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Based on observation and staff interview, the facility failed to assure that a corridor door is not blocked open, making it take more than one motion to close the corridor door in a fire emergency. This affects 1 of 2 smoke zones. The facility has a capacity of 40 with a census of 25.

Findings include:

During the tour on 3/15/11 between 10:30 AM and 1:15 PM it is observed corridor door 207 is held open with a small trash can.

Staff A was present and confirmed the finding. Staff A stated the door has been planed but has not helped the door to stay open without an object in front of the door.

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 is not assuring that one of four smoke barriers is free of penetrations that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone. This deficient practice affects 2 of 2 smoke zones. This facility has a capacity of 49 and a census of 25.

Findings include:

During the tour on 3/15/11 between 10:30 AM and 1:15 PM it is observed there are penetrations in the smoke barrier wall where red wires are penetrating through the wall on the north side of the smoke barrier wall by the LTCU Med room.

Staff A was present and confirmed the finding. Staff A was aware fire rated caulking will need to be used to fill the penetrations.

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 provide means of egress that are maintained free of all obstructions or impediments to a full instant use in case of fire or other emergency. The deficient practice prevents exits from being arranged so that they are readily available and accessible, affecting two exits from the facility, including the main dining area in 2 of 2 smoke zones. This facility has a capacity of 49 and a census of 29.

Findings include:

During the tour on 3/15/11 between 10:30 AM and 1:15 PM the following is observed:

--1) There is no contrasting back ground color on the 15 second delay signs at the North and East exit doors.
--2) The delay device does not alarm within the vicinity of the 15 second door at the North exit door, but does alarm at the main Nurses desk that is located at the center of building/entrance to all three corridors. This delay door is located past the 1 hour smoke barrier wall at the end of the building.

Staff A was present and is aware of the findings.

NFPA Standard: Approved, listed, delayed-egress locks shall be permitted to be installed on doors serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7, provided that the following criteria are met: doors shall unlock upon actuation of an approved, supervised automatic sprinkler system or any heat detector or activation of not more than two smoke detectors of an approved, supervised automatic fire detection system; the doors shall unlock upon loss of power; an irreversible process shall release the lock within 15 seconds upon application of a force not to exceed 15 pounds nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only; on the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 inch high and not less than 1/8 inch wide on a contrasting background that reads as follows: PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS. 2000 NFPA 101, 7.2.1.6.1

Based on observation and staff interview the facility failed to maintain the exit discharge lighting so that the failure of one bulb would not leave the path from the facility to the parking lot in darkness, affecting 2 of 2 smoke zones. This facility has a capacity of 49 and a census of 25..

Findings include:

During the tour on 3/15/11 between 10:30 AM and 1:15 PM it is observed the two bulb fixtures for exit discharge are on keyed switches for all exit doors.

Staff A was present and observed the findings. Staff A stated the keyed switches are disabled but did not prove to surveyor that they are disabled.

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 held at unexpected times under varying conditions. 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 2 of 2 smoke zones. The facility has a capacity of 49 with a census of 25.

Findings include:

During the tour on 3/15/11 between 10:30 AM and 1:15 PM the following is observed:

--1) The fire drills conducted on 2nd shift for the last four quarters have all been conducted between 2:20 PM and 5:55 PM.
--2) The fire drill conducted on 3rd shift for the last four quarters have all been conducted between 9:45 PM and 10:40 PM.

Staff A confirmed the observations and findings at time of review.

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 observation and staff interview the facility fails to assure non-working battery powered smoke detectors are maintained. Although the battery operated smoke detectors are not required, they must be maintained if they remain installed. This deficient practice effects 2 of 2 smoke zones. The facility has a capacity of 49 and a census of 25.

Findings include:

During the tour on 3/15/11 between 10:30 AM and 1:15 PM it is observed there are battery powered type smoke detectors located in all rooms that have no batteries installed and are not tested/maintained monthly.

Staff A was present and confirmed the finding. There is hardwired smoke detectors added in rooms due to the 15 second delay doors in a non-sprinkled building. The old battery smoke detectors were never removed because the facility did not want the holes in the ceiling from the removal of the detector.

NFPA Standard: In non-sprinklered buildings, battery powered smoke detectors will be installed in all resident sleeping rooms, common areas and other areas where residents may gather. Detectors shall be installed in accordance with the manufacturer ' s recommendations and at least one shall be installed in each resident sleeping room. In larger rooms detectors shall be installed not more than 30 feet apart. The detectors shall be tested weekly and batteries changed at least semi-annually, or, if the battery has a longer life in accordance with the manufacture ' s recommendations. Inspection, testing and maintenance records shall be kept and provided to surveyors. Compliance is required by May 24, 2007. 42 CFR 483.70 (a) (7)

Based on record review and staff interview, the facility fails to conduct and properly document testing and maintenance of the generator in accordance with NFPA 99 and NFPA 110. The deficient practice potentially reduces the reliability of the generator. The deficient practice affects 2 of 2 smoke zones. The facility has a capacity of 49 with a census of 25.

Findings include:

During the tour on 3/15/11 between 10:30 AM and 1:15 PM it is observed there was no transfer time recorded during monthly load test for all of 2010.

Staff A was present and confirmed the finding. Staff A has begun recording the transfer time beginning Jan 2011.


NFPA Standard: Generator sets or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures. 1999 NFPA 99, 3-4.4.1.1

Based on observation and staff interview the facility failed to ensure that extension cords and
power strips are not being used as permanent wiring. This deficient practice could cause an electrical fire or the equipment to fail in the event the equipment overloads the capacity of the power strip or extension cord, affecting 1 out of 2 smoke zones. This facility has a capacity of 49 and a census of 25.

Findings include:

During the tour on 3/15/11 between 10:30 AM and 1:15 PM it is observed there is an electric lift chair plugged into a power strip in room 206.

Staff A was present and confirmed the finding. Staff A plugged the electric chair directly into the wall correcting this deficiency.


NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8

Based on observation and staff interview, the facility failed to assure that a corridor door is not blocked open, making it take more than one motion to close the corridor door in a fire emergency. This affects 1 of 2 smoke zones. The facility has a capacity of 40 with a census of 25.

Findings include:

During the tour on 3/15/11 between 10:30 AM and 1:15 PM it is observed corridor door 207 is held open with a small trash can.

Staff A was present and confirmed the finding. Staff A stated the door has been planed but has not helped the door to stay open without an object in front of the door.

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 is not assuring that one of four smoke barriers is free of penetrations that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone. This deficient practice affects 2 of 2 smoke zones. This facility has a capacity of 49 and a census of 25.

Findings include:

During the tour on 3/15/11 between 10:30 AM and 1:15 PM it is observed there are penetrations in the smoke barrier wall where red wires are penetrating through the wall on the north side of the smoke barrier wall by the LTCU Med room.

Staff A was present and confirmed the finding. Staff A was aware fire rated caulking will need to be used to fill the penetrations.

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 provide means of egress that are maintained free of all obstructions or impediments to a full instant use in case of fire or other emergency. The deficient practice prevents exits from being arranged so that they are readily available and accessible, affecting two exits from the facility, including the main dining area in 2 of 2 smoke zones. This facility has a capacity of 49 and a census of 29.

Findings include:

During the tour on 3/15/11 between 10:30 AM and 1:15 PM the following is observed:

--1) There is no contrasting back ground color on the 15 second delay signs at the North and East exit doors.
--2) The delay device does not alarm within the vicinity of the 15 second door at the North exit door, but does alarm at the main Nurses desk that is located at the center of building/entrance to all three corridors. This delay door is located past the 1 hour smoke barrier wall at the end of the building.

Staff A was present and is aware of the findings.

NFPA Standard: Approved, listed, delayed-egress locks shall be permitted to be installed on doors serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7, provided that the following criteria are met: doors shall unlock upon actuation of an approved, supervised automatic sprinkler system or any heat detector or activation of not more than two smoke detectors of an approved, supervised automatic fire detection system; the doors shall unlock upon loss of power; an irreversible process shall release the lock within 15 seconds upon application of a force not to exceed 15 pounds nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only; on the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 inch high and not less than 1/8 inch wide on a contrasting background that reads as follows: PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS. 2000 NFPA 101, 7.2.1.6.1

Based on observation and staff interview the facility failed to maintain the exit discharge lighting so that the failure of one bulb would not leave the path from the facility to the parking lot in darkness, affecting 2 of 2 smoke zones. This facility has a capacity of 49 and a census of 25..

Findings include:

During the tour on 3/15/11 between 10:30 AM and 1:15 PM it is observed the two bulb fixtures for exit discharge are on keyed switches for all exit doors.

Staff A was present and observed the findings. Staff A stated the keyed switches are disabled but did not prove to surveyor that they are disabled.

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 held at unexpected times under varying conditions. 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 2 of 2 smoke zones. The facility has a capacity of 49 with a census of 25.

Findings include:

During the tour on 3/15/11 between 10:30 AM and 1:15 PM the following is observed:

--1) The fire drills conducted on 2nd shift for the last four quarters have all been conducted between 2:20 PM and 5:55 PM.
--2) The fire drill conducted on 3rd shift for the last four quarters have all been conducted between 9:45 PM and 10:40 PM.

Staff A confirmed the observations and findings at time of review.

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 observation and staff interview the facility fails to assure non-working battery powered smoke detectors are maintained. Although the battery operated smoke detectors are not required, they must be maintained if they remain installed. This deficient practice effects 2 of 2 smoke zones. The facility has a capacity of 49 and a census of 25.

Findings include:

During the tour on 3/15/11 between 10:30 AM and 1:15 PM it is observed there are battery powered type smoke detectors located in all rooms that have no batteries installed and are not tested/maintained monthly.

Staff A was present and confirmed the finding. There is hardwired smoke detectors added in rooms due to the 15 second delay doors in a non-sprinkled building. The old battery smoke detectors were never removed because the facility did not want the holes in the ceiling from the removal of the detector.

NFPA Standard: In non-sprinklered buildings, battery powered smoke detectors will be installed in all resident sleeping rooms, common areas and other areas where residents may gather. Detectors shall be installed in accordance with the manufacturer ' s recommendations and at least one shall be installed in each resident sleeping room. In larger rooms detectors shall be installed not more than 30 feet apart. The detectors shall be tested weekly and batteries changed at least semi-annually, or, if the battery has a longer life in accordance with the manufacture ' s recommendations. Inspection, testing and maintenance records shall be kept and provided to surveyors. Compliance is required by May 24, 2007. 42 CFR 483.70 (a) (7)

Based on record review and staff interview, the facility fails to conduct and properly document testing and maintenance of the generator in accordance with NFPA 99 and NFPA 110. The deficient practice potentially reduces the reliability of the generator. The deficient practice affects 2 of 2 smoke zones. The facility has a capacity of 49 with a census of 25.

Findings include:

During the tour on 3/15/11 between 10:30 AM and 1:15 PM it is observed there was no transfer time recorded during monthly load test for all of 2010.

Staff A was present and confirmed the finding. Staff A has begun recording the transfer time beginning Jan 2011.


NFPA Standard: Generator sets or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures. 1999 NFPA 99, 3-4.4.1.1

Based on observation and staff interview the facility failed to ensure that extension cords and
power strips are not being used as permanent wiring. This deficient practice could cause an electrical fire or the equipment to fail in the event the equipment overloads the capacity of the power strip or extension cord, affecting 1 out of 2 smoke zones. This facility has a capacity of 49 and a census of 25.

Findings include:

During the tour on 3/15/11 between 10:30 AM and 1:15 PM it is observed there is an electric lift chair plugged into a power strip in room 206.

Staff A was present and confirmed the finding. Staff A plugged the electric chair directly into the wall correcting this deficiency.


NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8