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Based on observation and staff interview the facility fails to maintain smoke barriers to at least one hour fire resistance. This deficient practice would prevent containment of fire and smoke, affecting approximately 48 residents in two of three smoke zones. The facility has a capacity of 72 with a census of 25 at the time of survey.

Findings include:

During the survey on April 19, 2016 at 2:05 PM it is observed that the 1 hour smoke barrier wall between the Sunrise smoke compartment and the Cedar smoke compartment has two penetrations. There is a 4 inch square opening in this barrier above the ductwork and a ¾ inch hole below the ductwork observed above the ceiling tile level above the smoke barrier doors in the corridor east of the dining area.

The Facilities Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1 hour.

Exception No. 1: Where an atrium is used, smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with Exception No. 2 to 8.2.5.6(1). Not less than two separate smoke compartments shall be provided on each floor.
Exception No. 2:* Dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems. 2000 NFPA 101, 18.3.7.3

Review of the following NFPA Standard revealed: 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

Based on record review and staff interview, the facility is not conducting fire drills as required quarterly on each shift and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency, affecting all occupants in three of three smoke zones. The facility has a capacity of 72 with a census of 25 at the time of survey.

Findings include:

On April 18, 2016 at 3:45 PM fire drills records were reviewed from October 2015 to date and during the review it is observed that there is no documentation of fire drills conducted during the 1st quarter of 2016.

The Facilities Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 2000 NFPA 101, 18.7.1.2

Based on observation and staff interview, the facility fails to provide a metal container with self-closing cover device in the designated smoking areas. This deficient practice increases the risk of fire affecting two of two outdoor smoking areas. The facility has a capacity of 72 with a census of 25 at the time of survey.

Findings include:

During the survey on April 18, at 12:10 PM it is observed that neither of the designated smoking areas on the east side of the building is provided with a metal receptacle with self-closing lid that is readily available.

The Facilities Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Smoking. Smoking regulations shall be adopted and shall include not less than the following provisions:

(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.

Exception: In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.

(2) Smoking by patients classified as not responsible shall be prohibited.

Exception: The requirement of 18.7.4(2) shall not apply where the patient is under direct supervision.

(3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.

(4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. 2000 NFPA 101, Section 18.7.4

Based on observation and staff interview, the facility failed to provide documentation proving that water heaters requiring a boiler inspection have been inspected and certified. Failure to comply with the State's inspection requirements could result in a hazardous condition due improper installation or the malfunction of a heat-producing appliance, affecting approximately 24 residents in one of three smoke zones. The facility has a capacity of 72 with a census of 25 at the time of survey.

Findings include:

During the survey on April 18, 2016 at 11:15 PM it is observed that two boilers and two water storage tanks located in the Sunrise smoke compartment exterior boiler room do not have a current boiler certificates posted.

The Facilities Director was present and acknowledged the findings.

Based on observation and staff interview the facility failed to provide a remote stop for the emergency generator power supply as required. The deficient practice may prevent the emergency power supply from being stopped at the time of a power loss or malfunction of the generator set, affecting all occupants in three of three smoke zones. The facility has a capacity of 72 with a census of 25 at the time of survey.

Findings include:

During the survey on April 18, 2016 at 11:30 AM it is observed that the remote stop for the generator is located on the external weatherproof exterior of the generator enclosure.

The Facilities Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems. 2000 NFPA 101, 7.9.2.3

Review of the following NFPA Standard revealed: Emergency generators, where required for compliance with this Code, shall be tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. 2000 NFPA 101, 9.1.3

Review of the following NFPA Standard revealed: All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building. 1999 NFPA 110, 3-5.5.6

Based on observation and staff interview the facility fails to maintain smoke barriers to at least one hour fire resistance. This deficient practice would prevent containment of fire and smoke, affecting approximately 48 residents in two of three smoke zones. The facility has a capacity of 72 with a census of 25 at the time of survey.

Findings include:

During the survey on April 19, 2016 at 2:05 PM it is observed that the 1 hour smoke barrier wall between the Sunrise smoke compartment and the Cedar smoke compartment has two penetrations. There is a 4 inch square opening in this barrier above the ductwork and a ¾ inch hole below the ductwork observed above the ceiling tile level above the smoke barrier doors in the corridor east of the dining area.

The Facilities Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1 hour.

Exception No. 1: Where an atrium is used, smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with Exception No. 2 to 8.2.5.6(1). Not less than two separate smoke compartments shall be provided on each floor.
Exception No. 2:* Dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems. 2000 NFPA 101, 18.3.7.3

Review of the following NFPA Standard revealed: 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

Based on record review and staff interview, the facility is not conducting fire drills as required quarterly on each shift and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency, affecting all occupants in three of three smoke zones. The facility has a capacity of 72 with a census of 25 at the time of survey.

Findings include:

On April 18, 2016 at 3:45 PM fire drills records were reviewed from October 2015 to date and during the review it is observed that there is no documentation of fire drills conducted during the 1st quarter of 2016.

The Facilities Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 2000 NFPA 101, 18.7.1.2

Based on observation and staff interview, the facility fails to provide a metal container with self-closing cover device in the designated smoking areas. This deficient practice increases the risk of fire affecting two of two outdoor smoking areas. The facility has a capacity of 72 with a census of 25 at the time of survey.

Findings include:

During the survey on April 18, at 12:10 PM it is observed that neither of the designated smoking areas on the east side of the building is provided with a metal receptacle with self-closing lid that is readily available.

The Facilities Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Smoking. Smoking regulations shall be adopted and shall include not less than the following provisions:

(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.

Exception: In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.

(2) Smoking by patients classified as not responsible shall be prohibited.

Exception: The requirement of 18.7.4(2) shall not apply where the patient is under direct supervision.

(3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.

(4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. 2000 NFPA 101, Section 18.7.4

Based on observation and staff interview, the facility failed to provide documentation proving that water heaters requiring a boiler inspection have been inspected and certified. Failure to comply with the State's inspection requirements could result in a hazardous condition due improper installation or the malfunction of a heat-producing appliance, affecting approximately 24 residents in one of three smoke zones. The facility has a capacity of 72 with a census of 25 at the time of survey.

Findings include:

During the survey on April 18, 2016 at 11:15 PM it is observed that two boilers and two water storage tanks located in the Sunrise smoke compartment exterior boiler room do not have a current boiler certificates posted.

The Facilities Director was present and acknowledged the findings.

Based on observation and staff interview the facility failed to provide a remote stop for the emergency generator power supply as required. The deficient practice may prevent the emergency power supply from being stopped at the time of a power loss or malfunction of the generator set, affecting all occupants in three of three smoke zones. The facility has a capacity of 72 with a census of 25 at the time of survey.

Findings include:

During the survey on April 18, 2016 at 11:30 AM it is observed that the remote stop for the generator is located on the external weatherproof exterior of the generator enclosure.

The Facilities Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems. 2000 NFPA 101, 7.9.2.3

Review of the following NFPA Standard revealed: Emergency generators, where required for compliance with this Code, shall be tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. 2000 NFPA 101, 9.1.3

Review of the following NFPA Standard revealed: All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building. 1999 NFPA 110, 3-5.5.6