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Based on observation and testing, the facility failed to provide partitions that resist the passage of smoke in a fully sprinkled building.

Findings include:

While inspecting corridor walls on March 5, 2013 at 12:05 p.m., the surveyor observed penetrations in the corridor wall above the electrical and data rooms located near the nurses station on the south wing of the facility.

These deficient practices have the potential of 1 of 6 smoke compartments. The maintenance supervisor and the administrator were notified during an 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 5, 2013 at 12:30 p.m., the maintenance supervisor and the surveyor observed the smoke barrier walls had the following unsealed penetrations:

1. Southeast wing smoke barrier wall had a small penetration around the metal pipe penetrating the wall.
2. Smoke barrier wall across from the chapel had penetrations around data cable that penetrated the wall.
3. Smoke barrier wall located near pharmacy had a 18" x 18" penetrations in wall.

This deficient practice has the potential of affecting 3 of 6 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 doors with self-closing or automatic -closing in accordance with 19.2.2.2.6. This condition has the potential to affect about 50% of the residents and staff.

Finding include:

While inspecting smoke barrier doors on March 5, 2013 at 1:30 p.m., the maintenance supervisor and the surveyor observed a door in the smoke barrier walls, located near the pharmacy did not close completely.

This deficient practice has the potential of affecting 2 of 6 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 the one hour fire rated construction (with 45 minute fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4. This condition affected 25% of the residents and staff or 1 of 4 smoke compartments.

Findings include:

While inspecting hazardous areas on March 5, 2013 at 2:00 p.m., the maintenance person and the the surveyor found the following hazardous areas to have penetrations:

1. Dry Storage Room located behind the kitchen needs a door closure on the door.
2. Boiler Room located on the north end of the building was not sealed all the way to the deck above.

This deficient practice has the potential of affecting 2 of 6 smoke compartments. The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observation, the facility failed to provide readily accessible exit discharge as per NFPA 101 19.2.1, NFPA 101 chapter 7.7.1, 7.1.6.4, 7.1.10.1. and all states letter Ref: S&C -07-05. This condition had the potential to affect 25% of the residents and staff.

Findings Include:

While inspecting exit access on March 5, 2013 at 2:30 p.m., the maintenance person and surveyor found 1 of the 5 required exits to be inaccessible. The exit from the southeast stairwell lacked an all weather surface to the public way.

7.7.1*
Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or
other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.

Exception No. 1: This requirement shall not apply to interior exit discharge as otherwise provided in 7.7.2.
Exception No. 2: This requirement shall not apply to rooftop exit discharge as otherwise provided in 7.7.6.
Exception No. 3: Means of egress shall be permitted to terminate in an exterior area of refuge as provided in Chapters 22 and 23.

7.1.6.4* Slip Resistance.
Walking surfaces shall be slip resistant under foreseeable conditions. The walking surface of each element in the means of egress shall be uniformly slip resistant along the natural path of travel.
K-038 Continued

7.1.10.1*
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

This deficient practice has the potential of affecting 1 of 5 required exits. 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 5, 2013 at 12:15 p.m., the surveyor observed the facility did not provide fire drill information for fire drills from the past 12 months including date, time, what shift, and personnel attending the fire drill.

This deficient practice has the potential of affecting 100% of the residents and staff. 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 as all smoke compartments were affected.

Findings include:

While inspecting documentation on March 5, 2013 at 12:30 p.m., the could not provide documentation stating that they had performed the quarterly test on the sprinkler system. The maintenance supervisor advised that he was not aware that this had to be done quarterly.

This deficient practice has the potential of affecting 100% of the residents and staff. The administrator and maintenance director were notified during the survey and in the exit conference.

Part A

Observation and interview reveals the facility does not monitor the operational status of the emergency generator in accordance with NFPA 110, 1999 Edition, Section 3-5.6, Remote Controls and Alarms and Table 3-5.5.2(d) Safety Indications and Shutdown, where there is no requirement for life support.

Findings include:

On March 5, 2013 at 2:45 p.m., the surveyor and maintenance supervisor observed the generator lacked remote common audible alarm powered by the storage battery as specified in Table 3-5.5.2(d), to monitor low coolant level. This remote alarm shall be located outside of the EPS Service Room at a work site readily observable by personnel..

Specific Code: The National Electrical Code, 1999 Edition. Article 517-40, Essential Electrical Systems for Nursing Homes and Limited Care Facilities

This deficient practice has the potential of affecting 100% of the residents and staff. The administrator and maintenance director were notified during the survey and in the exit conference.

Part B

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.

While reviewing generator testing documentation on March 5, 2013 at 12:50 p.m., the facility failed to provide the monthly and weekly generator testing documentation for the last 12 months.

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 observation and testing, the facility failed to provide partitions that resist the passage of smoke in a fully sprinkled building.

Findings include:

While inspecting corridor walls on March 5, 2013 at 12:05 p.m., the surveyor observed penetrations in the corridor wall above the electrical and data rooms located near the nurses station on the south wing of the facility.

These deficient practices have the potential of 1 of 6 smoke compartments. The maintenance supervisor and the administrator were notified during an 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 5, 2013 at 12:30 p.m., the maintenance supervisor and the surveyor observed the smoke barrier walls had the following unsealed penetrations:

1. Southeast wing smoke barrier wall had a small penetration around the metal pipe penetrating the wall.
2. Smoke barrier wall across from the chapel had penetrations around data cable that penetrated the wall.
3. Smoke barrier wall located near pharmacy had a 18" x 18" penetrations in wall.

This deficient practice has the potential of affecting 3 of 6 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 doors with self-closing or automatic -closing in accordance with 19.2.2.2.6. This condition has the potential to affect about 50% of the residents and staff.

Finding include:

While inspecting smoke barrier doors on March 5, 2013 at 1:30 p.m., the maintenance supervisor and the surveyor observed a door in the smoke barrier walls, located near the pharmacy did not close completely.

This deficient practice has the potential of affecting 2 of 6 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 the one hour fire rated construction (with 45 minute fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4. This condition affected 25% of the residents and staff or 1 of 4 smoke compartments.

Findings include:

While inspecting hazardous areas on March 5, 2013 at 2:00 p.m., the maintenance person and the the surveyor found the following hazardous areas to have penetrations:

1. Dry Storage Room located behind the kitchen needs a door closure on the door.
2. Boiler Room located on the north end of the building was not sealed all the way to the deck above.

This deficient practice has the potential of affecting 2 of 6 smoke compartments. The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observation, the facility failed to provide readily accessible exit discharge as per NFPA 101 19.2.1, NFPA 101 chapter 7.7.1, 7.1.6.4, 7.1.10.1. and all states letter Ref: S&C -07-05. This condition had the potential to affect 25% of the residents and staff.

Findings Include:

While inspecting exit access on March 5, 2013 at 2:30 p.m., the maintenance person and surveyor found 1 of the 5 required exits to be inaccessible. The exit from the southeast stairwell lacked an all weather surface to the public way.

7.7.1*
Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or
other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.

Exception No. 1: This requirement shall not apply to interior exit discharge as otherwise provided in 7.7.2.
Exception No. 2: This requirement shall not apply to rooftop exit discharge as otherwise provided in 7.7.6.
Exception No. 3: Means of egress shall be permitted to terminate in an exterior area of refuge as provided in Chapters 22 and 23.

7.1.6.4* Slip Resistance.
Walking surfaces shall be slip resistant under foreseeable conditions. The walking surface of each element in the means of egress shall be uniformly slip resistant along the natural path of travel.
K-038 Continued

7.1.10.1*
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

This deficient practice has the potential of affecting 1 of 5 required exits. 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 5, 2013 at 12:15 p.m., the surveyor observed the facility did not provide fire drill information for fire drills from the past 12 months including date, time, what shift, and personnel attending the fire drill.

This deficient practice has the potential of affecting 100% of the residents and staff. 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 as all smoke compartments were affected.

Findings include:

While inspecting documentation on March 5, 2013 at 12:30 p.m., the could not provide documentation stating that they had performed the quarterly test on the sprinkler system. The maintenance supervisor advised that he was not aware that this had to be done quarterly.

This deficient practice has the potential of affecting 100% of the residents and staff. The administrator and maintenance director were notified during the survey and in the exit conference.

Part A

Observation and interview reveals the facility does not monitor the operational status of the emergency generator in accordance with NFPA 110, 1999 Edition, Section 3-5.6, Remote Controls and Alarms and Table 3-5.5.2(d) Safety Indications and Shutdown, where there is no requirement for life support.

Findings include:

On March 5, 2013 at 2:45 p.m., the surveyor and maintenance supervisor observed the generator lacked remote common audible alarm powered by the storage battery as specified in Table 3-5.5.2(d), to monitor low coolant level. This remote alarm shall be located outside of the EPS Service Room at a work site readily observable by personnel..

Specific Code: The National Electrical Code, 1999 Edition. Article 517-40, Essential Electrical Systems for Nursing Homes and Limited Care Facilities

This deficient practice has the potential of affecting 100% of the residents and staff. The administrator and maintenance director were notified during the survey and in the exit conference.

Part B

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.

While reviewing generator testing documentation on March 5, 2013 at 12:50 p.m., the facility failed to provide the monthly and weekly generator testing documentation for the last 12 months.

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.