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Based on observations, the facility did not maintain the 1-hour fire/smoke resistive construction of ceiling and wall assemblies.

Findings include:

1. On 12/28/11 at 9:12 a.m., the penetration around the sprinkler inspector's test pipe extending through the ceiling was not sealed with a fire stop material in the small open area off of the kitchen that housed refrigerators.

2. On 12/28/11 at 9:46 a.m., an unsealed/unfinished construction space at the wall separation between the south exit stair case in the basement and the vacuum air machine room. There is a gap approximately three feet long and one half inch wide between the former outside wall rock facade and the wall of the vacuum air machine room.

3. On 12/28/2011 at 9:47 a.m., the pass through for the vacuum air machine supply lines were reviewed. The lines go through the old outer wall of the facility into the ceiling space of the basement floor. The lines and vacuum system enters the space with voids around the penetrations. The dryer vent to the east that is not longer in use is not rated for at least 1 hour as well. This wall shall be maintained at at least a 1 hour separation.

4. On 12/28/2011 at 10:55 a.m., the crawl space access panel was found in the storage room in the basement. The panel had a single 5/8th inch gypsum board construction with metal frame. The access panel to the crawl space did not have a latching mechanism as well. The crawl space was not sprinklered. The panel frame within the 1-hour rated wall had exposed 2 inch by 4 inch framing as well. This opening should be protected with at least 1 hour construction.

Based on observations, the facility did not maintain the fire resistive construction of all corridor walls to be resistant to the passage of smoke.

Findings include:

On 12/27/2011 at 5:00 p.m., a penetration around two gray colored call light wires was not sealed in the corridor wall of the lower section of the skylight located above the exit corridor across from resident room 7.

Based on observation, the facility did not ensure that vertical openings between floors were sealed and/or enclosed by fire resistive construction.

Findings include:

In accordance with Section 19.3.1.1 of NFPA 101, 2000 Edition, any vertical opening shall be enclosed or protected in accordance with 8.2.5 of the Life Safety Code. Where enclosure is provided, the construction shall have not less than a 1-hour resistance rating.

On 12/28/2011 at 11:10 a.m., the sprinkler head penetration within the elevator's fire rated shaft (at the top) was sealed with unrated foam material.

Based on observations, the facility failed to maintain the fire resistance rating of smoke barriers.

Findings include:

In accordance with Section 8.3.6.1 of NFPA 101, 2000 Edition; 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: (1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions: a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

1. On 12/28/2011 at 8:10 a.m., two unsealed penetrations around two different sprinkler pipes were observed in the smoke barrier above the ceiling in the attic at the smoke barrier near the nursing home entrance.

2. On 12/28/2011 at 8:35 a.m., two unsealed penetrations around two different sprinkler pipes were observed above the ceiling at the smoke barrier near the dining room.

3. On 12/28/2011 at 10:30 a.m., several previously sealed penetrations in the smoke barrier near the CEO's office in the basement were in need of repaired to be refilled with a fire stop material.

Based on observations, the facility did not maintain the fire rated assemblies protecting smoke compartments, and assure that smoke barrier doors closed flush with each other at the meeting edges to prevent the passage of smoke.

Findings include:

A set of 1-hour rated smoke barrier doors separating the kitchen, the dining room and the activity rooms from the rest of the facility were exercised on 12/27/2011 at 5:03 p.m. The doors failed to latch when exercised at least 3 times. The northern most door was catching on the upper horizontal part of the door frame as evidence of the rubbing of paint on the frame.

Based on observation, the facility did not maintain the fire/smoke rating of all hazardous areas.

Findings include:

On 12/28/2011 at 10:15 a.m., an unsealed ceiling penetration was observed above the air charge valve in the boiler room.

Based on observation and staff interview, the facility failed to ensure that the location of the electrical circuit servicing the fire alarm panel was permanently addressed on the panel.

Findings include:

In accordance with 1-5.2.5.2 of NFPA 72 (1999 edition) the connections to the light and power service for the Fire Alarm Control Panel (FACP) shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

On 12/27/2011 at 3:39 p.m., it was observed that the location of the electrical circuit servicing the fire alarm panel was not permanently addressed on the panel. When the maintenance director was asked, he stated he was not aware of this requirement. The maintenance director showed the electrical panel that housed the circuit breaker (#8 in panel CE in the ice machine room adjacent to the main nurses' station) and it was also not identified with red marking.

Based on observation, the facility did not ensure complete coverage of the building by an approved automatic sprinkler system.

Findings include:

The building is of Type V (111) construction that requires that it be protected throughout by an approved automatic sprinkler system meeting the standards of NFPA 13, 1999 Edition.

In accordance with NFPA 13, section 5-13.6.1, sidewall spray sprinklers shall be installed at the bottom of each elevator hoistway not more than 2 ft (0.61 m) above the floor of the pit.
Exception: For enclosed, noncombustible elevator shafts that do not contain combustible hydraulic fluids, the sprinklers at the bottom of the shaft are not required.

On 12/28/2011 at 11:05 a.m., the elevator shaft was inspected with the maintenance director. The shaft lacked an automatic sprinkler head at the base of the hoistway. There was evidence of spilled hydraulic fluid at the bottom of the shaft.

Based on observations, the facility did not ensure portable fire extinguishers were maintained in accordance with the standards of NFPA 10.

Findings included:

In accordance with NFPA 10 1998 Edition, section 4-3.2 Procedures;
periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility

On 12/28/2011 at 10:48 a.m., a fire extinguisher was observed hanging behind a corridor door of the bookkeeping room in the basement. Additionally, the fire extinguisher was blocked by the facility network server.

Based on observations and staff interview, the facility did not ensure that kitchen hood exhaust system had been inspected semiannually by a qualified and certified company or person(s).

Findings include:

The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction at frequent intervals, at least semiannually, prior to surfaces becoming heavily contaminated with grease or oily sludge per section 8-3.1 of NFPA 96, 1998 Edition. Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the exhaust system shall be cleaned by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction per section 8-3.1.1 of NFPA 96. When a vent cleaning service is used, a certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company per 8-3.1.2 of NFPA 96.

On 12/28/2011 at 9:01 a.m., label provided by the professional company who cleaned the kitchen hood exhaust system indicated that the hood was cleaned in April of 2011 and the next inspection/cleaning was due in April of 2012. When asked, the dietary manager, also verified this information and stated that the hood was cleaned annually by the company stated on the label affixed on the hood.

The review of the kitchen hood extinguishing reports and other maintenance logs on 12/27/2011 did not confirm that the hood exhaust system had been inspected/cleaned in October of 2011. There was no additional evidence that the hood was inspected every 6 months (semiannually) by the contractor and cleaned if necessary.

Based on observations, the facility did not to maintain exit corridors free from obstructions that would interfere with their instant use in case of fire or other emergency.

Findings include:

In accordance with Centers for Medicare and Medicaid Services Survey and Certification letters S&C-04-41 and S&C-10-18 items not in use in exit corridors (i.e. left unattended for more than 30 minutes), such as linen carts, medication carts, janitorial equipment, chairs, wheelchairs, delivery items and other similar items must be stored properly or removed from the corridor.

On 12/27/2011 and on 12/28/11 an orange colored bench was observed reducing the width of the nursing home corridor from 8 feet down to 69 inches in front of the main entrance. On 10/28/2011 at 10:00 a.m., staff member B relocated the obstruction to reestablish the proper corridor width after he was notified.

Based on observation, the facility did not to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 Edition and NFPA 99, 1999 Edition; or interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings include:

In accordance with NFPA 101 and Section 39.5.1 Utilities, Utilities shall comply with the provisions of Section 9.1. Further, Section 9.1.2 Electric requires that electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

The limited use of circuit breaker protected power strips is acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, washers, dryers, heating units and oxygen concentrators are connected to the power strip.

In accordance with Article 110-26 and table 110-26(a) of NFPA 70 there shall be maintained a clear working space of at least 36" around electrical equipment such as panel boards to permit ready and safe operations of such equipment. This working space can not be used for storage purposes.

1. On 12/27/2011 at 3:51 p.m., circuit breaker #'s 13, 15, and 17 in electrical panel CE were in on positions, however, they were marked as spares in the panel directory. The circuit number 39 was not identified in the panel directory and it was in on position.

2. On 12/27/2011 at 3:52 p.m., circuit breaker #16 in electrical panel C was in on position and marked as spare in the panel directory.

3. On 10/28/2011 at 8:50 a.m., circuit breaker #'s 41 and 42 were once marked as Whirlpool tub and crossed off on the panel directory of electric panel D. At 5:12 p.m. the breakers were tested by staff member B and discovered that they belonged to the whirlpool tub.

4. On 12/28/2011 at 9:58 a.m. a Maytag clothes washer was plugged into a surge protector in the laundry room.

5. On 12/28/2011 at 10:01 a.m., an electrical panel marked "Emergency" had none of its circuits breakers numbered to identify them.

6. On 12/28/2011 at 10:25 a.m., a refrigerator in the dentist's office was plugged into a surge protector.

7. On 12/28/2011 at 10:40 a.m., the electrical panel was blocked by a desk in the social worker's office.

Based on observations, the facility did not maintain the 1-hour fire/smoke resistive construction of ceiling and wall assemblies.

Findings include:

1. On 12/28/11 at 9:12 a.m., the penetration around the sprinkler inspector's test pipe extending through the ceiling was not sealed with a fire stop material in the small open area off of the kitchen that housed refrigerators.

2. On 12/28/11 at 9:46 a.m., an unsealed/unfinished construction space at the wall separation between the south exit stair case in the basement and the vacuum air machine room. There is a gap approximately three feet long and one half inch wide between the former outside wall rock facade and the wall of the vacuum air machine room.

3. On 12/28/2011 at 9:47 a.m., the pass through for the vacuum air machine supply lines were reviewed. The lines go through the old outer wall of the facility into the ceiling space of the basement floor. The lines and vacuum system enters the space with voids around the penetrations. The dryer vent to the east that is not longer in use is not rated for at least 1 hour as well. This wall shall be maintained at at least a 1 hour separation.

4. On 12/28/2011 at 10:55 a.m., the crawl space access panel was found in the storage room in the basement. The panel had a single 5/8th inch gypsum board construction with metal frame. The access panel to the crawl space did not have a latching mechanism as well. The crawl space was not sprinklered. The panel frame within the 1-hour rated wall had exposed 2 inch by 4 inch framing as well. This opening should be protected with at least 1 hour construction.

Based on observations, the facility did not maintain the fire resistive construction of all corridor walls to be resistant to the passage of smoke.

Findings include:

On 12/27/2011 at 5:00 p.m., a penetration around two gray colored call light wires was not sealed in the corridor wall of the lower section of the skylight located above the exit corridor across from resident room 7.

Based on observation, the facility did not ensure that vertical openings between floors were sealed and/or enclosed by fire resistive construction.

Findings include:

In accordance with Section 19.3.1.1 of NFPA 101, 2000 Edition, any vertical opening shall be enclosed or protected in accordance with 8.2.5 of the Life Safety Code. Where enclosure is provided, the construction shall have not less than a 1-hour resistance rating.

On 12/28/2011 at 11:10 a.m., the sprinkler head penetration within the elevator's fire rated shaft (at the top) was sealed with unrated foam material.

Based on observations, the facility failed to maintain the fire resistance rating of smoke barriers.

Findings include:

In accordance with Section 8.3.6.1 of NFPA 101, 2000 Edition; 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: (1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions: a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

1. On 12/28/2011 at 8:10 a.m., two unsealed penetrations around two different sprinkler pipes were observed in the smoke barrier above the ceiling in the attic at the smoke barrier near the nursing home entrance.

2. On 12/28/2011 at 8:35 a.m., two unsealed penetrations around two different sprinkler pipes were observed above the ceiling at the smoke barrier near the dining room.

3. On 12/28/2011 at 10:30 a.m., several previously sealed penetrations in the smoke barrier near the CEO's office in the basement were in need of repaired to be refilled with a fire stop material.

Based on observations, the facility did not maintain the fire rated assemblies protecting smoke compartments, and assure that smoke barrier doors closed flush with each other at the meeting edges to prevent the passage of smoke.

Findings include:

A set of 1-hour rated smoke barrier doors separating the kitchen, the dining room and the activity rooms from the rest of the facility were exercised on 12/27/2011 at 5:03 p.m. The doors failed to latch when exercised at least 3 times. The northern most door was catching on the upper horizontal part of the door frame as evidence of the rubbing of paint on the frame.

Based on observation, the facility did not maintain the fire/smoke rating of all hazardous areas.

Findings include:

On 12/28/2011 at 10:15 a.m., an unsealed ceiling penetration was observed above the air charge valve in the boiler room.

Based on observation and staff interview, the facility failed to ensure that the location of the electrical circuit servicing the fire alarm panel was permanently addressed on the panel.

Findings include:

In accordance with 1-5.2.5.2 of NFPA 72 (1999 edition) the connections to the light and power service for the Fire Alarm Control Panel (FACP) shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

On 12/27/2011 at 3:39 p.m., it was observed that the location of the electrical circuit servicing the fire alarm panel was not permanently addressed on the panel. When the maintenance director was asked, he stated he was not aware of this requirement. The maintenance director showed the electrical panel that housed the circuit breaker (#8 in panel CE in the ice machine room adjacent to the main nurses' station) and it was also not identified with red marking.

Based on observation, the facility did not ensure complete coverage of the building by an approved automatic sprinkler system.

Findings include:

The building is of Type V (111) construction that requires that it be protected throughout by an approved automatic sprinkler system meeting the standards of NFPA 13, 1999 Edition.

In accordance with NFPA 13, section 5-13.6.1, sidewall spray sprinklers shall be installed at the bottom of each elevator hoistway not more than 2 ft (0.61 m) above the floor of the pit.
Exception: For enclosed, noncombustible elevator shafts that do not contain combustible hydraulic fluids, the sprinklers at the bottom of the shaft are not required.

On 12/28/2011 at 11:05 a.m., the elevator shaft was inspected with the maintenance director. The shaft lacked an automatic sprinkler head at the base of the hoistway. There was evidence of spilled hydraulic fluid at the bottom of the shaft.

Based on observations, the facility did not ensure portable fire extinguishers were maintained in accordance with the standards of NFPA 10.

Findings included:

In accordance with NFPA 10 1998 Edition, section 4-3.2 Procedures;
periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility

On 12/28/2011 at 10:48 a.m., a fire extinguisher was observed hanging behind a corridor door of the bookkeeping room in the basement. Additionally, the fire extinguisher was blocked by the facility network server.

Based on observations and staff interview, the facility did not ensure that kitchen hood exhaust system had been inspected semiannually by a qualified and certified company or person(s).

Findings include:

The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction at frequent intervals, at least semiannually, prior to surfaces becoming heavily contaminated with grease or oily sludge per section 8-3.1 of NFPA 96, 1998 Edition. Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the exhaust system shall be cleaned by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction per section 8-3.1.1 of NFPA 96. When a vent cleaning service is used, a certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company per 8-3.1.2 of NFPA 96.

On 12/28/2011 at 9:01 a.m., label provided by the professional company who cleaned the kitchen hood exhaust system indicated that the hood was cleaned in April of 2011 and the next inspection/cleaning was due in April of 2012. When asked, the dietary manager, also verified this information and stated that the hood was cleaned annually by the company stated on the label affixed on the hood.

The review of the kitchen hood extinguishing reports and other maintenance logs on 12/27/2011 did not confirm that the hood exhaust system had been inspected/cleaned in October of 2011. There was no additional evidence that the hood was inspected every 6 months (semiannually) by the contractor and cleaned if necessary.

Based on observations, the facility did not to maintain exit corridors free from obstructions that would interfere with their instant use in case of fire or other emergency.

Findings include:

In accordance with Centers for Medicare and Medicaid Services Survey and Certification letters S&C-04-41 and S&C-10-18 items not in use in exit corridors (i.e. left unattended for more than 30 minutes), such as linen carts, medication carts, janitorial equipment, chairs, wheelchairs, delivery items and other similar items must be stored properly or removed from the corridor.

On 12/27/2011 and on 12/28/11 an orange colored bench was observed reducing the width of the nursing home corridor from 8 feet down to 69 inches in front of the main entrance. On 10/28/2011 at 10:00 a.m., staff member B relocated the obstruction to reestablish the proper corridor width after he was notified.

Based on observation, the facility did not to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 Edition and NFPA 99, 1999 Edition; or interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings include:

In accordance with NFPA 101 and Section 39.5.1 Utilities, Utilities shall comply with the provisions of Section 9.1. Further, Section 9.1.2 Electric requires that electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

The limited use of circuit breaker protected power strips is acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, washers, dryers, heating units and oxygen concentrators are connected to the power strip.

In accordance with Article 110-26 and table 110-26(a) of NFPA 70 there shall be maintained a clear working space of at least 36" around electrical equipment such as panel boards to permit ready and safe operations of such equipment. This working space can not be used for storage purposes.

1. On 12/27/2011 at 3:51 p.m., circuit breaker #'s 13, 15, and 17 in electrical panel CE were in on positions, however, they were marked as spares in the panel directory. The circuit number 39 was not identified in the panel directory and it was in on position.

2. On 12/27/2011 at 3:52 p.m., circuit breaker #16 in electrical panel C was in on position and marked as spare in the panel directory.

3. On 10/28/2011 at 8:50 a.m., circuit breaker #'s 41 and 42 were once marked as Whirlpool tub and crossed off on the panel directory of electric panel D. At 5:12 p.m. the breakers were tested by staff member B and discovered that they belonged to the whirlpool tub.

4. On 12/28/2011 at 9:58 a.m. a Maytag clothes washer was plugged into a surge protector in the laundry room.

5. On 12/28/2011 at 10:01 a.m., an electrical panel marked "Emergency" had none of its circuits breakers numbered to identify them.

6. On 12/28/2011 at 10:25 a.m., a refrigerator in the dentist's office was plugged into a surge protector.

7. On 12/28/2011 at 10:40 a.m., the electrical panel was blocked by a desk in the social worker's office.