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Based on observation and staff interview, the facility fails to assure that fire barrier walls are maintained and are free of penetrations. The deficient practice compromises the fire resistance rating of the wall and would not prevent the passage of fire or smoke to other areas of the building, affecting approximately 3 patients and all visitors and staff in 2 of 5 smoke zones. The facility has a capacity of 25 with a census of 9 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 06/25/2013, between 8:00 a.m. and 6:00 p.m., it is observed that:

-- 1. Fire barrier wall across from the Courtyard has unsealed penetrations around cables and wires that pass through it.

-- 2. Fire barrier wall separating the Main Hospital and Clinic has unsealed penetrations around conduit, pipes, wires and cables. A portion of the cables and wires pass through the wall through a PVC sleeve which has been sealed with an unidentified silicone-type material.

Maintenance Staff A and B were present and acknowledged the unsealed penetrations in the rated walls.

NFPA Standard: Floor-ceiling assemblies and walls used as fire barriers, including supporting construction, shall be of a design that has been tested to meet the conditions of acceptance of NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials. Fire barriers shall be continuous in accordance with 8.2.2.2 per NFPA 101, 8.2.3.1.1. Space between wires and similar building service equipment that pass through fire barriers shall be protected by filling the space with a material that is capable of maintaining the fire resistance of the fire barrier or shall be protected by an approved device that is designed for the specific purpose 2000 NFPA 101, 8.2.3.2.4.2

Based upon observation and staff interview, the facility fails to assure that spaces between penetrating items and smoke barriers are filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. The deficient practice would not prevent the passage of smoke to other areas of the building, affecting approximately 5 of 25 residents in 2 of 5 smoke zones. The facility has a capacity of 25 with a census of 9 at the time of the survey.

Findings include:

During the tour conducted on 06/25/2013, between 8:00 a.m. and 6:00 p.m., it is observed:

-- 1. Smoke barrier wall near Patient Room 412 has unsealed gaps around sprinkler piping.

Maintenance Staff A and B were present and acknowledged the presence of unsealed penetrations in 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 upon a review of records, observation and staff interview, the facility does not assure that cooking facilities are protected in accordance with NFPA 96. The deficient practice could result in the perpetuation of a kitchen range fire, affecting zero patients in 1 of 5 smoke zones. The facility has a capacity of 25 with a census of 9 at the time of the survey.

Findings include:

During the tour conducted on 06/25/2013, between 8:00 a.m. and 6:00 p.m., a review of records revealed no documented cleaning of the kitchen ventilation and duct work.

Maintenance Staff A and B were present and acknowledged the results of the records review.

NFPA Standard: Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s). 1998 NFPA 96, 8-3.1

Based upon a review of records and staff interview, the facility fails to assure generators are inspected and exercised in accordance with NFPA 99. The deficient practice does not ensure that the generator will perform as expected in the event of an emergency, affecting all 25 patients, visitors and staff in 5 of 5 smoke zones. The facility has a capacity of 25 with a census of 9 at the time of the survey.

Findings Include:

During the tour conducted on 06/25/2013, between 8:00 a.m. and 6:00 p.m., a review of records revealed the following:

-- 1. The monthly load testing of the On-Site (brand) diesel generator is not with sufficient load to reach 30% of the 400 Amps listed on the data plate of the generator and no load bank has test been performed within the last 12 months.

Maintenance Staff A indicated the generator is operated under load for 30 minutes weekly and logs indicate that the amperage has been less than required on all load tests.

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

NFPA Standard: Inspection and Testing of Level 3 generator sets shall be inspected and tested in accordance with 3-4.4.1.1(b). 1999 NFPA 99, 3-6.4.1.1

Based on observation and staff interview, the facility fails to assure that fire barrier walls are maintained and are free of penetrations. The deficient practice compromises the fire resistance rating of the wall and would not prevent the passage of fire or smoke to other areas of the building, affecting approximately 3 patients and all visitors and staff in 2 of 5 smoke zones. The facility has a capacity of 25 with a census of 9 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 06/25/2013, between 8:00 a.m. and 6:00 p.m., it is observed that:

-- 1. Fire barrier wall across from the Courtyard has unsealed penetrations around cables and wires that pass through it.

-- 2. Fire barrier wall separating the Main Hospital and Clinic has unsealed penetrations around conduit, pipes, wires and cables. A portion of the cables and wires pass through the wall through a PVC sleeve which has been sealed with an unidentified silicone-type material.

Maintenance Staff A and B were present and acknowledged the unsealed penetrations in the rated walls.

NFPA Standard: Floor-ceiling assemblies and walls used as fire barriers, including supporting construction, shall be of a design that has been tested to meet the conditions of acceptance of NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials. Fire barriers shall be continuous in accordance with 8.2.2.2 per NFPA 101, 8.2.3.1.1. Space between wires and similar building service equipment that pass through fire barriers shall be protected by filling the space with a material that is capable of maintaining the fire resistance of the fire barrier or shall be protected by an approved device that is designed for the specific purpose 2000 NFPA 101, 8.2.3.2.4.2

Based upon observation and staff interview, the facility fails to assure that spaces between penetrating items and smoke barriers are filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. The deficient practice would not prevent the passage of smoke to other areas of the building, affecting approximately 5 of 25 residents in 2 of 5 smoke zones. The facility has a capacity of 25 with a census of 9 at the time of the survey.

Findings include:

During the tour conducted on 06/25/2013, between 8:00 a.m. and 6:00 p.m., it is observed:

-- 1. Smoke barrier wall near Patient Room 412 has unsealed gaps around sprinkler piping.

Maintenance Staff A and B were present and acknowledged the presence of unsealed penetrations in 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 upon a review of records, observation and staff interview, the facility does not assure that cooking facilities are protected in accordance with NFPA 96. The deficient practice could result in the perpetuation of a kitchen range fire, affecting zero patients in 1 of 5 smoke zones. The facility has a capacity of 25 with a census of 9 at the time of the survey.

Findings include:

During the tour conducted on 06/25/2013, between 8:00 a.m. and 6:00 p.m., a review of records revealed no documented cleaning of the kitchen ventilation and duct work.

Maintenance Staff A and B were present and acknowledged the results of the records review.

NFPA Standard: Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s). 1998 NFPA 96, 8-3.1

Based upon a review of records and staff interview, the facility fails to assure generators are inspected and exercised in accordance with NFPA 99. The deficient practice does not ensure that the generator will perform as expected in the event of an emergency, affecting all 25 patients, visitors and staff in 5 of 5 smoke zones. The facility has a capacity of 25 with a census of 9 at the time of the survey.

Findings Include:

During the tour conducted on 06/25/2013, between 8:00 a.m. and 6:00 p.m., a review of records revealed the following:

-- 1. The monthly load testing of the On-Site (brand) diesel generator is not with sufficient load to reach 30% of the 400 Amps listed on the data plate of the generator and no load bank has test been performed within the last 12 months.

Maintenance Staff A indicated the generator is operated under load for 30 minutes weekly and logs indicate that the amperage has been less than required on all load tests.

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

NFPA Standard: Inspection and Testing of Level 3 generator sets shall be inspected and tested in accordance with 3-4.4.1.1(b). 1999 NFPA 99, 3-6.4.1.1