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Based on observation, the facility is not providing doors to the corridor that stay latched tightly within the doorframes. This deficient practice would not prevent the spread of smoke, affecting all occupants in one of seven smoke zones. This facility has a capacity of 25 with a census of 14 residents.

Findings include:

Observation on 4/15/11, revealed the door to the East Entrance of the Dining Hall would not stay closed tightly within the doorframe. Maintenance Staff A confirmed these observations.

NFPA Standard: Doors in corridor walls shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed per 2000 NFPA 101, 19.3.6.3.1

Based on observation, the facility failed to maintain smoke doors to close and resist the passage of smoke. The smoke doors affected two of the seven smoke compartments in the building. The facility has 25 certified beds and at the time of the survey the census was 14.

Findings include:

Observations on 4/15/11 at 10:20 a.m., revealed while testing the smoke doors outside of the South Entrance of the Dining Hall that the doors did not close completely when tested. Maintenance Staff A confirmed these observations during the survey process.

NFPA standard: Requires doors in smoke barriers to be self-closing and resist the passage of smoke, 2000 NFPA 101, 19.3.7.6

Based on observation, the facility did not provide unobstructed exiting out of two areas in the building. The deficient practice affects all occupants in one of seven smoke zones. This facility has a capacity of 25 with a census of 14.

Findings include:

Observation on 4/15/11, revealed the doors in the Dining Hall had double key dead bolts for the latching mechanism and the Kitchen had four doors with dead bolts and door hardware. Maintenance Staff A verified the observation. According to the facility layout, this was a required exit.

NFPA Standard: Exits shall be located and exit access shall be arranged so that exits are readily accessible at all times. 2000 NFPA 101, 7.5.1.1

(A)
Based on record review and interview, the facility failed to document the emergency egress lighting monthly and annually. This deficient practice affects all compartments and all occupants of the facility.

Findings include:

Record review and staff interview on 4/15/11, revealed the absence of documentation regarding the testing of the emergency battery lighting system. According to Maintenance Staff A, the lights were tested weekly and monthly, but there was no documentation to show that the monthly tests were conducted for 30 seconds or that an annual test was completed for 90 minutes under load.

NFPA standard: Requires a documented monthly test of battery-powered emergency lighting for at least 30 seconds, and an annual test for a duration of 1-1/2 hours. 2000 NFPA 101, 7.9.3

B.)

Based on observation the facility failed to maintain all battery back-up emergency lights. This deficient practice affects all occupants in the Clinic.

Findings include:

Observation on 4/15/11, revealed the emergency light located in the Main entrance did not illuminate when tested. Maintenance Staff A verified this finding.

Based on record review and interview, the facility failed to document the emergency egress lighting monthly and annually. This deficient practice affects all compartments and all occupants of the facility. This facility has a capacity of 25 and a census of 14 residents.

Findings include:

Record review and staff interview on 4/15/11, revealed the absence of documentation regarding the testing of the emergency battery lighting system. According to Maintenance Staff A, the lights were tested weekly and monthly, but there was no documentation to show that the monthly tests were conducted for 30 seconds or that an annual test was completed for 90 minutes under load.

NFPA standard: Requires a documented monthly test of battery-powered emergency lighting for at least 30 seconds, and an annual test for a duration of 1-1/2 hours. 2000 NFPA 101, 7.9.3

Based on observation and record review, the facility did not provide documentation of testing of the battery back-up exit signs and did not maintain the exit signs. This deficient practice affects residents, staff and visitors in the Clinic.

Findings include:

1. Observation on 4/15/11, revealed the facility did not maintain documentation of monthly testing of the emergency lights in the Clinic

2. The following exit signs did not illuminate when tested:

1. Outside of Treatment A
2. Outside of Exam room #3
3. By the Main entrance entrance doors (by the glass doors).

According to the facility layout, which is used in conjunction with the emergency procedures, this designated exit is a required exit.

Based on record review, the facility failed to provide proper documentation of the fire alarm system. All of the facility was directly affected by the deficient practice. The facility has 25 certified beds and at the time of the survey the census was 14.

Findings include:

Record revieew on 4/15/11, revealed the facility did not have documentation of the sensitivity testing of the fire alarm system. The fire alarm is a intelligent system and a print out of the testing shall be provided. Maintenance Staff A confirmed observations during the survey process.

NFPA standard: A permanent record of all inspections, testing, and maintenance shall be maintained that includes periodic tests and applicable information, per the 1999 edition of NFPA 72, table 7-3.2. and listed as required by NFPA 72, 7-5.2.2

Based on observation, the facility failed to maintain fire extinguishers as required. The deficient practice could affect all occupants in one of seven smoke zones. The facility has 25 certified beds and at the time of the survey the census was 14.

Findings include:

Observation of the fire extinguishers on 04/15/11, revealed the fire extinguisher in the CT room was not secured to the wall, just sitting on the counter. Maintenance Staff A verified this finding.

Based on record review, the facility failed to provide a commercial cooking suppression system that is maintained as required. The facility kitchen area is located in one of seven smoke zones and would affect all occupants in that zone. The facility has 25 certified beds and at the time of the survey the facility census was 14.

Findings include:

Record review on 04/15/11, revealed that the kitchen suppression system documentation did not indicate that the system was connected to the fire alarm system. Maintenance Staff A confirmed observations during the survey process.



NFPA Standard: Required fire extinguishing systems for commercial cooking applications shall comply with standard UL 300, required by 1998 NFPA 17, 7-3.2, 1998 NFPA 17A, 3-1.1 and 1998 NFPA 96, 7-2.2

Based on observation, the facility failed to maintain all compressed Carbon Dioxide cylinders secured. This deficient practice affects all occupants in one of the seven smoke zones. The facility has a certified capacity of 25 with the current census of 14 residents.

Findings include:

Observation on 4/15/11, revealed large Carbon Dioxide cylinder unsecured in the garage. Maintenance Staff A verified this finding.

Based on observation, the facility failed maintain the electrical system in accordance with the National Fire Protection Association 70. This deficient practice affects all occupants in the building,

Findings include:

Observation on 4/15/11, revealed the following items plugged into a surge protector in the Breakroom:
1. Refrigerator
2. Toaster
3. Microwave
4. Coffee pot
Maintenance Staff A confirmed observations.

NFPA standard: 1999 NFPA 70, article 240-4

Based on observation, the facility failed to maintain the electrical system in accordance with the National Fire Protections Association 70. This deficient practice affects all occupants in that smoke zone. The facility has a certified capacity of 25 with the current census of 14 residents.

Findings include:

Observation of 4/15/11 at 10:10 a.m., revealed an open electrical junction box located above the Old CT (File room) door in the corridor. Maintenance Staff A confirmed this finding.

Based on observation, the facility is not providing doors to the corridor that stay latched tightly within the doorframes. This deficient practice would not prevent the spread of smoke, affecting all occupants in one of seven smoke zones. This facility has a capacity of 25 with a census of 14 residents.

Findings include:

Observation on 4/15/11, revealed the door to the East Entrance of the Dining Hall would not stay closed tightly within the doorframe. Maintenance Staff A confirmed these observations.

NFPA Standard: Doors in corridor walls shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed per 2000 NFPA 101, 19.3.6.3.1

Based on observation, the facility failed to maintain smoke doors to close and resist the passage of smoke. The smoke doors affected two of the seven smoke compartments in the building. The facility has 25 certified beds and at the time of the survey the census was 14.

Findings include:

Observations on 4/15/11 at 10:20 a.m., revealed while testing the smoke doors outside of the South Entrance of the Dining Hall that the doors did not close completely when tested. Maintenance Staff A confirmed these observations during the survey process.

NFPA standard: Requires doors in smoke barriers to be self-closing and resist the passage of smoke, 2000 NFPA 101, 19.3.7.6

Based on observation, the facility did not provide unobstructed exiting out of two areas in the building. The deficient practice affects all occupants in one of seven smoke zones. This facility has a capacity of 25 with a census of 14.

Findings include:

Observation on 4/15/11, revealed the doors in the Dining Hall had double key dead bolts for the latching mechanism and the Kitchen had four doors with dead bolts and door hardware. Maintenance Staff A verified the observation. According to the facility layout, this was a required exit.

NFPA Standard: Exits shall be located and exit access shall be arranged so that exits are readily accessible at all times. 2000 NFPA 101, 7.5.1.1

(A)
Based on record review and interview, the facility failed to document the emergency egress lighting monthly and annually. This deficient practice affects all compartments and all occupants of the facility.

Findings include:

Record review and staff interview on 4/15/11, revealed the absence of documentation regarding the testing of the emergency battery lighting system. According to Maintenance Staff A, the lights were tested weekly and monthly, but there was no documentation to show that the monthly tests were conducted for 30 seconds or that an annual test was completed for 90 minutes under load.

NFPA standard: Requires a documented monthly test of battery-powered emergency lighting for at least 30 seconds, and an annual test for a duration of 1-1/2 hours. 2000 NFPA 101, 7.9.3

B.)

Based on observation the facility failed to maintain all battery back-up emergency lights. This deficient practice affects all occupants in the Clinic.

Findings include:

Observation on 4/15/11, revealed the emergency light located in the Main entrance did not illuminate when tested. Maintenance Staff A verified this finding.

Based on record review and interview, the facility failed to document the emergency egress lighting monthly and annually. This deficient practice affects all compartments and all occupants of the facility. This facility has a capacity of 25 and a census of 14 residents.

Findings include:

Record review and staff interview on 4/15/11, revealed the absence of documentation regarding the testing of the emergency battery lighting system. According to Maintenance Staff A, the lights were tested weekly and monthly, but there was no documentation to show that the monthly tests were conducted for 30 seconds or that an annual test was completed for 90 minutes under load.

NFPA standard: Requires a documented monthly test of battery-powered emergency lighting for at least 30 seconds, and an annual test for a duration of 1-1/2 hours. 2000 NFPA 101, 7.9.3

Based on observation and record review, the facility did not provide documentation of testing of the battery back-up exit signs and did not maintain the exit signs. This deficient practice affects residents, staff and visitors in the Clinic.

Findings include:

1. Observation on 4/15/11, revealed the facility did not maintain documentation of monthly testing of the emergency lights in the Clinic

2. The following exit signs did not illuminate when tested:

1. Outside of Treatment A
2. Outside of Exam room #3
3. By the Main entrance entrance doors (by the glass doors).

According to the facility layout, which is used in conjunction with the emergency procedures, this designated exit is a required exit.

Based on record review, the facility failed to provide proper documentation of the fire alarm system. All of the facility was directly affected by the deficient practice. The facility has 25 certified beds and at the time of the survey the census was 14.

Findings include:

Record revieew on 4/15/11, revealed the facility did not have documentation of the sensitivity testing of the fire alarm system. The fire alarm is a intelligent system and a print out of the testing shall be provided. Maintenance Staff A confirmed observations during the survey process.

NFPA standard: A permanent record of all inspections, testing, and maintenance shall be maintained that includes periodic tests and applicable information, per the 1999 edition of NFPA 72, table 7-3.2. and listed as required by NFPA 72, 7-5.2.2

Based on observation, the facility failed to maintain fire extinguishers as required. The deficient practice could affect all occupants in one of seven smoke zones. The facility has 25 certified beds and at the time of the survey the census was 14.

Findings include:

Observation of the fire extinguishers on 04/15/11, revealed the fire extinguisher in the CT room was not secured to the wall, just sitting on the counter. Maintenance Staff A verified this finding.

Based on record review, the facility failed to provide a commercial cooking suppression system that is maintained as required. The facility kitchen area is located in one of seven smoke zones and would affect all occupants in that zone. The facility has 25 certified beds and at the time of the survey the facility census was 14.

Findings include:

Record review on 04/15/11, revealed that the kitchen suppression system documentation did not indicate that the system was connected to the fire alarm system. Maintenance Staff A confirmed observations during the survey process.



NFPA Standard: Required fire extinguishing systems for commercial cooking applications shall comply with standard UL 300, required by 1998 NFPA 17, 7-3.2, 1998 NFPA 17A, 3-1.1 and 1998 NFPA 96, 7-2.2

Based on observation, the facility failed to maintain all compressed Carbon Dioxide cylinders secured. This deficient practice affects all occupants in one of the seven smoke zones. The facility has a certified capacity of 25 with the current census of 14 residents.

Findings include:

Observation on 4/15/11, revealed large Carbon Dioxide cylinder unsecured in the garage. Maintenance Staff A verified this finding.

Based on observation, the facility failed maintain the electrical system in accordance with the National Fire Protection Association 70. This deficient practice affects all occupants in the building,

Findings include:

Observation on 4/15/11, revealed the following items plugged into a surge protector in the Breakroom:
1. Refrigerator
2. Toaster
3. Microwave
4. Coffee pot
Maintenance Staff A confirmed observations.

NFPA standard: 1999 NFPA 70, article 240-4

Based on observation, the facility failed to maintain the electrical system in accordance with the National Fire Protections Association 70. This deficient practice affects all occupants in that smoke zone. The facility has a certified capacity of 25 with the current census of 14 residents.

Findings include:

Observation of 4/15/11 at 10:10 a.m., revealed an open electrical junction box located above the Old CT (File room) door in the corridor. Maintenance Staff A confirmed this finding.