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Based on observation and staff interview the facility failed to maintain corridor walls with a fire resistance rating of not less than 1/2 hour and that were smoke resistive. The deficient practice affects 1 of 4 smoke zones. The facility has a capacity of 25 and a census of 8.

Findings include:

During the tour on 3/22/11 between 11:30 AM and 3:00 PM it is observed the corridor walls above the ceiling tiles do not go to the roof deck in the Admissions/X-ray corridor. There is no sprinkler coverage in this area of the building.

Staff A was present and confirmed the finding. Staff A stated the building may soon be sprinkled.


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 assuring that one of three smoke barriers is free of penetrations that compromise the fire-resistance rating of the smoke barrier walls and allow for the passage of smoke and fire to another smoke zone. This deficient practice affects 2 of 4 smoke zones. This facility has a capacity of 25 and a census of 8.

Findings include:

During the tour on 3/22/11 between 11:30 AM and 3:00 PM it is observed there had been some reconstruction done to the smoke barrier wall. In doing so, the bottom section of the smoke barrier wall had been cut out and is now replaced with a metal bracing. There is no sheet rock covering the metal, or documentation of the rating of the metal bracing to the 100 hall smoke barrier wall, nurse desk side.


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 observation and staff interview the facility failed to ensure proper separation of hazardous areas from other spaces. This deficient practice would allow for the spread of smoke and fire to travel into the adjacent area, affecting 1 of 4 smoke zones. This facility has a capacity of 25 and a census of 8.

Findings include:

During the tour on 3/22/11 between 11:30 AM and 3:00 PM it is observed the self closer is not latching the door to the door frame inside the Emergency Soiled Utility that leads into the Emergency room.

Staff A was present and confirmed the finding. Staff A stated the door is not latching due to humidity.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Based on observation and staff interview the facility fails to assure there is normal illumination in all exit corridors, failing to ensure that all areas of egress will not be left in total darkness. This deficient practice affects in 2 of 4 smoke zones. The facility has a capacity of 25 and a census of 8.

Findings include:

During the tour on 3/22/11 between 11:30 AM and 3:00 PM the following is observed:

--1) There is no normal illumination in the X-ray exit corridor, South basement exit stairwell, Therapy area in the basement, and the 500 corridor. These lights can be turned off with a manual switch leaving the area in darkness.
--2) There is a keyed switch for the over head lights for the 200 hall.

Staff A was present and confirmed the finding. Staff A stated the lights will be rewired and switches will be replaced with cover plates.

NFPA Standard: Required illumination shall be arranged so that the failure of any single bulb or unit does not result in less than .2 foot-candles of illumination in any designated area. 2000 NFPA 101, 7.8.1.4

Based on record review and staff interview, the facility fails to assure that fire drills are conducted using the fire alarm except when a silent drill is acceptable per code. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of an emergency, affecting 4 of 4 smoke zones. The facility has a capacity of 25 with a census of 8.

Findings include:

During the tour on 3/22/11 between 11:30 AM and 3:00 PM it is observed the 2nd shift fire drill on 2/9/11 was conducted at 7:05 PM and was a silent drill.


Staff A confirmed the observations and findings at time of review. Staff a stated the fire drill silent drills will only be conducted between 9:00 PM and 6:00 AM.


NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 19.7.1.2

Based on record review and staff interview the facility failed to assure that the fire alarm system required for life safety is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. This deficiency fails to ensure that the fire alarm system control functions are working properly jeopardizing the safety of all building occupants. This deficiency would affect 4 of the 4 smoke zones. This facility has a capacity of 25 with a census of 8.

Findings include:

During the tour on 3/22/11 between 11:30 AM and 3:00 PM it is observed there is no smoke detection at the fire alarm panel that is located in the Physical Plant.

Staff A was present and confirmed the finding. Staff A stated this issue has already been discussed with the fire alarm company.


NFPA Standard: Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of the code, such device, equipment, system, condition, arrangement, level of protection, or any other feature shall thereafter be maintained unless the Code exempts such maintenance. 2000 NFPA 101, 4.5.7

Based on observation and staff interview the facility failed to assure that sprinklers are properly maintained and clear of obstructions. The deficient practice fails to ensure the required sprinkler coverage in the event of a fire, affecting 1 of the 4 smoke zones. The facility has a capacity of 25 with a census of 8.

Findings include:

During the tour on 3/22/11 between 11:30 AM and 3:00 PM it is observed there is a rusted sprinkler head in patient room 206 bath room.

Staff A was present and confirmed the finding. Staff A stated it appeared there was a leak in the attic.

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

Based on observation and staff interview the facility failed to maintain corridor walls with a fire resistance rating of not less than 1/2 hour and that were smoke resistive. The deficient practice affects 1 of 4 smoke zones. The facility has a capacity of 25 and a census of 8.

Findings include:

During the tour on 3/22/11 between 11:30 AM and 3:00 PM it is observed the corridor walls above the ceiling tiles do not go to the roof deck in the Admissions/X-ray corridor. There is no sprinkler coverage in this area of the building.

Staff A was present and confirmed the finding. Staff A stated the building may soon be sprinkled.


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 assuring that one of three smoke barriers is free of penetrations that compromise the fire-resistance rating of the smoke barrier walls and allow for the passage of smoke and fire to another smoke zone. This deficient practice affects 2 of 4 smoke zones. This facility has a capacity of 25 and a census of 8.

Findings include:

During the tour on 3/22/11 between 11:30 AM and 3:00 PM it is observed there had been some reconstruction done to the smoke barrier wall. In doing so, the bottom section of the smoke barrier wall had been cut out and is now replaced with a metal bracing. There is no sheet rock covering the metal, or documentation of the rating of the metal bracing to the 100 hall smoke barrier wall, nurse desk side.


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 observation and staff interview the facility failed to ensure proper separation of hazardous areas from other spaces. This deficient practice would allow for the spread of smoke and fire to travel into the adjacent area, affecting 1 of 4 smoke zones. This facility has a capacity of 25 and a census of 8.

Findings include:

During the tour on 3/22/11 between 11:30 AM and 3:00 PM it is observed the self closer is not latching the door to the door frame inside the Emergency Soiled Utility that leads into the Emergency room.

Staff A was present and confirmed the finding. Staff A stated the door is not latching due to humidity.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Based on observation and staff interview the facility fails to assure there is normal illumination in all exit corridors, failing to ensure that all areas of egress will not be left in total darkness. This deficient practice affects in 2 of 4 smoke zones. The facility has a capacity of 25 and a census of 8.

Findings include:

During the tour on 3/22/11 between 11:30 AM and 3:00 PM the following is observed:

--1) There is no normal illumination in the X-ray exit corridor, South basement exit stairwell, Therapy area in the basement, and the 500 corridor. These lights can be turned off with a manual switch leaving the area in darkness.
--2) There is a keyed switch for the over head lights for the 200 hall.

Staff A was present and confirmed the finding. Staff A stated the lights will be rewired and switches will be replaced with cover plates.

NFPA Standard: Required illumination shall be arranged so that the failure of any single bulb or unit does not result in less than .2 foot-candles of illumination in any designated area. 2000 NFPA 101, 7.8.1.4

Based on record review and staff interview, the facility fails to assure that fire drills are conducted using the fire alarm except when a silent drill is acceptable per code. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of an emergency, affecting 4 of 4 smoke zones. The facility has a capacity of 25 with a census of 8.

Findings include:

During the tour on 3/22/11 between 11:30 AM and 3:00 PM it is observed the 2nd shift fire drill on 2/9/11 was conducted at 7:05 PM and was a silent drill.


Staff A confirmed the observations and findings at time of review. Staff a stated the fire drill silent drills will only be conducted between 9:00 PM and 6:00 AM.


NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 19.7.1.2

Based on record review and staff interview the facility failed to assure that the fire alarm system required for life safety is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. This deficiency fails to ensure that the fire alarm system control functions are working properly jeopardizing the safety of all building occupants. This deficiency would affect 4 of the 4 smoke zones. This facility has a capacity of 25 with a census of 8.

Findings include:

During the tour on 3/22/11 between 11:30 AM and 3:00 PM it is observed there is no smoke detection at the fire alarm panel that is located in the Physical Plant.

Staff A was present and confirmed the finding. Staff A stated this issue has already been discussed with the fire alarm company.


NFPA Standard: Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of the code, such device, equipment, system, condition, arrangement, level of protection, or any other feature shall thereafter be maintained unless the Code exempts such maintenance. 2000 NFPA 101, 4.5.7

Based on observation and staff interview the facility failed to assure that sprinklers are properly maintained and clear of obstructions. The deficient practice fails to ensure the required sprinkler coverage in the event of a fire, affecting 1 of the 4 smoke zones. The facility has a capacity of 25 with a census of 8.

Findings include:

During the tour on 3/22/11 between 11:30 AM and 3:00 PM it is observed there is a rusted sprinkler head in patient room 206 bath room.

Staff A was present and confirmed the finding. Staff A stated it appeared there was a leak in the attic.

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