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Based on observation, staff interview and record review, this facility is not assuring that 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 2 of 11 smoke zones. This facility has a capacity of 74 and a census of 60.

Findings include:

During the tour on 2/24/11 between 11:00 AM and 5:00 PM it is observed there is two penetrations of the smoke barrier wall where the fire rated caulking has fallen out and there is no sheet rock where the caulking had been to the 400 hall smoke barrier wall by room 408.

Staff A and Staff B were present and confirmed the finding. Staff B stated they were not sure what they were going to do to correct the smoke barrier wall.


NFPA Standard: 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 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 1 of 11 smoke zones. This facility has a capacity of 74 and a census of 60.

Findings include:

During the tour on 2/24/11 between 11:00 AM and 5:00 PM the following is observed:

--1) There is no self closing device on the SE door to the Gift Shop storage room.
--2) There is a slide bolt lock on the inside of the corridor door in Laundry.
--3) There is no self closing device on the two doors of Maintenance storage in the Basement.
--4) There is a maintenance work cart stored against the corridor door inside of Maintenance storage in the basement.
--5) There is a gap in the ceiling tile by the escutcheon ring in the Linen closet by room 408 and in the Laundry chute closet in the 400 hall.

Staff A and Staff B were present and confirmed the finding. Staff B stated the slide bolt will be removed. Staff A stated caulking will be used to seal the gaps around the escutcheon rings.

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

Based on observation and staff interview, the facility failed to provide means of egress that are maintained free of all obstructions or impediments to a full instant use in case of fire or other emergency. The deficient practice prevents exits from being arranged so that they are readily available and accessible, affecting 3 of 11 smoke zones. This facility has a capacity of 74 and a census of 60.

Findings include:

During the tour on 2/24/11 between 11:00 AM and 5:00 PM the following is observed:

--1) There is an orange construction fence laying across the sidewalk out of the stairwell for the Administrative hall exit discharge egress.
--2) The newly constructed sidewalk has a dip that collects rain water and/or ice out of the stairwell for the Administrative hall exit discharge egress.
--3) The 400 Hall exit discharge sidewalk does not have an all weather surface due to the parking lot that this exit sidewalk was connected to no longer exists. Currently, off of this sidewalk is a mud yard due to the recent construction of a new acute wing. The parking lot has been relocated to the opposite side of the new wing. Upon review of the code footprint, it is evident that a path of egress for this exit discharge during construction was not allocated.
--4) There are three chairs, a trash can and a metal container for cigarettes obstructing the exit discharge out of the basement South exit.

Staff A and Staff B were present and aware of the findings. Staff B had Staff C lay down plywood boards that will connect 400 hall exit discharge sidewalk to the newly installed sidewalk by the new acute wing.

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 fails to assure there is normal illumination in all exit corridors, failing to ensure that all areas of egress will not be left in total darkness. This deficient practice affects 3 of 11 smoke zones including the Dining room. The facility has a capacity of 74 and a census of 60.

Findings include:

During the tour on 2/24/11 between 11:00 AM and 5:00 PM the following is observed:

--1) There is no normal illumination in the Administrative exit corridor. All lights can be turned off with a manual switch.
--2) There is no normal illumination in the 300 exit corridor, the NS exit corridor in 300 hall, and EW exit corridor in the 300 hall by the DON office.
--3) There is no normal illumination in the Basement corridor by Therapy. All lights can be turned off with a manual switch.

Staff A and Staff B were present and confirmed the finding. Staff a stated every other light could be left on at all times the building is occupied.

NFPA Standard: Required illumination shall be arranged so that the failure of any single bulb or unit does not result in less than .2 foot-candles of illumination in any designated area. 2000 NFPA 101, 7.8.1.4

Based on observation and staff interview the facility failed to provide adequate emergency lighting as required for exit corridors and exit discharges. The deficient practice could leave the exit corridors and exit discharge paths without illumination during a disruption of normal power or in the event of an emergency. This deficiency affects all residents in 4 of 11 smoke zones. This facility has a capacity of 74 and a census of 60.

Findings Include:

During the tour on 2/24/11 between 11:00 AM and 5:00 PM the following is observed:

--1) The exit egress stairwell lights used for emergency lighting can be turned off with a key switch to the Administrative stairwell.
--2) There is no two bulb light fixture for the exit discharge for the Time Clock exit connected to emergency back up.
--3) There is no emergency lighting provided by the generator or battery back up for the Basement storage room where the north door leads to SNF main lobby.
--4) There is no two bulb light fixture for the exit discharge stairwell out of the staff Dining room which is near the Time clock exit.

Staff A and Staff B were present and confirmed the finding. Staff B stated the light poles that are located outside of the time clock exit are owned by the city, but the facility will be installing their own light poles and removing the city poles.

NFPA Standard: Emergency lighting for means of egress shall be provided in accordance with Section 7.9 for the following: buildings or structures where required by the occupancy chapters, underground and windowless structures as required by Section 11.7, high-rise buildings as required by other sections of this Code, doors equipped with delayed egress locks, and stair shaft and vestibules of smoke proof enclosures. For the purposes of this requirement, exit access shall include designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit and exit discharge shall include designated stairs, ramps, aisles, walkways, and escalators leading to a public way. 2000 NFPA 101, 7.9.1.1

NFPA Standard: Emergency illumination shall be provided for not less than 11/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 foot-candle. 2000 NFPA 101, 7.9.2.1.

Based on observation and staff interview the facility fails to assure directional and exit signs are properly displayed. This deficient practice fails to direct occupants to a safe path of egress in case of an emergency, affecting 3 of 11 smoke zones. The facility has a capacity of 74 and a census of 60.

Findings include:

During the tour on 2/24/11 between 11:00 AM and 5:00 PM the following is observed:

--1) There is no exit sign posted at the double doors into the Skilled nursing unit. The double doors have recently been added to separate the skilled unit from the hospital unit.
--2) There is no exit sign posted at the north door in the Basement storage room that leads to the main lobby of the skilled unit.
--3) There is an illuminated exit sign at the end of the 400 hall. When surveyor walked out of this exit, surveyor observed this had been a construction area. A new acute wing has been added near the 400 wing. There had been a parking lot out of the 400 exit before construction for building occupants to exit onto to get away from the building. However, during construction the parking lot was removed and relocated to the opposite side of the new wing, leaving a muddy yard and resulting in the eliminatin of the hard surface to a public way. This exit was not redirected during construction.

Staff A and Staff B were present and aware of the findings. Staff B had Staff C put down plywood boards so occupants out of the 400 wing could get access to the sidewalk of the Acute addition.

NFPA Standard: Every sign required in Section 7.10 shall be located and of such size, distinctive color, and design that it is readily visible and shall provide contrast with decorations, interior finish, or other signs. No decorations, furnishings, or equipment that impairs visibility of a sign shall be permitted. No brightly illuminated sign (for other than exit purposes), display, or object in or near the line of vision of the required exit sign that could detract attention from the exit sign shall be permitted. 2000 NFPA 101, 7.10.1.7

Based on record review and staff interview the facility failed to assure that fire drills are held at least quarterly on each shift. This deficient practice may prevent proper evacuation in a timely manner due to staff ' s inability to respond in the event of an emergency, affecting 11 out of 11 smoke zones including the Dining room. This facility has a capacity of 74 with a census of 60.

Findings Include:

During the tour on 2/24/11 between 11:00 AM and 5:00 PM the following is observed:

--1) There is no record of a fire drill conducted on the 3rd shift for the second quarter of 2010.
--2) Fire drills were not conducted at unexpected times on 1st shift. Two of the drills were conducted between 10:21 AM and 10:35 AM, the other two drills were conducted between 8:40 AM and 8:45 AM.
--3) There were four fire drills conducted between 7:00 PM and 7:42 PM for the last four quarters of 2010 on 2nd shift.

Staff A and Staff B were present and confirmed the findings. Staff A stated fire drills may start to be conducted using two shifts instead of three shifts.


NFPA Standard: The proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy ' s fire safety plan. 2000 NFPA 101, 19.7.2.1

Based on observation and staff interviews, the facility does not assure that the automatic fire sprinkler system is maintained properly. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting 2 of 11 smoke zones. The facility has a capacity of 74 and a census of 60.

Findings include:

During the tour on 2/24/11 between 11:00 AM and 5:00 PM the following is observed:

--1) There is no escutcheon ring around the sprinkler in the south basement by the 2 hour wall.

Staff A and Staff B were present and confirmed the findings.


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. 1999 NFPA 13, 12.1

Based on observation and staff interview the facility failed to ensure that portable fire extinguishers are properly mounted. This deficient practice may prevent the portable fire extinguisher from being readily accessible due to difficulty in retrieving it from the mounting bracket, affecting 1 of 11 smoke zones. The facility has a capacity of 70 and a census of 64.

Findings include:

During the tour on 2/24/11 between 11:00 AM and 5:00 PM it is observed there is a fire extinguisher mounted higher than 5 ft from the top of the extinguisher at the 300 hall exit door.

Staff A and Staff B were present and confirmed the finding. Staff B stated the fire extinguisher could be lowered.

NFPA Standard: 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

Based on observation and staff interview the facility failed to ensure that empty and full oxygen cylinders were not stored in the same rack. This deficient practice could cause an empty cylinder to be retrieved in an emergency situation, affecting 1 of 11 smoke zones. The facility has a capacity 74 and a census of 60.

Findings Include:

During the tour on 2/24/11 between 11:00 AM and 5:00 PM it is observed there are two full oxygen tanks stored in the empty oxygen tank rack.

Staff A and Staff B were present and confirmed the finding. Staff B moved the full tanks to the full rack and stated the tanks were placed there by hospice.


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 record review and staff interview, the facility fails to conduct and properly document testing and maintenance of the generator in accordance with NFPA 99 and NFPA 110. The deficient practice potentially reduces the reliability of the generator. The deficient practice affects 11 of 11 smoke zones including the Dining room. The facility has a capacity of 74 with a census of 60.

Findings include:

During the tour on 2/24/11 between 11:00 AM and 5:00 PM it is observed there was no transfer time recorded on the natural gas generator for Jan '11, Dec '10, Nov '10, Oct '10, Sept '10, June '10, May '10, April '10, March '10 and Feb '10.

Staff A and Staff B were present and confirmed the finding.


NFPA Standard: Generator sets or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures. 1999 NFPA 99, 3-4.4.1.1

Based on observation and staff interview the facility failed to assure that electrical equipment is properly maintained and installed in accordance with NFPA 70, National Electric Code. This deficient practice could cause an electrical failure or fire, affecting 2 out of 11 smoke zones. This facility has a capacity of 74 with a census of 60.

Findings include:

During the tour on 2/24//11 between 11:00 AM and 5:00 PM the following is observed:

--1) There are three open spaces in the #24 electrical panel in the Generator room.
--2) There is an open junction box above the ceiling tiles by room 201.

Staff A and Staff B were present and confirmed the finding. Staff A stated the open spaces in the electrical panel will have covers put on.


NFPA Standard: All energized distribution panels/components shall be provided with protective covers that keep personnel separated from live electrical components. NFPA 70, 1999 ed

Based on observation and staff interview, the facility fails to assure alcohol based hand rub containers are not installed above or adjacent to an ignition source. This deficient practice could result in a fire by failing to ensure that the ABHS does not come into contact with an ignition source, affecting occupants in 1 of 11 smoke zones including the Dining room. The facility has a capacity of 74 and a census of 64.

Findings include:

During the tour on 2/24/11 between 11:00 AM and 5:00 PM it is observed there is an alcohol gel container mounted adjacent to an electrical light switch in 300 hall Dining room.

Standard: Dispensers shall not be installed in a corridor that is under 6 feet wide; the maximum dispenser capacity for rooms, corridors and areas open to the corridor is 1.2 liters (2.0 liters in suites of rooms); the minimum horizontal spacing shall be 4 feet; not more than 37.8 liters shall be mounted within a smoke compartment; storage of quantities greater than 5 gallons (18.9 liters) in a single smoke compartment shall meet the requirements of NFPA 30; dispensers installed directly over carpeted surfaces shall be permitted only in sprinklered smoke compartments; and the dispensers shall not be installed over or directly adjacent to an ignition source. Centers for Medicare & Medicaid Services, 42 CFR Parts 403, 416, 418, 460, 482, 483, and 485, [CMS-3145-IFC], RIN 0938-AN36, Medicare and Medicaid Programs; Fire Safety Requirements Federal Register, Vol. 70, No. 57, Friday, March 25, 2005 42 CFR 483.70 (a) (7)