 17, 9-3 and 1998 NFPA 17A, 5-3

NFPA Standard: Required fire extinguishing systems for commercial cooking applications shall comply with standard UL 300, required by 1998 NFPA 17, 7-3.2, 1998 NFPA 17A, 3-1.1 and 1998 NFPA 96, 7-2.2


B)
Based on record review, the facility failed to provide a commercial cooking suppression system that is maintained as required. The facility kitchen area is located in one of twelve smoke zones and would affect all occupants in that zone. The facility has 25 certified beds and at the time of the survey the facility census was 4.

Findings include:

Record review on 01/03/11, revealed that the kitchen suppression system documentation did not indicate that the system was connected to the fire alarm system. Maintenance Staff A confirmed observations during the survey process.



NFPA Standard: Required fire extinguishing systems for commercial cooking applications shall comply with standard UL 300, required by 1998 NFPA 17, 7-3.2, 1998 NFPA 17A, 3-1.1 and 1998 NFPA 96, 7-2.2

Based on record review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice would affect all smoke compartments and all of the residents and staff. The facility has 25 certified beds and at the time of the survey the facility census was 4.

Findings include:

Documentation review on 1/03/11, revealed weekly inspections of the generator had not been maintained. Maintenance Staff A verified this finding.

NFPA standard: Level 1 and level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes. NFPA 110, 6.4.1 and 6.4.2.

Based on observation, the facility failed to maintain all components in the electrical system. This deficient practice affects one out of twelve smoke zones. The facility has a certified capacity of 25 with the current census of 4 residents.

Findings include:

Observation on 1/3/11 at 11:10 a.m., revealed two open junction boxes in the 1987 Penthouse Mechanical room. Maintenance Staff A verified these findings.

NFPA standard: 1999 NFPA 70,