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Based on observations and interview, it was determined the facility failed to maintain smoke barriers that would resist the passage of smoke between smoke compartments in accordance with NFPA standards. The deficiency had the potential to affect eleven (11) of eleven (11) smoke compartments, all residents, staff, and visitors. The facility is certified for eighty (80) beds with a census of twenty-four (24) on the day of the survey. The facility failed to ensure the smoke barriers were sealed around pipes and wires and extended to the roof decking. This deficiency was cited on the survey last year on 03/01/12.

The findings include:

Observations, on 01/09/13 between 8:14 AM and 1:10 PM with the Maintenance Specialist, revealed the smoke partitions, extending above the ceiling located throughout the facility, were penetrated by pipes and wires.

Interview, on 01/09/13 between 8:14 AM and 1:10 PM with the Maintenance Specialist, revealed he had patched the large holes but did not have time to get to all the smaller holes in the smoke barriers.

Interview, on 01/09/13 at 9:00 AM with the Administrator, revealed she was unaware of the penetrations in the smoke barriers. She revealed the Maintenance personnel were in charge of the smoke barriers and the work should have been verified by the Maintenance Manager. She also revealed that she had not followed up the work on the smoke barriers in the facility.

Interview, on 01/09/13 at 9:55 AM with the Maintenance Manager, revealed the Maintenance Specialist had reported to him the smoke barriers had been repaired. At this point the Maintenance Manager did not feel he needed to follow up on the work since it had been reported completed.

This is a repeat deficiency.

Reference: NFPA 101 (2000 Edition).

8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(a) The space between the penetrating item and the smoke barrier shall
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(b) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(c) Where designs take transmission of vibration into consideration, any vibration isolation shall
1. Be made on either side of the smoke barrier, or
2. Be made by an approved device designed for the specific purpose.

Based on observation and interview, it was determined the facility failed to ensure the exits were maintained in accordance with NFPA standards. The deficiency had the potential to affect four (4) of eleven (11) smoke compartments, twenty (20) residents, staff, and visitors. The facility is certified for eighty (80) beds with a census of twenty-four (24) on the day of the survey. The facility failed to ensure two (2) exits had a durable surface to the public way. This deficiency was cited on the survey last year on 03/01/12.

The findings include:

Observation, on 01/09/13 between 8:14 AM and 1:10 PM with the Maintenance Specialist, revealed the North 1 exit does not have a four foot wide durable surface to a public way. Further observation revealed the exit at the playground has a surface to the playground that ends at the playground and starts again on the other side of the playground equipment.

Interview, on 01/09/13 between 8:14 AM and 1:10 PM with the Maintenance Specialist, revealed he was not in charge of this project and that the Chief Financial Officer was in charge of this project.

Interview, on 01/09/13 at 9:00 AM with the Administrator, revealed the Chief Financial Officer and the Vice President of Operations were in charge of the sidewalk project and she had not followed up on the project once it was completed.

Interview, on 01/09/13 at 12:32 PM with the Chief Financial Officer, revealed he was under the impression the sidewalk at the playground had been constructed to meet the 2000 edition. of Life Safety Code. He stated the sections of the playground are removable so the mulch area of the playground could be used. Further interview revealed no staff was trained on the removal of the playground sides in case of an emergency. He also stated he consulted the previous administrator for guidance on the sidewalk install.

This is a repeat deficiency.

Exits must terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge must be of required width and size to provide all occupants with safe access to a public way. 7.7.1.

Reference: NFPA 101 (2000 edition)
7.1.10.1* 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.
7.5.1.1 Exits shall be located and exit access shall be arranged
so that exits are readily accessible at all times.
7.7.1* Exits shall terminate directly at a public way or at an
exterior exit discharge. Yards, courts, open spaces, or other
portions of the exit discharge shall be of required width and
size to provide all occupants with a safe access to a public way.
Exception No. 1: This requirement shall not apply to interior exit discharge
as otherwise provided in 7.7.2.
Exception No. 2: This requirement shall not apply to rooftop exit discharge
as otherwise provided in 7.7.6.
Exception No. 3: Means of egress shall be permitted to terminate in an
exterior area of refuge as provided in Chapters 22 and 23.

CMS S&C letter 5-38

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted quarterly on each shift at random times, in accordance with NFPA standards. The deficiency had the potential to affect eleven (11) of eleven (11) smoke compartments, all residents, staff, and visitors. The facility is certified for eighty (80) beds with a census of twenty-four (24) on the day of the survey. The facility failed to vary the fire drills to ensure they are being conducted at unexpected times and failed to conduct a fire drill in the fourth quarter of 2012. This deficiency was cited on the survey last year on 03/01/12.

The findings include:

Fire Drill review, on 01/08/13 at 3:30 PM with the Maintenance Specialist, revealed the fire drills were not being conducted at random times on all shifts. Fire drills on first shift were conducted routinely between 9:00 AM and 10:00 AM, second shift routinely between 2:50 PM and 3:19 PM, and third shift routinely between 12:05 and 12:40 PM. Further review revealed the last fire drill in 2012 was conducted on 08/30/2012. This deficiency was cited on the survey last year on 03/01/12.

Interview, on 01/08/13 at 3:30 PM with the Maintenance Specialist, revealed he had missed the drills in the fourth quarter and was trying to get back on track in 2013. He stated with one person doing everything that it was hard for him to complete the fire drills as expected. Further interview revealed he did not understand why the fire drills had to be done at random times.

Interview, on 01/08/2013 at 4:25 PM with the Administrator, revealed only Maintenance is responsible for the fire drills conducted at the facility. Maintenance is its own department and ultimately the Vice President of Operations would be responsible for the Maintenance Department. She stated that she does not review the completed fire drills.

Interview, on 01/09/2013 at 9:55 AM with the Maintenance Manager, revealed the Maintenance Specialist was the one who was solely responsible for the fire drills in this facility. The Maintenance Manager does try to ask monthly if the fire drill for the month had been completed. The Maintenance Manager also stated that if the Maintenance Specialist needs help on occasion he will ask him to help and conduct a fire drill.

Interview, on 01/09/2013 at 2:05 PM with the Chief Executive Officer, revealed that Maintenance was solely responsible for fire drills in the facility and she had noy completed any follow up with them to determine if the drills were being completed correctly.

This is a repeat deficiency.

Reference: NFPA 101 (2000 edition)

19.7.1.2.
Fire drills shall be conducted at least quarterly on each shift and at unexpected times under varied conditions on all shifts.

Based on observation and interview, it was determined the facility failed to maintain doors within a required means of egress in accordance with NFPA standards. The deficiency had the potential to affect eleven (11) of eleven (11) smoke compartments, all residents, staff, and visitors. The facility is certified for eighty (80) beds with a census of twenty-four (24) on the day of the survey. The facility failed to ensure egress doors throughout the facility did not have a slide-bolt type lock installed on the egress side of the door. This deficiency was cited on the survey last year on 03/01/12.

The findings include:

Observation, on 01/09/13 between 8:46 AM and 12:30 PM with the Maintenance Specialist, revealed an unapproved lock (slide bolt type) was installed on the egress side of the cross-corridor doors throughout the facility.

Interview, on 01/09/13 between 8:46 AM and 12:30 PM with the Maintenance Specialist, revealed he was aware the slide bolts were supposed to be removed from the cross-corridor doors but he was not aware of how to lock the doors without the slide bolts intact.

Interview, on 01/09/13 at 9:55 AM with the Maintenance Manager, revealed that he did review the plan of correction submitted and was under the impression that the slide bolts had been removed in the facility. Further interview revealed the last thing he knew about the slide bolts was they were removed from the facility.

Interview, on 01/09/13 at 11:00 AM with the Administrator, revealed Maintenance was in charge of removing the slide bolts from the facility. She revealed the Maintenance Director was in charge of ensuring no slide bolts were on egress doors in the facility. Further interview revealed she did not follow up on the plan of correction and check the doors to ensure no slide bolts were installed on them.

This is a repeat deficiency.

Reference: NFPA 101 (2000 Edition)

19.2.2.2.4
Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.

Based on observation and interview it was determined the facility failed to ensure that Alcohol Based Hand Rub dispensers were not installed over or adjacent to an ignition source in accordance with NFPA standards. The deficiency had the potential to affect one (1) of eleven (11) smoke compartments, no residents, staff, and visitors. The facility is certified for eighty (80) beds with a census of twenty-four (24) on the day of the survey. The facility failed to ensure one (1) alcohol dispenser was not installed over a carpeted area. This deficiency was cited on the survey last year on 03/01/12.

The findings include:

Observation, on 01/08/13 at 4:23 PM with the Maintenance Specialist, revealed an Alcohol Based Hand Rub Dispenser installed adjacent to the light switch in the ACR room. Further observation revealed the dispenser was mounted over carpet in a partially sprinklered building.

Interview, on 01/08/13 at 4:23 PM with the Maintenance Specialist, revealed he thought he had removed all the dispensers from the carpeted area of the facility.

Interview, on 01/08/13 at 4:25 PM with the Administrator, revealed maintenance was in charge of moving the alcohol dispensers away from carpeted areas in the facility. She revealed she was under the impression the dispensers had been moved but she had not followed up to determine if all the dispensers had been moved.

Interview, on 01/09/13 at 9:55 AM with the Maintenance Manager, revealed he was under the impression all the alcohol dispensers were moved away from carpeted areas in the facility. The Maintenance Specialist had reported all the dispensers were moved in the facility so there was no follow up to determine compliance.

Interview, on 01/09/13 at 2:05 PM with the Chief Executive Officer, revealed the facility must have overlooked the alcohol dispenser located in the ACR room. She also revealed she had not followed up once the dispensers were moved to determine compliance throughout the facility.

Reference: NFPA 101 (2000 Edition)

Where Alcohol Based Hand Rub (ABHR) dispensers are installed in a corridor:
o The corridor is at least 6 feet wide
o The maximum individual fluid dispenser capacity shall be 1.2 liters (2 liters in suites of rooms)
o The dispensers have a minimum spacing of 4 ft from each other
o Not more than 10 gallons are used in a single smoke compartment outside a storage cabinet.
o Dispensers are not installed over or adjacent to an ignition source.
o If the floor is carpeted, the building is fully sprinklered. 19.3.2.7, CFR 403.744, 418.100, 460.72, 482.41, 483.70, 483.623, 485.623