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Based on observation and staff interview, the facility failed to assure that the 2 hour wall separating the new healthcare facility from the old healthcare facility is properly sealed on both sides, failing to provide the proper fire resistance rating, increasing the risk for the spread of smoke and fire. This deficiency affects one of two smoke zones. The facility has a capacity of 25 with a census of 4 at the time of survey.

Findings Include:

During the tour on January 11th, 2012 between 11:35am and 11:55am the following is observed:
-1) The North 2 hour wall separating the new healthcare facility from the old healthcare facility has a 1 foot by 1 foot hole for the wiring to pass through.
-2) The South 2 hour wall separating the new healthcare facility from the old healthcare facility has a 1 foot by 1 foot hole for the wiring to pass through.

Maintenance Staff A was present and acknowledged the findings.

NFPA Standard: Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2 hour fire resistance rating and constructed of materials as required for the addition. Communicating openings in the fire barriers shall be permitted only in corridors and protected by approved self closing fire doors. 2000 NFPA 101, 19.1.1.4.1 and 19.1.1.4.2

NFPA Standard: Occupied buildings shall meet the minimum construction requirements of the occupancy chapters and NFPA 220. Additions or connected structures of different construction types shall have the ratings and classification based on: separate buildings if a 2 hour or greater vertically aligned fire barrier wall in accordance with NFPA 221 exists between the buildings, or the least fire resistive type of construction of the connected portions. 2000 NFPA 101, 8.2.1

Based on observation and staff interview, the facility failed to assure that corridor doors close tightly to prevent gaps, allowing the spread of smoke and fire. This affects 1 of 2 smoke zones. The facility has a capacity of 25 with a census of 4.

Findings include:

During the tour on January 11, 2012 at 10:30am the following is observed:
-1) The Business Office Admissions door that is open to the corridor is held open with a rubber wedge.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Based upon observation and staff interview, the facility fails to assure that smoke barriers are constructed to provide at least a one half hour fire resistance rating. The deficient practice would not prevent the passage of smoke to other areas of the building, affecting 2 out of 2 smoke zones. The facility has a capacity of 25 with a census of 4 at the time of this survey.

Findings include:

During the tour on Janaury 11, 2012 at 11:30am the following is observed:
-1) The smoke barrier wall by the dietary kitchen has a gap between the varigated roof and the wall.

Maintenance Staff A was present and acknowledged the gap.

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

NFPA Standard: Requires smoke walls to have a fire resistance rating of at least a half hour and to be continuous from floor to roof deck and from outside wall to outside wall. 2000 NFPA 101, 19.3.7.3

Based on observation and staff interview the facility failed to ensure proper separation of hazardous areas from other spaces. This deficient practice would allow for the spread of smoke and fire to travel into the adjacent area, affecting 1 of 2 smoke zones. This facility has a capacity of 25 and a census of 4 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on January 11, 2012 between 11:00am and 11:15am the following is observed:
-1) The mechanical room has penetrations around the metal support beams at the ceiling level of this room.
-2) The medical gas room has penetrations around the metal support beams at the ceiling level of this room.

Maintenance Staff A was present acknowledged these findings.

NFPA Standard: 2000 NFPA 101, 19.3.2.1, "Any hazardous area shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1..."

Based on records review, observation and staff interview the facility failed to ensure that exit lights are testing on a monthly and annual basis. This deficient practice affects 2 of 2 smoke zones. This facility has a capacity of 25 and a census of 4 residents at the time of the survey.

FINDINGS INCLUDE:

During records review and staff interview on January 11, 2012 at 10:10am the following is observed:
-1) There is no documentation that the exit signs have been tested for 30 seconds monthly and 90 minute annually.

Maintenance Staff A was present acknowledged these findings.

NFPA Standard: A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 and 1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 2000 NFPA 101, 7.9.3 and 7.10.9

Based upon a review of records and staff interview the facility fails to assure that the fire alarm system is maintained in accordance with NFPA 72. The deficient practice could result in failure to provide early notification of a fire/smoke condition, affecting 2 of 2 smoke zones. The facility has a capacity of 25 with a census of 4 at the time of this survey.

Findings include:

During records review and staff interview on Janaury 11, 2012 the following is observed:
-1) Review of records revelaed no documentation of the fire dampers being tested in the last 4 years.

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

NFPA Standard: A permanent record of all inspections, testing, and maintenance shall be maintained that includes periodic tests and applicable information, per 1999 NFPA 72, 7-5.2.2 and figure 7-5.2.2; A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70. 2000 NFPA 101, 9.6.1.4

Based on observation, staff interview and record review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice may prevent the emergency power supply from being available at the time of a power loss, affecting 2 out of 2 smoke zones. The facility has a capacity of 25 with a census of 4 at the time of survey.

Findings Include:

During records review and staff interview on January 11, 2012 at 9:30am the following is observed:
-1) There is no start and stop time for the generator test from January 2011 through August 2011.

Maintenance Staff A was present and acknowleged the finding.

NFPA Standard: A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows: Individual visual signals shall indicate: when the emergency power source is operating to supply power to load and when the battery charger is malfunctioning. Individual visual signals plus an audible signal shall warn of the following engine-generator alarm conditions: low oil pressure, low water temperature, excessive water temperature, low fuel (main fuel storage tank contains less than a 3-hour supply), over crank (failed to start), and over speed. Where a regular workstation will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions occur, but need not display these conditions individually. [110: 3-5.5.2]. 1999 NFPA 99, 3-4.1.1.15, 3-5.1, 3-6.1

Based on observation and staff interview the facility failed to assure that electrical equipment is properly maintained and installed in accordance with NFPA 70, National Electric Code. This deficient practice could cause an electrical failure or fire, affecting 1 of 2 smoke zones. This facility has a capacity of 25 with a census of 4.

Findings include:

During the tour on January 11, 2012 at 10:30am the following is observed:
-1) In the Business/Admissions Office there is an extension cord plugged into a surge protector.

Maintenance Staff A was present and acknowleged the finding.

NFPA Standard: All energized distribution panels/components shall be provided with protective covers that keep personnel separated from live electrical components. NFPA 70, 1999 ed

Based on observation and staff interview, the facility failed to assure that the 2 hour wall separating the new healthcare facility from the old healthcare facility is properly sealed on both sides, failing to provide the proper fire resistance rating, increasing the risk for the spread of smoke and fire. This deficiency affects one of two smoke zones. The facility has a capacity of 25 with a census of 4 at the time of survey.

Findings Include:

During the tour on January 11th, 2012 between 11:35am and 11:55am the following is observed:
-1) The North 2 hour wall separating the new healthcare facility from the old healthcare facility has a 1 foot by 1 foot hole for the wiring to pass through.
-2) The South 2 hour wall separating the new healthcare facility from the old healthcare facility has a 1 foot by 1 foot hole for the wiring to pass through.

Maintenance Staff A was present and acknowledged the findings.

NFPA Standard: Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2 hour fire resistance rating and constructed of materials as required for the addition. Communicating openings in the fire barriers shall be permitted only in corridors and protected by approved self closing fire doors. 2000 NFPA 101, 19.1.1.4.1 and 19.1.1.4.2

NFPA Standard: Occupied buildings shall meet the minimum construction requirements of the occupancy chapters and NFPA 220. Additions or connected structures of different construction types shall have the ratings and classification based on: separate buildings if a 2 hour or greater vertically aligned fire barrier wall in accordance with NFPA 221 exists between the buildings, or the least fire resistive type of construction of the connected portions. 2000 NFPA 101, 8.2.1

Based on observation and staff interview, the facility failed to assure that corridor doors close tightly to prevent gaps, allowing the spread of smoke and fire. This affects 1 of 2 smoke zones. The facility has a capacity of 25 with a census of 4.

Findings include:

During the tour on January 11, 2012 at 10:30am the following is observed:
-1) The Business Office Admissions door that is open to the corridor is held open with a rubber wedge.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Based upon observation and staff interview, the facility fails to assure that smoke barriers are constructed to provide at least a one half hour fire resistance rating. The deficient practice would not prevent the passage of smoke to other areas of the building, affecting 2 out of 2 smoke zones. The facility has a capacity of 25 with a census of 4 at the time of this survey.

Findings include:

During the tour on Janaury 11, 2012 at 11:30am the following is observed:
-1) The smoke barrier wall by the dietary kitchen has a gap between the varigated roof and the wall.

Maintenance Staff A was present and acknowledged the gap.

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

NFPA Standard: Requires smoke walls to have a fire resistance rating of at least a half hour and to be continuous from floor to roof deck and from outside wall to outside wall. 2000 NFPA 101, 19.3.7.3

Based on observation and staff interview the facility failed to ensure proper separation of hazardous areas from other spaces. This deficient practice would allow for the spread of smoke and fire to travel into the adjacent area, affecting 1 of 2 smoke zones. This facility has a capacity of 25 and a census of 4 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on January 11, 2012 between 11:00am and 11:15am the following is observed:
-1) The mechanical room has penetrations around the metal support beams at the ceiling level of this room.
-2) The medical gas room has penetrations around the metal support beams at the ceiling level of this room.

Maintenance Staff A was present acknowledged these findings.

NFPA Standard: 2000 NFPA 101, 19.3.2.1, "Any hazardous area shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1..."

Based on records review, observation and staff interview the facility failed to ensure that exit lights are testing on a monthly and annual basis. This deficient practice affects 2 of 2 smoke zones. This facility has a capacity of 25 and a census of 4 residents at the time of the survey.

FINDINGS INCLUDE:

During records review and staff interview on January 11, 2012 at 10:10am the following is observed:
-1) There is no documentation that the exit signs have been tested for 30 seconds monthly and 90 minute annually.

Maintenance Staff A was present acknowledged these findings.

NFPA Standard: A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 and 1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 2000 NFPA 101, 7.9.3 and 7.10.9

Based upon a review of records and staff interview the facility fails to assure that the fire alarm system is maintained in accordance with NFPA 72. The deficient practice could result in failure to provide early notification of a fire/smoke condition, affecting 2 of 2 smoke zones. The facility has a capacity of 25 with a census of 4 at the time of this survey.

Findings include:

During records review and staff interview on Janaury 11, 2012 the following is observed:
-1) Review of records revelaed no documentation of the fire dampers being tested in the last 4 years.

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

NFPA Standard: A permanent record of all inspections, testing, and maintenance shall be maintained that includes periodic tests and applicable information, per 1999 NFPA 72, 7-5.2.2 and figure 7-5.2.2; A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70. 2000 NFPA 101, 9.6.1.4

Based on observation, staff interview and record review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice may prevent the emergency power supply from being available at the time of a power loss, affecting 2 out of 2 smoke zones. The facility has a capacity of 25 with a census of 4 at the time of survey.

Findings Include:

During records review and staff interview on January 11, 2012 at 9:30am the following is observed:
-1) There is no start and stop time for the generator test from January 2011 through August 2011.

Maintenance Staff A was present and acknowleged the finding.

NFPA Standard: A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows: Individual visual signals shall indicate: when the emergency power source is operating to supply power to load and when the battery charger is malfunctioning. Individual visual signals plus an audible signal shall warn of the following engine-generator alarm conditions: low oil pressure, low water temperature, excessive water temperature, low fuel (main fuel storage tank contains less than a 3-hour supply), over crank (failed to start), and over speed. Where a regular workstation will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions occur, but need not display these conditions individually. [110: 3-5.5.2]. 1999 NFPA 99, 3-4.1.1.15, 3-5.1, 3-6.1

Based on observation and staff interview the facility failed to assure that electrical equipment is properly maintained and installed in accordance with NFPA 70, National Electric Code. This deficient practice could cause an electrical failure or fire, affecting 1 of 2 smoke zones. This facility has a capacity of 25 with a census of 4.

Findings include:

During the tour on January 11, 2012 at 10:30am the following is observed:
-1) In the Business/Admissions Office there is an extension cord plugged into a surge protector.

Maintenance Staff A was present and acknowleged the finding.

NFPA Standard: All energized distribution panels/components shall be provided with protective covers that keep personnel separated from live electrical components. NFPA 70, 1999 ed