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Based on observation and staff interview the facility fails to maintain the integrity of the building construction by allowing openings into the ceiling. This deficient practice would allow fire products to spread to the concealed ceiling space in one of three smoke zones. The facility has a capacity of 25 residents with a census of 7 at the time of survey.

Findings Include:

During the tour conducted on 10/22/12 between 9:30 a.m. and 12:00 p.m., the following is observed:

1.) There is a penetration of the ceiling around the ducting in the closet between rooms 9 and 10.

2.) There is open space around the ceiling tile and ceiling-mounted smoke detector Z-2 in the surgery hall.

Maintenance Staff A and B were present and acknowledged the finding. The detector was made to fit tightly to resist the passage of smoke by staff at the time of the survey and the repairs were confirmed by the surveyor.

NFPA Standard: One story is permitted with complete sprinkler coverage and one-hour rated ceilings for all parts of a facility composed of wood frame construction, type V (111). 2000 NFPA 101, table 18/19.1.6.2

Based on observation and staff interview the facility is not ensuring that room doors latch properly. This deficient practice of not ensuring that corridor doors latch properly prevents the ability of the facility to properly confine fire and smoke products, affecting one of three smoke zones. The facility has a capacity of 25 with a census of 7 at the time of survey.

Findings Include:

During the tour conducted on 10/22/12 between 9:30 a.m. and 12:00 p.m., the following is observed:

1.) The blanket closet door does not positively latch between rooms 11 and 12.

Maintenance Staff A and B were present and acknowledged the findings.

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 record review and staff interview, the facility is not conducting fire drills as required quarterly on each shift and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency and affects three of three smoke zones. This facility has a capacity of 25 and a census of 7 at the time of the survey.

Findings Include:

During the tour conducted on 10/22/12 between 9:30 a.m. and 12:00 p.m., the following is observed:

1.) Review of the facility's fire drill records shows that fire drills conducted on the 2nd and 3rd shift during the last two quarters revealed that each drill is being held within 30 minutes on each occasion.

Maintenance Staff A and B were present and acknowledged the findings.

NFPA Standard: Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 2000 NFPA 101, 19.7.1.2.

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, including the improper maintenance of and access to the electrical panel. 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 25 and a census of 7 at the time of the survey.

Findings Include:

During the tour conducted on 10/22/12 between 9:30 a.m. and 12:00 p.m., the following is observed:

1.) There are blankets obstructing access to the electrical panel in the closet between rooms 11 and 12.

2.) There is a multiplug adaptor in use on the upper west wall behind the nurse's station.

Maintenance Staff A and B were present and acknowledged the findings.

NFPA Standard: A working space of not less than 30 inches in width, 36 inches in depth and 78 inches in height shall be provided in front of electrical service equipment (panel). Where electrical service equipment is wider than 30 inches, the working space shall not be less than the width of the equipment. 1999 NFPA 70, 110-26 (a) (2).

Based on observation and staff interview the facility fails to maintain the integrity of the building construction by allowing openings into the ceiling. This deficient practice would allow fire products to spread to the concealed ceiling space in one of three smoke zones. The facility has a capacity of 25 residents with a census of 7 at the time of survey.

Findings Include:

During the tour conducted on 10/22/12 between 9:30 a.m. and 12:00 p.m., the following is observed:

1.) There is a penetration of the ceiling around the ducting in the closet between rooms 9 and 10.

2.) There is open space around the ceiling tile and ceiling-mounted smoke detector Z-2 in the surgery hall.

Maintenance Staff A and B were present and acknowledged the finding. The detector was made to fit tightly to resist the passage of smoke by staff at the time of the survey and the repairs were confirmed by the surveyor.

NFPA Standard: One story is permitted with complete sprinkler coverage and one-hour rated ceilings for all parts of a facility composed of wood frame construction, type V (111). 2000 NFPA 101, table 18/19.1.6.2

Based on observation and staff interview the facility is not ensuring that room doors latch properly. This deficient practice of not ensuring that corridor doors latch properly prevents the ability of the facility to properly confine fire and smoke products, affecting one of three smoke zones. The facility has a capacity of 25 with a census of 7 at the time of survey.

Findings Include:

During the tour conducted on 10/22/12 between 9:30 a.m. and 12:00 p.m., the following is observed:

1.) The blanket closet door does not positively latch between rooms 11 and 12.

Maintenance Staff A and B were present and acknowledged the findings.

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 record review and staff interview, the facility is not conducting fire drills as required quarterly on each shift and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency and affects three of three smoke zones. This facility has a capacity of 25 and a census of 7 at the time of the survey.

Findings Include:

During the tour conducted on 10/22/12 between 9:30 a.m. and 12:00 p.m., the following is observed:

1.) Review of the facility's fire drill records shows that fire drills conducted on the 2nd and 3rd shift during the last two quarters revealed that each drill is being held within 30 minutes on each occasion.

Maintenance Staff A and B were present and acknowledged the findings.

NFPA Standard: Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 2000 NFPA 101, 19.7.1.2.

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, including the improper maintenance of and access to the electrical panel. 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 25 and a census of 7 at the time of the survey.

Findings Include:

During the tour conducted on 10/22/12 between 9:30 a.m. and 12:00 p.m., the following is observed:

1.) There are blankets obstructing access to the electrical panel in the closet between rooms 11 and 12.

2.) There is a multiplug adaptor in use on the upper west wall behind the nurse's station.

Maintenance Staff A and B were present and acknowledged the findings.

NFPA Standard: A working space of not less than 30 inches in width, 36 inches in depth and 78 inches in height shall be provided in front of electrical service equipment (panel). Where electrical service equipment is wider than 30 inches, the working space shall not be less than the width of the equipment. 1999 NFPA 70, 110-26 (a) (2).