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Based on observation and interview, the facility failed to display exits signs with continuos illumination during a power failure in all egress paths as evidenced by exit signs that failed to illuminate when tested. This could delay egress in two of eight smoke compartments and cause potential harm to patients and staff in the event of a fire emergency.

Findings:

During a tour of the facility with the Plant Operations Manager (POM) on May 22, 2012, the egress path exit signs were observed and a staff person was interviewed.

At 8:34 a.m., the exit sign near Patient Room 122 was not illuminating when the test button was pressed.

At 8:35 a.m., the POM was interviewed and he stated "that sign is absolutely dead".

At 8:40 a.m., the exit sign outside of the Dayroom was not illuminating when the test button was pressed.

At 8:41 a.m., the POM was interviewed and stated "the battery (pointing at the exit sign) is not working".

Based on observation and interview, the facility failed to maintain the smoke barrier walls. This was evidenced by an unsealed penetration in one of four smoke barrier walls. This affected two of eight smoke compartments, and could result in the spread of smoke or fire to other smoke compartments.

NFPA 101, Life Safety Code, 2000 edition
8.3.6.1 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.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve 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.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a facility tour with the Plant Operations Manager (POM) on May 22, 2012, the facility's smoke barrier walls were observed and the POM was interviewed.

At 12:10 p.m., there was an approximate 1/4 inch round unsealed penetration in the smoke barrier wall near the DON (Director of Nursing) Office. The unsealed penetration in the west side of the wall had two blue and two tan cables coming through the hole.

At 12:11 p.m., the POM was interviewed and he stated "the hole appears to be about 1/4 inch".

Based on observation and interview, the facility failed to maintain its cross-corridor doors to continuously serve as a smoke barrier to prevent the spread of smoke and/or fire. This was evidenced by cross-corridor fire doors that were equipped with latching hardware, and that failed to latch when tested. This deficient practice affected five of eight smoke compartments within the facility, and could result in the spread of smoke and/or fire.

Findings:

During fire alarm testing with the Plant Operations Manager (POM) on May 22, 2012, the cross-corridor doors were observed and a staff member was interviewed.

1. At 9:50 a.m., the North cross-corridor door by Patient Room D101 was not positive latching upon activation of the fire alarm system.
At 9:51 a.m., the POM was interviewed and he stated "the North door needs a little adjusting".

2. At 9:58 a.m., the West ross-corridor door near Patient Room 3 was not positive latching upon activation of the fire alarm system.
At 9:59 a.m., the POM was interviewed and he stated "the door needs to be speeded up a little to latch".

3. At 10:05 a.m., the North cross-corridor door near Patient Room 7 was not positive latching upon activation of the fire alarm system.
At 10:06 a.m., the POM was interviewed and he stated "this door needs to be adjusted to slow down. The door bounces out right before it can latch".

Based on documentation and interview, the facility failed to ensure smoke detectors are provided in accordance with NFPA 72, as evidenced by outdated documentation of sensitivity testing. The smoke detectors could fail and cause potential harm to patients in the event of a fire emergency. This affected eight of eight smoke compartments.

7-3.2.1* Detector sensitivity shall be checked within 1 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. To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the
detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction.

Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.

Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.

Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.

The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Findings:

During a document review with the Plant Operations Manager (POM) on May 22, 2012, the smoke detectors maintenance records were reviewed and staff person was interviewed.

At 9:22 a.m., the smoke detector records were reviewed and provided the following information: the last documented test was performed by Simplex Grinnell on September 29, 2009. No other documentation for sensitivity testing was provided.

At 9:24 a.m., the POM was interviewed and he stated "this (the September 29, 2009 document by Simplex) is the only documented smoke sensitivity test that we have".

Based on observation, the facility failed to maintain the automatic sprinkler system as evidenced by sprinklers escutcheon rings that were missing. The failure to maintain the sprinkler heads could result in a malfunction during a fire. Sprinkler heads are UL listed to respond to a calculated ceiling temperature. Escutcheon rings are part of the UL listing of the sprinkler assembly and a missing escutcheon ring could allow heat and smoke to affect other areas in the building, which could cause harm to patients and staff. This affected one of eight smoke compartments.

Findings:

During a tour of the facility with the Plant Operations Manager on May 22, 2012. the sprinkler system was examined.

At 8:23 a.m., there were two of four sprinklers in the Dry Storage room in the Kitchen that were missing escutcheon rings. The sprinkler near the sever (computer network system) and the sprinkler above the boxed cups on a rack were missing the escutcheon rings.

Based on observation and interview, the facility failed to display exits signs with continuos illumination during a power failure in all egress paths as evidenced by exit signs that failed to illuminate when tested. This could delay egress in two of eight smoke compartments and cause potential harm to patients and staff in the event of a fire emergency.

Findings:

During a tour of the facility with the Plant Operations Manager (POM) on May 22, 2012, the egress path exit signs were observed and a staff person was interviewed.

At 8:34 a.m., the exit sign near Patient Room 122 was not illuminating when the test button was pressed.

At 8:35 a.m., the POM was interviewed and he stated "that sign is absolutely dead".

At 8:40 a.m., the exit sign outside of the Dayroom was not illuminating when the test button was pressed.

At 8:41 a.m., the POM was interviewed and stated "the battery (pointing at the exit sign) is not working".

Based on observation and interview, the facility failed to maintain the smoke barrier walls. This was evidenced by an unsealed penetration in one of four smoke barrier walls. This affected two of eight smoke compartments, and could result in the spread of smoke or fire to other smoke compartments.

NFPA 101, Life Safety Code, 2000 edition
8.3.6.1 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.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve 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.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a facility tour with the Plant Operations Manager (POM) on May 22, 2012, the facility's smoke barrier walls were observed and the POM was interviewed.

At 12:10 p.m., there was an approximate 1/4 inch round unsealed penetration in the smoke barrier wall near the DON (Director of Nursing) Office. The unsealed penetration in the west side of the wall had two blue and two tan cables coming through the hole.

At 12:11 p.m., the POM was interviewed and he stated "the hole appears to be about 1/4 inch".

Based on observation and interview, the facility failed to maintain its cross-corridor doors to continuously serve as a smoke barrier to prevent the spread of smoke and/or fire. This was evidenced by cross-corridor fire doors that were equipped with latching hardware, and that failed to latch when tested. This deficient practice affected five of eight smoke compartments within the facility, and could result in the spread of smoke and/or fire.

Findings:

During fire alarm testing with the Plant Operations Manager (POM) on May 22, 2012, the cross-corridor doors were observed and a staff member was interviewed.

1. At 9:50 a.m., the North cross-corridor door by Patient Room D101 was not positive latching upon activation of the fire alarm system.
At 9:51 a.m., the POM was interviewed and he stated "the North door needs a little adjusting".

2. At 9:58 a.m., the West ross-corridor door near Patient Room 3 was not positive latching upon activation of the fire alarm system.
At 9:59 a.m., the POM was interviewed and he stated "the door needs to be speeded up a little to latch".

3. At 10:05 a.m., the North cross-corridor door near Patient Room 7 was not positive latching upon activation of the fire alarm system.
At 10:06 a.m., the POM was interviewed and he stated "this door needs to be adjusted to slow down. The door bounces out right before it can latch".

Based on documentation and interview, the facility failed to ensure smoke detectors are provided in accordance with NFPA 72, as evidenced by outdated documentation of sensitivity testing. The smoke detectors could fail and cause potential harm to patients in the event of a fire emergency. This affected eight of eight smoke compartments.

7-3.2.1* Detector sensitivity shall be checked within 1 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. To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the
detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction.

Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.

Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.

Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.

The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Findings:

During a document review with the Plant Operations Manager (POM) on May 22, 2012, the smoke detectors maintenance records were reviewed and staff person was interviewed.

At 9:22 a.m., the smoke detector records were reviewed and provided the following information: the last documented test was performed by Simplex Grinnell on September 29, 2009. No other documentation for sensitivity testing was provided.

At 9:24 a.m., the POM was interviewed and he stated "this (the September 29, 2009 document by Simplex) is the only documented smoke sensitivity test that we have".

Based on observation, the facility failed to maintain the automatic sprinkler system as evidenced by sprinklers escutcheon rings that were missing. The failure to maintain the sprinkler heads could result in a malfunction during a fire. Sprinkler heads are UL listed to respond to a calculated ceiling temperature. Escutcheon rings are part of the UL listing of the sprinkler assembly and a missing escutcheon ring could allow heat and smoke to affect other areas in the building, which could cause harm to patients and staff. This affected one of eight smoke compartments.

Findings:

During a tour of the facility with the Plant Operations Manager on May 22, 2012. the sprinkler system was examined.

At 8:23 a.m., there were two of four sprinklers in the Dry Storage room in the Kitchen that were missing escutcheon rings. The sprinkler near the sever (computer network system) and the sprinkler above the boxed cups on a rack were missing the escutcheon rings.