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Based on observation and interview, the facility had a room that did not meet the requirements of NFPA 101 LSC (00) Section 19.3.6.3.2. This deficient practice could affect the safety of all patients, staff and visitors, if smoke were allowed to enter the exit access corridors making it untenable.

Findings include:

During the facility tour between 12:00 PM and 4:00PM on 03/09/2015, it was observed that a data room door on the second floor, is a metal frame door with plywood attached to it. A vent is attached to the wood to allow heat to leave to room therefore, because it was open to the corridor it does not meet the requirements with LSC (00), Section 19.3.6.3.2.


This deficient practice was verified by the Facilities Maintence Director(FS).

Based on observation and staff interview, the facility failed to assure fire drills were conducted once per shift per quarter for all staff under varying times and conditions as required by 2000 NFPA 101, Section 19.7.1.2. This deficient practice could affect all patients, visitors and staff.


Findings include:

On facility tour between 12:00 and 4:00 PM on 03/09/2015, the review of the fire drills reports for 06/2014 and 07/2014 were unclear when the drills were performed. When interviewing staff they were also not clear.

1. 2nd quarter



These deficient practices were confirmed by the Facility Maintenance Director (FS) at the time of discovery.

Based on observations, the automatic sprinkler system is not installed and maintained in accordance with NFPA 13 the Standard for the Installation of Sprinkler Systems (99). The failure to maintain the sprinkler system in compliance with NFPA 13 (99) could allow system being place out of service causing a decrease in the fire protection system capability in the event of an emergency that would affect all residents, visitors and staff of the facility.

Findings include:

On facility tour between 12:00 PM to 4:00 PM on 03/09/2015, observations reveled the following deficient conditions were found affecting the facility's fire sprinkler system:

1. The sprinkler gauges located on the main fire sprinkler riser have not been tested/replaced since 2009.


These deficient practices were verified by the Facility Maintenance Director (FS).

Based on documentation review and staff interview, that the facility's general ventilating and air conditioning system (HVAC) was not maintained in accordance with the LSC, Section 19.5.2.1 and NFPA 90A, Section 3-4.7. A noncompliant HVAC system could affect all patients, visitors and staff.

Findings include:

On facility tour between 12:00 PM and 4:00 PM on 03/09/2015, documentation review for fire damper testing for the past 6 years revealed, that the fire/smoke dampers have not been tested. Last documented testing was on not found.

This deficient practice was confirmed by the Facility Maintenance Director (FS) at the time of discovery.

Based on observation and interview, the facility had a room that did not meet the requirements of NFPA 101 LSC (00) Section 19.3.6.3.2. This deficient practice could affect the safety of all patients, staff and visitors, if smoke were allowed to enter the exit access corridors making it untenable.

Findings include:

During the facility tour between 12:00 PM and 4:00PM on 03/09/2015, it was observed that a data room door on the second floor, is a metal frame door with plywood attached to it. A vent is attached to the wood to allow heat to leave to room therefore, because it was open to the corridor it does not meet the requirements with LSC (00), Section 19.3.6.3.2.


This deficient practice was verified by the Facilities Maintence Director(FS).

Based on observation and staff interview, the facility failed to assure fire drills were conducted once per shift per quarter for all staff under varying times and conditions as required by 2000 NFPA 101, Section 19.7.1.2. This deficient practice could affect all patients, visitors and staff.


Findings include:

On facility tour between 12:00 and 4:00 PM on 03/09/2015, the review of the fire drills reports for 06/2014 and 07/2014 were unclear when the drills were performed. When interviewing staff they were also not clear.

1. 2nd quarter



These deficient practices were confirmed by the Facility Maintenance Director (FS) at the time of discovery.

Based on observations, the automatic sprinkler system is not installed and maintained in accordance with NFPA 13 the Standard for the Installation of Sprinkler Systems (99). The failure to maintain the sprinkler system in compliance with NFPA 13 (99) could allow system being place out of service causing a decrease in the fire protection system capability in the event of an emergency that would affect all residents, visitors and staff of the facility.

Findings include:

On facility tour between 12:00 PM to 4:00 PM on 03/09/2015, observations reveled the following deficient conditions were found affecting the facility's fire sprinkler system:

1. The sprinkler gauges located on the main fire sprinkler riser have not been tested/replaced since 2009.


These deficient practices were verified by the Facility Maintenance Director (FS).

Based on documentation review and staff interview, that the facility's general ventilating and air conditioning system (HVAC) was not maintained in accordance with the LSC, Section 19.5.2.1 and NFPA 90A, Section 3-4.7. A noncompliant HVAC system could affect all patients, visitors and staff.

Findings include:

On facility tour between 12:00 PM and 4:00 PM on 03/09/2015, documentation review for fire damper testing for the past 6 years revealed, that the fire/smoke dampers have not been tested. Last documented testing was on not found.

This deficient practice was confirmed by the Facility Maintenance Director (FS) at the time of discovery.