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Based on observation and staff interview, the facility failed to ensure that smoke separation doors would prevent smoke from escaping into the next smoke compartment. Facility census was 6 of 16.

Findings are:
Observations during the facility tour on 12/22/11, from 12:32 pm to 12:40 pm revealed:
1. The double doors by Pre/Post Op failed to fully close and latch.
2. The double doors in the Nursing Corridor failed to fully close and latch.
In an interview conducted at the time of observations, (12/22/11, from 12:32 pm to 12:40 pm), Maintenance A acknowledged the condition of the doors.

Based on observation and staff interview, the facility failed to provide a door that positively latched to separate a hazardous area. This condition had the potential to allow super-heated gasses from a fire to push open a door and allow smoke and fire to escape the room. Facility census was 6 of 16.

Findings are:
Observations during the facility tour on 12/22/11, at 12:01 pm revealed the Server Room Door Number One failed to latch when swung shut by the automatic closure. This Server Room was equipped with a clean agent suppression system.
In an interview conducted at the time of observations (12/22/11, at 12:01 pm), Maintenance A agreed the door did not latch.

Based on observation and staff interview, the facility failed to provide a new stairwell in accordance with the National Fire Protection Association, 101, 7.2. This condition had the potential to allow smoke and fire to spread directly into the stairwell. Facility census was 6 of 16.

Findings are:
Observation during the facility tour on 12/22/11, from 11:48 am to 11:59 am revealed:
1. The one hour fire resistance rated North Stairwell that served Area D revealed the penthouse at the top level opened directly into the stairwell. The facility failed to prohibit the room from entering directly into the stair tower.
2. The Area D Penthouse door failed to close and latch when swung shut by the automatic closure.
3. The facility failed to prohibit storage in the North and South Area D Stairwells. Storage at the base of each stairwell such as book cases, shelves and picture frames were stored in the stairwells.
In an interview conducted at the time of observation, (12/22/11, from 11:48 am to 11:59 am), Maintenance A acknowledged the findings.

Actual NFPA Standard:
NFPA 101, 7.1.3.2.1 (d) Openings in exit enclosures shall be limited to those necessary for access to the enclosure from normally occupied spaces and corridors and for egress from the enclosure.

NFPA 101, 7.2.2.5.3* Usable Space.
There shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress.
Exception: Enclosed, usable space shall be permitted under stairs, provided that the space is separated from the stair enclosure by the same fire resistance as the exit enclosure. Entrance to such enclosed usable space shall not be from within the stair enclosure. (See also 7.1.3.2.3.)

Based on observation and staff interview, the facility failed to maintain a horizontal exit door in accordance with the National Fire Protection, 101. This condition had the potential to allow the doors to swing open during a fire due to the superheated gases from the fire conditions, spreading smoke and fire throughout the exit corridors. Facility census was 6 of 16.

Findings are:
Observation during the facility tour on 12/22/11, from 12:29 pm to 1:08 pm revealed:
1. The 90 minute Pre/Post Op Fire Doors failed to latch when swung shut by the closures.
2. The 500 Hall LTC 90 minute Fire Doors failed to latch when swung shut by the closures.
In an interview conducted at the time of observation, (12/22/11, from 12:29 pm to 1:08 pm), Maintenance A acknowledged that the doors failed to latch.

Based on record review and staff interview, the facility failed to maintain the fire alarm system in accordance with the National Fire Protection Association, 72. This condition increased the potential that the fire alarm would fail to detect smoke. Facility census was 6 of 16.

Findings are:
Record review of fire alarm inspection reports revealed the fire alarm failed to be tested on a semiannual basis. The last recorded inspection occurred on 3/4/2011.
In an interview conducted at the time of record review, (12/20/11, at 11:28 am), Administrator A confirmed the inspection failed to be conducted.

Based on observation, record review and staff interview, the facility failed to maintain the automatic sprinkler system in accordance with the National Fire Protection Association, 25. This condition had the potential to slow the activation of the sprinkler system in the Long Term Care or for the sprinkler system to activate without notifying occupants by fire alarm activation. Facility census was 6 of 16.

Findings are:
Observation during the facility tour on 12/22/11, at 12:54 pm revealed missing ceiling tiles due to construction in the 300 Hall of the Long Term Care and by the Nurse Station in the Long Term Care.
Record review during the facility tour revealed the facility failed to provide quarterly testing of the wet sprinkler system. The last recorded quarterly inspection occurred on 6/30/11.
In an interview conducted at the time of observation and record review (12/22/11, at 12:54 pm), Maintenance A acknowledged the missing quarterly test and ceiling tiles.

NFPA 25, 2-2.6 Alarm Devices.
Alarm devices shall be inspected quarterly to verify that they are free of physical damage.

Based on observation and staff interview, the facility failed to ensure that smoke separation doors would prevent smoke from escaping into the next smoke compartment. Facility census was 6 of 16.

Findings are:
Observations during the facility tour on 12/22/11, from 12:32 pm to 12:40 pm revealed:
1. The double doors by Pre/Post Op failed to fully close and latch.
2. The double doors in the Nursing Corridor failed to fully close and latch.
In an interview conducted at the time of observations, (12/22/11, from 12:32 pm to 12:40 pm), Maintenance A acknowledged the condition of the doors.

Based on observation and staff interview, the facility failed to provide a door that positively latched to separate a hazardous area. This condition had the potential to allow super-heated gasses from a fire to push open a door and allow smoke and fire to escape the room. Facility census was 6 of 16.

Findings are:
Observations during the facility tour on 12/22/11, at 12:01 pm revealed the Server Room Door Number One failed to latch when swung shut by the automatic closure. This Server Room was equipped with a clean agent suppression system.
In an interview conducted at the time of observations (12/22/11, at 12:01 pm), Maintenance A agreed the door did not latch.

Based on observation and staff interview, the facility failed to provide a new stairwell in accordance with the National Fire Protection Association, 101, 7.2. This condition had the potential to allow smoke and fire to spread directly into the stairwell. Facility census was 6 of 16.

Findings are:
Observation during the facility tour on 12/22/11, from 11:48 am to 11:59 am revealed:
1. The one hour fire resistance rated North Stairwell that served Area D revealed the penthouse at the top level opened directly into the stairwell. The facility failed to prohibit the room from entering directly into the stair tower.
2. The Area D Penthouse door failed to close and latch when swung shut by the automatic closure.
3. The facility failed to prohibit storage in the North and South Area D Stairwells. Storage at the base of each stairwell such as book cases, shelves and picture frames were stored in the stairwells.
In an interview conducted at the time of observation, (12/22/11, from 11:48 am to 11:59 am), Maintenance A acknowledged the findings.

Actual NFPA Standard:
NFPA 101, 7.1.3.2.1 (d) Openings in exit enclosures shall be limited to those necessary for access to the enclosure from normally occupied spaces and corridors and for egress from the enclosure.

NFPA 101, 7.2.2.5.3* Usable Space.
There shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress.
Exception: Enclosed, usable space shall be permitted under stairs, provided that the space is separated from the stair enclosure by the same fire resistance as the exit enclosure. Entrance to such enclosed usable space shall not be from within the stair enclosure. (See also 7.1.3.2.3.)

Based on observation and staff interview, the facility failed to maintain a horizontal exit door in accordance with the National Fire Protection, 101. This condition had the potential to allow the doors to swing open during a fire due to the superheated gases from the fire conditions, spreading smoke and fire throughout the exit corridors. Facility census was 6 of 16.

Findings are:
Observation during the facility tour on 12/22/11, from 12:29 pm to 1:08 pm revealed:
1. The 90 minute Pre/Post Op Fire Doors failed to latch when swung shut by the closures.
2. The 500 Hall LTC 90 minute Fire Doors failed to latch when swung shut by the closures.
In an interview conducted at the time of observation, (12/22/11, from 12:29 pm to 1:08 pm), Maintenance A acknowledged that the doors failed to latch.

Based on record review and staff interview, the facility failed to maintain the fire alarm system in accordance with the National Fire Protection Association, 72. This condition increased the potential that the fire alarm would fail to detect smoke. Facility census was 6 of 16.

Findings are:
Record review of fire alarm inspection reports revealed the fire alarm failed to be tested on a semiannual basis. The last recorded inspection occurred on 3/4/2011.
In an interview conducted at the time of record review, (12/20/11, at 11:28 am), Administrator A confirmed the inspection failed to be conducted.

Based on observation, record review and staff interview, the facility failed to maintain the automatic sprinkler system in accordance with the National Fire Protection Association, 25. This condition had the potential to slow the activation of the sprinkler system in the Long Term Care or for the sprinkler system to activate without notifying occupants by fire alarm activation. Facility census was 6 of 16.

Findings are:
Observation during the facility tour on 12/22/11, at 12:54 pm revealed missing ceiling tiles due to construction in the 300 Hall of the Long Term Care and by the Nurse Station in the Long Term Care.
Record review during the facility tour revealed the facility failed to provide quarterly testing of the wet sprinkler system. The last recorded quarterly inspection occurred on 6/30/11.
In an interview conducted at the time of observation and record review (12/22/11, at 12:54 pm), Maintenance A acknowledged the missing quarterly test and ceiling tiles.

NFPA 25, 2-2.6 Alarm Devices.
Alarm devices shall be inspected quarterly to verify that they are free of physical damage.