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Based on observation and staff interview, the facility failed to provide separation of corridors from use areas. This deficient practice would allow smoke and fire products to travel from the use area into the exit corridor, affecting one of three smoke zones. This facility has a capacity of 26 and a census of 16 patients.

Findings Include:

During the survey on 07/02/2012 between 8:45 AM and 1:15 PM the following is observed:

1. There is a pass through grill in the wall at the west end of hall 1 from the exterior oxygen storage room.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, and shall have a fire resistance rating of not less than 1/2 hour. Exception: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system, a corridor shall be permitted to be separated from all other areas by non-rated partitions and terminate at the ceiling if the ceiling is constructed to limit the transfer of smoke. Exception: Existing corridor partitions shall be permitted to terminate at ceilings that are not an integral part of a floor construction if 5 ft or more of space exists between the top of the ceiling subsystem and the bottom of the floor or roof above, provided that the ceiling is a fire-rated assembly tested to have a fire resistance rating of not less than 1 hour in compliance with the provisions of 8.2.3.1. 2000 NFPA 101, 19.3.6.2.

Based on observation and staff interview, the facility is not ensuring that corridor doors fit tightly within the door frame to resist the passage of smoke. This deficient practice of allowing gaps around doors will not ensure the doors will resist the passage of smoke, affecting one of three smoke zones. The facility has a capacity of 26 with a census of 16 patients.

Findings Include:

During the survey on 07/02/2012 between 8:45 AM and 1:15 PM the following is observed:

1. There is a gap at the top of the corridor door to the physical therapy department.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop down or plunger type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3.

Based on observation and staff interview the facility fails to maintain one of four smoke barriers to at least one half hour fire resistance and ensure that all penetrations are properly sealed. This deficient practice would prevent containment of fire and smoke, affecting two of three smoke zones. This facility has a capacity of 26 and census of 16 patients.

Findings Include:

During the survey on 07/02/2012 between 8:45 AM and 1:15 PM the following is observed:

1. There is a section of drywall missing above the smoke doors on the right hand side of the hall 1 side of the smoke barrier to the lobby.

2. There is an unsealed penetration around wires above the smoke doors between hall 1 and the lobby.

Maintenance Staff A was present and acknowledged the findings.

NFPA Standard: Requires smoke walls to have a fire resistance rating of at least a half hour and to be continuous from floor to roof deck and from outside wall to outside wall. 2000 NFPA 101, 19.3.7.3.

NFPA Standard: 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 failed to maintain and test smoke detectors for sensitivity in accordance with NFPA 72, 7-3.2.1. This deficient practice may prevent the prompt initiating of smoke detectors alerting the residents and staff to smoke products due to the devices being out of calibration, affecting three of three smoke zones This facility has a capacity of 26 and a census of 17 at the time of the survey.

Findings Include:

During the survey on 07/02/2012 between 8:45 AM and 1:15 PM the following is observed:

1. There is no record of sensitivity testing on file.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Smoke detector sensitivity shall be checked within one year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed. 1999 NFPA 72, 7-3.2.1.

Based on record review and staff interviews, the facility failed to assure that the sprinkler system is maintained and tested in accordance with the NFPA 13 and NFPA 25. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting one of three smoke zones. The facility has a capacity of 26 with a census of 16.

Findings Include:

During the survey on 07/02/2012 between 8:45 AM and 1:15 PM the following is observed:

1. The sprinkler head and piping are hanging below the ceiling and not covered by an escutcheon.

Maintenance Staff A was present and acknowledged the finding.


NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. 1999 NFPA 13, 12.1.

NFPA Standard: Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. 1998 NFPA 25, 2 2.1.1.

NFPA Standard: Corrective maintenance includes, but is not limited to, replacing loaded, corroded, or painted sprinklers; replacing missing or loose pipe hangers; cleaning clogged fire pump impellers; replacing valve seats and gaskets; restoring heat in areas subject to freezing temperatures where water filled piping is installed; and replacing worn or missing fire hose or nozzles. 1998 NFPA 25, 1-11.3.

Based on observation and staff interview the facility fails to ensure that all means of egress are free of all obstructions or impediments to a full instant use. This deficient practice could impede all occupants from exiting in the event of a fire or other emergency situation, affecting one of three smoke zones. This facility has a capacity of 26 and a census of 16 at the time of the survey.

Findings Include:

During the survey on 07/02/2012 between 8:45 AM and 1:15 PM the following is observed:

1. Two charting stations that pull down from the wall were left down and unattended in the 500 hall and extend approximately 2 feet from the wall.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress from, or visibility thereof. 2000 NFPA 101, 7.1.10.2.1.

NFPA Standard: 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. 2000 NFPA 101, 7.1.10.1.

Based on observation, record review and staff interview the facility fails to ensure the facility will have adequate backup power in the event of an electrical outage to maintain equipment for patients on life support. This deficient practice could result in patient deaths and affects all smoke zones. The facility has a capacity of 26 and a census of 16 at the time or the survey.

Findings include:

During the survey on 07/02/2012 between 8:45 AM and 1:15 PM the following is observed:

1. The facility has a Cummings 100 kW Type I diesel generator on a trailer connected to the facility for emergency power. This generator has a 130 gallon capacity fuel tank. The facility operates at or below 25 percent of the generators output. This generator is temporary until one can be purchased and permanently set. Based on documentation by Cummings on fuel consumption, there is not enough onsite fuel to maintain the operation of the generator for the required 96 hours.

Maintenance Staff A and Administrative Staff A were present and acknowledged the findings. Maintenance Staff A stated he was working with the local Cummings office to have a 300 gallon additional tank set on the site.

NFPA Standard: The following energy sources shall be permitted for use for the emergency power supply (EPS): liquid petroleum products at atmospheric pressure or liquefied petroleum gas (liquid or vapor withdrawal) or natural or synthetic gas. Exception: For Level 1 installations in locations where the probability of interruption of off-site fuel supplies is high (e.g., due to earthquake, flood damage, or a demonstrated utility unreliability), on-site storage of an alternate energy source sufficient to allow full output of the emergency power supply system (EPSS) to be delivered for the class specified shall be required, with provision for automatic transfer from the primary energy source to the alternate energy source. 1999 NFPA 110, 3-1 and 1999 NFPA 99 3-4.1.1.13
NFPA Standard: The fuel supply for the generator set shall comply with 3-1.1 and 3-4.2 of NFPA 110, Standard for Emergency and Standby Power Systems. 1999 NFPA 99 3-4.1.1.13

Based on observation and staff interview, the facility did not ensure that electrical wiring and equipment is installed and maintained in accordance with NFPA 70, National Electrical Code. This deficient practice does not ensure prevention of an electrical fire or electric shock hazard, affecting one of three smoke zones. This facility has a capacity of 26 and a census of 16.

Findings Include:

During the survey on 07/02/2012 between 8:45 AM and 1:15 PM the following is observed:

1. An electrical outlet junction box was loose and extruding from the wall in room 518

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Boxes used to enclose flush devices shall be of such design that the devices will be completely enclosed on back and sides, and that substantial support for the devices will be provided. Screws for supporting the box shall not be used in attachment of the device contained therein. 1999 NFPA 70, 370-19.

NFPA Standard: In walls or ceilings of concrete, tile, or other noncombustible material, boxes shall be intstalled so that the front edge of the box will not be set back of the finished surface more than 1/4 inch (6.35 mm). In walls and ceilings constructed of wood or other combustible material, boxes shall be flush with the finished surface or project therefrom.