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Based upon observations made in the presence of the plant manager on 9/25/14, it was determined that the facility did not maintain fire barrier in accordance with NFPA 101: 19.1.1.4.1 and NFPA 80: 2-3.1.7.

Findings include:

The main double fire rated doors had ½ " opening between the double doors and would not resist the passage of smoke and fire.

Based upon staff interview and observations made in the presence of the plant manager on 9/25/14, it was determined that the facility did not maintain hazardous areas to be fire and smoke separated from other sections of the facility in accordance with NFPA 101: 19.3.2.1., 8.4 and 7.2.1.8.

Findings include:

The soiled utility room had 4 " opening on the wall from where the old nurse call system was.

Based upon review of fire drill documentation made in the presence of the plant manager on 9/25/14, it was determined that the facility did not conduct fire drills at unexpected times under varying conditions for each shift in accordance with Life Safety Code regulations and NFPA 101: 19.7.1.2.

Findings include:

The facility did not have documentation that the fire drill for the afternoon shift 4th quarter was conducted during the previous 12-month period.

Based upon staff interview and observations made in the presence of the plant manager on 9/25/14, it was determined that the facility had in use portable space heater in the facility in accordance with NFPA 101: 19.7.8.

Findings include:

The medical records area had two portable space heaters in use during survey. The heaters were removed during survey.

Based upon staff interview and observations made in the presence of the plant manager on 9/25/14, it was determined that the facility did not maintain flame retardant treatment on combustible decorations in accordance with NFPA101 19.3.5.5 and NFPA 701.

Findings include:

The main lobby area had a 4 ' x 26 ' carpeted display case. The carpet was lacking documentation that the display was either inherently flame retardant or treated to be flame resistant.

Based upon observations made in the presence of the plant manager on 9/25/14, it was determined that the facility did not maintain fire barrier in accordance with NFPA 101: 19.1.1.4.1 and NFPA 80: 2-3.1.7.

Findings include:

The main double fire rated doors had ½ " opening between the double doors and would not resist the passage of smoke and fire.

Based upon staff interview and observations made in the presence of the plant manager on 9/25/14, it was determined that the facility did not maintain hazardous areas to be fire and smoke separated from other sections of the facility in accordance with NFPA 101: 19.3.2.1., 8.4 and 7.2.1.8.

Findings include:

The soiled utility room had 4 " opening on the wall from where the old nurse call system was.

Based upon review of fire drill documentation made in the presence of the plant manager on 9/25/14, it was determined that the facility did not conduct fire drills at unexpected times under varying conditions for each shift in accordance with Life Safety Code regulations and NFPA 101: 19.7.1.2.

Findings include:

The facility did not have documentation that the fire drill for the afternoon shift 4th quarter was conducted during the previous 12-month period.

Based upon staff interview and observations made in the presence of the plant manager on 9/25/14, it was determined that the facility had in use portable space heater in the facility in accordance with NFPA 101: 19.7.8.

Findings include:

The medical records area had two portable space heaters in use during survey. The heaters were removed during survey.

Based upon staff interview and observations made in the presence of the plant manager on 9/25/14, it was determined that the facility did not maintain flame retardant treatment on combustible decorations in accordance with NFPA101 19.3.5.5 and NFPA 701.

Findings include:

The main lobby area had a 4 ' x 26 ' carpeted display case. The carpet was lacking documentation that the display was either inherently flame retardant or treated to be flame resistant.