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Based on observation made during the fire life safety tour, and interviews with Maintenance Staff, the facility failed to properly maintain the required Fire/Smoke barrier penetrations, which had not been fire stopped or smoke sealed per the requirements of NFPA 101(2000 edition). This condition could allow Fire/Smoke to travel from one compartment to other compartments, thus endangering occupants of the facility.

Findings include:

During the facility tour with the Maintenance Staff on 01/21/2016 at 11am, it was found that penetrations through the wall above the ceiling have not been fire stopped or smoke sealed. The following locations were observed to have penetrations:

1) 2nd floor, door going into geriatrics, penetration above the ceiling tile
2) 2nd floor, door going into the client elevator lobby, penetration above the ceiling tile
3) 2nd floor, door going into the visitors elevator lobby, penetration above the ceiling tile
4) 1st floor IT room spray foam used to seal a penetration
5) Outside electrical room penetration in wall
All locations were not properly protected with the required fire caulk. Maintenance was shown the penetrations and confirmed the findings.

According to NFPA 101(2000 edition) 8.3 and 19.3.7

Based on document review, the facility failed to conduct and document the required annual External disaster drills. These drills increase the knowledge of staff of the action to take in an emergency situation and helps prevent confusion to occupants and staff in the event of an emergency.

The findings include:

During document review with Maintenance Director and Administrator on 01/21/2016 at 1:45pm, it was found that the annual External disaster drill had not been done. Each organizational cooperation entity shall implement two or more (Internal & External) specific responses of the emergency operations plan during each year. According to CMS, drills must be separated by 4 to 7 months.

According to NFPA 101 (2012 Edition)

Based on observations made during the fire life safety tour, and interviews with Maintenance Staff, the facility failed to provide inspection, maintenance and testing of the fire sprinkler system. Failure to inspect, maintain, and test system components could result in the system failing to perform as designed thereby endangering the occupants of the building.

The findings Include:

During the facility tour with Maintenance Staff on 01/21/2016 at 11:30am, it was observed that several sprinkler heads were in need of cleaning. Maintenance was shown the sprinkler heads and confirmed the findings.

1. Kitchen walk-in cooler (x2)
2. Kitchen serving line area (x4)

All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25 (1999 edition Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems).
NFPA 101 Life Safety Code (2000 edition)

Based on observation made during the fire life safety tour, and interviews with Maintenance Staff, the facility failed to provide ashtrays of a safe design or a designated smoking area. These unapproved ashtrays could result in a fire/smoke situation and could result in a fire, smoke, and fire gasses permeating the building and jeopardizing patients and staff.

Findings include:

During the facility tour with Maintenance Staff on 01/21/2016 at 11:40am it was observed that the facility did not have:

1. A designated smoking area for staff
2. Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. (Note smoking tower disposal receptacles are not ashtrays)
3. Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.

An interview with Maintenance staff conducted during the observation confirmed the findings.

In accordance with NFPA 101 (2000 edition)

Based on observation made during the fire life safety tour, and interviews with Maintenance Staff, the facility failed to properly maintain the required Fire/Smoke barrier penetrations, which had not been fire stopped or smoke sealed per the requirements of NFPA 101(2000 edition). This condition could allow Fire/Smoke to travel from one compartment to other compartments, thus endangering occupants of the facility.

Findings include:

During the facility tour with the Maintenance Staff on 01/21/2016 at 11am, it was found that penetrations through the wall above the ceiling have not been fire stopped or smoke sealed. The following locations were observed to have penetrations:

1) 2nd floor, door going into geriatrics, penetration above the ceiling tile
2) 2nd floor, door going into the client elevator lobby, penetration above the ceiling tile
3) 2nd floor, door going into the visitors elevator lobby, penetration above the ceiling tile
4) 1st floor IT room spray foam used to seal a penetration
5) Outside electrical room penetration in wall
All locations were not properly protected with the required fire caulk. Maintenance was shown the penetrations and confirmed the findings.

According to NFPA 101(2000 edition) 8.3 and 19.3.7

Based on document review, the facility failed to conduct and document the required annual External disaster drills. These drills increase the knowledge of staff of the action to take in an emergency situation and helps prevent confusion to occupants and staff in the event of an emergency.

The findings include:

During document review with Maintenance Director and Administrator on 01/21/2016 at 1:45pm, it was found that the annual External disaster drill had not been done. Each organizational cooperation entity shall implement two or more (Internal & External) specific responses of the emergency operations plan during each year. According to CMS, drills must be separated by 4 to 7 months.

According to NFPA 101 (2012 Edition)

Based on observations made during the fire life safety tour, and interviews with Maintenance Staff, the facility failed to provide inspection, maintenance and testing of the fire sprinkler system. Failure to inspect, maintain, and test system components could result in the system failing to perform as designed thereby endangering the occupants of the building.

The findings Include:

During the facility tour with Maintenance Staff on 01/21/2016 at 11:30am, it was observed that several sprinkler heads were in need of cleaning. Maintenance was shown the sprinkler heads and confirmed the findings.

1. Kitchen walk-in cooler (x2)
2. Kitchen serving line area (x4)

All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25 (1999 edition Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems).
NFPA 101 Life Safety Code (2000 edition)

Based on observation made during the fire life safety tour, and interviews with Maintenance Staff, the facility failed to provide ashtrays of a safe design or a designated smoking area. These unapproved ashtrays could result in a fire/smoke situation and could result in a fire, smoke, and fire gasses permeating the building and jeopardizing patients and staff.

Findings include:

During the facility tour with Maintenance Staff on 01/21/2016 at 11:40am it was observed that the facility did not have:

1. A designated smoking area for staff
2. Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. (Note smoking tower disposal receptacles are not ashtrays)
3. Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.

An interview with Maintenance staff conducted during the observation confirmed the findings.

In accordance with NFPA 101 (2000 edition)