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Based on observation and staff interview, the facility failed to provide interior finish materials that meet the flame spread requirements in 2000 NFPA 101, Sections 19.3.3.1, 19.3.3.2 and 10.2.3. This deficient practice could affect all resident, staff, and visitors.

Findings include:
On facility tour between 09:00 AM and 11:30 AM on 08/10/2015, observation revealed, and was verified by facility maintenance director (SM), that the following areas had Plywood on walls. An interview with facility maintenance director (SM) revealed that the facility had no flame spread documentation on the material and when asked.

This deficient practice was verified by the facility Maintenance staff member (SM).

Based on interview and review of available documentation, the facility has not been conducting sensitivity testing of the smoke detectors on the fire alarm system in accordance with NFPA 72 (99), Sec. 7-3.2.1. This deficient practice could affect all residents, visitors, and staff.

Findings include:

On facility tour between 9:00 AM to 11:30 AM on 08/10/15, a review of the facility's available fire alarm test documentation revealed that the facility failed to conduct the required sensitivity test of each smoke detector. The last smoke detector sensitivity test was conducted on 07/20/12.


This deficient practice was verified by the facility Maintenance staff member (SM).

Based on documentation review and staff interview, the facility failed to insure the emergency generator as a reliable fuel source in accordance with the requirements of 2000 NFPA 101 - 9.1.3 and 1999 NFPA 110 6-4.2 (a) & (b) and 6-4.2.2. The deficient practice could affect all residents.

Findings include:

On facility tour between 9:00 AM and 11:30 AM on 08/15/2015, the documentation review of the natural gas emergency generator revealed and the Director of Maintenance confirmed the fuel source is natural gas for the emergency generator. The Facility Maintenance Director confirmed the facility did not have a letter. The letter needs to contain all five points as required below:

1. A statement of reasonable reliability of the natural gas delivery
2. A brief description that supports the statement regarding the reliability
3. A statement that there is a low probability of interruption of the natural gas
4. A brief description that supports the statement regarding the low probability of interruption
5. The signature of technical personnel from the natural gas vendor.


This deficient practice was confirmed by the Director of Maintenance (SM).

Based on observation and staff interview, the facility failed to provide interior finish materials that meet the flame spread requirements in 2000 NFPA 101, Sections 19.3.3.1, 19.3.3.2 and 10.2.3. This deficient practice could affect all resident, staff, and visitors.

Findings include:
On facility tour between 09:00 AM and 11:30 AM on 08/10/2015, observation revealed, and was verified by facility maintenance director (SM), that the following areas had Plywood on walls. An interview with facility maintenance director (SM) revealed that the facility had no flame spread documentation on the material and when asked.

This deficient practice was verified by the facility Maintenance staff member (SM).

Based on interview and review of available documentation, the facility has not been conducting sensitivity testing of the smoke detectors on the fire alarm system in accordance with NFPA 72 (99), Sec. 7-3.2.1. This deficient practice could affect all residents, visitors, and staff.

Findings include:

On facility tour between 9:00 AM to 11:30 AM on 08/10/15, a review of the facility's available fire alarm test documentation revealed that the facility failed to conduct the required sensitivity test of each smoke detector. The last smoke detector sensitivity test was conducted on 07/20/12.


This deficient practice was verified by the facility Maintenance staff member (SM).

Based on documentation review and staff interview, the facility failed to insure the emergency generator as a reliable fuel source in accordance with the requirements of 2000 NFPA 101 - 9.1.3 and 1999 NFPA 110 6-4.2 (a) & (b) and 6-4.2.2. The deficient practice could affect all residents.

Findings include:

On facility tour between 9:00 AM and 11:30 AM on 08/15/2015, the documentation review of the natural gas emergency generator revealed and the Director of Maintenance confirmed the fuel source is natural gas for the emergency generator. The Facility Maintenance Director confirmed the facility did not have a letter. The letter needs to contain all five points as required below:

1. A statement of reasonable reliability of the natural gas delivery
2. A brief description that supports the statement regarding the reliability
3. A statement that there is a low probability of interruption of the natural gas
4. A brief description that supports the statement regarding the low probability of interruption
5. The signature of technical personnel from the natural gas vendor.


This deficient practice was confirmed by the Director of Maintenance (SM).