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Based on observations the facility failed to provide the required 30 minute fire resistance rating for smoke barrier walls in accordance with 19.3.7.3, 19.1.6.3, 19.1.6.4. This condition has the potential to affect about 50% of the residents and staff.

Finding include:

While inspecting smoke barrier walls on March 12, 2013 at 10:30 a.m., the maintenance supervisor and the surveyor observed the smoke barrier walls had the following unsealed penetrations:
1. Smoke Barrier wall at the entrance to the Geriatric Psychiatric Wing had penetration around data cable that penetrated the smoke barrier wall.
2. Smoke barrier wall near the Emergency Department had penetrations around data cables that
penetrated the smoke barrier wall.

This deficient practice has the potential of affecting 2 of 3 smoke compartments. The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observations the facility failed to provide the required fire drill documentation as per NFPA 101 chapter 18.7.1.2, 19.7.1.2. This condition had the potential to affect 100% of the residents and staff.

Findings include:

While reviewing fire drill documentation on March 12, 2013 at 12:00 p.m., the surveyor observed the facility did not provide fire drill information for past fire drills including date, time, what shift, and personnel attending the fire drill. No documentation was provided for the last quarter.

This deficient practice has the potential of affecting 3 of 3 smoke compartments. The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observation and testing, the facility failed to provide a properly installed, tested and maintained fire alarm system in accordance with NFPA 70 and NFPA 72. This condition affected 25% of the residents and staff.

Findings include:

While inspecting the fire alarm system on March 12, 2013 at 11:45 a.m., the maintenance person and surveyor found that the horn/strobe located in the hallway next to the kitchen did not activate when the fire alarm was activated.

This deficient practice has the potential of affecting 1 of 3 smoke compartments. The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observation and record review, the facility failed to properly test and maintain the automatic sprinkler system contrary to NFPA 13, NFPA 25. This condition affected 100% of the residents and staff.

Findings include:

While reviewing sprinkler documentation on March 12, 2013 at 12:30 p.m., the facility could not provide documentation stating that they had performed the yearly test on the sprinkler system. The maintenance supervisor advised that the test was done but he has not received the report from the sprinkler contractor.

This deficient practice has the potential of affecting 3 of 3 smoke compartments. The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observations the facility failed to provide the required monthly generator testing in accordance with NFPA 99. This condition has the potential to affect 100% of the residents and staff.

Finding include:

While reviewing generator testing documentation on March 14, 2013 at 12:30 p.m., the facility failed to provide the monthly and weekly generator testing documentation for the months of January and February of 2013.

This deficient practice has the potential of affecting the entire facility. The administrator and the maintenance director were notified during the survey as well as the exit conference.

Based on observations the facility failed to provide the required 30 minute fire resistance rating for smoke barrier walls in accordance with 19.3.7.3, 19.1.6.3, 19.1.6.4. This condition has the potential to affect about 50% of the residents and staff.

Finding include:

While inspecting smoke barrier walls on March 12, 2013 at 10:30 a.m., the maintenance supervisor and the surveyor observed the smoke barrier walls had the following unsealed penetrations:
1. Smoke Barrier wall at the entrance to the Geriatric Psychiatric Wing had penetration around data cable that penetrated the smoke barrier wall.
2. Smoke barrier wall near the Emergency Department had penetrations around data cables that
penetrated the smoke barrier wall.

This deficient practice has the potential of affecting 2 of 3 smoke compartments. The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observations the facility failed to provide the required fire drill documentation as per NFPA 101 chapter 18.7.1.2, 19.7.1.2. This condition had the potential to affect 100% of the residents and staff.

Findings include:

While reviewing fire drill documentation on March 12, 2013 at 12:00 p.m., the surveyor observed the facility did not provide fire drill information for past fire drills including date, time, what shift, and personnel attending the fire drill. No documentation was provided for the last quarter.

This deficient practice has the potential of affecting 3 of 3 smoke compartments. The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observation and testing, the facility failed to provide a properly installed, tested and maintained fire alarm system in accordance with NFPA 70 and NFPA 72. This condition affected 25% of the residents and staff.

Findings include:

While inspecting the fire alarm system on March 12, 2013 at 11:45 a.m., the maintenance person and surveyor found that the horn/strobe located in the hallway next to the kitchen did not activate when the fire alarm was activated.

This deficient practice has the potential of affecting 1 of 3 smoke compartments. The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observation and record review, the facility failed to properly test and maintain the automatic sprinkler system contrary to NFPA 13, NFPA 25. This condition affected 100% of the residents and staff.

Findings include:

While reviewing sprinkler documentation on March 12, 2013 at 12:30 p.m., the facility could not provide documentation stating that they had performed the yearly test on the sprinkler system. The maintenance supervisor advised that the test was done but he has not received the report from the sprinkler contractor.

This deficient practice has the potential of affecting 3 of 3 smoke compartments. The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observations the facility failed to provide the required monthly generator testing in accordance with NFPA 99. This condition has the potential to affect 100% of the residents and staff.

Finding include:

While reviewing generator testing documentation on March 14, 2013 at 12:30 p.m., the facility failed to provide the monthly and weekly generator testing documentation for the months of January and February of 2013.

This deficient practice has the potential of affecting the entire facility. The administrator and the maintenance director were notified during the survey as well as the exit conference.