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Based on observation and staff interview the facility is not ensuring rooms and other ancillary areas are free of impediments that would prevent the doors from being closed. This deficient practice would prevent the doors from being closed quickly in an emergency and would not resist the passage of smoke, affecting one of two smoke zones. This facility has a capacity of 40 and a census of 21 at the time of the survey.

Findings Include:

On 1/3/2011 between 11:35 AM and 4:45 PM the following is observed:

The rooms labeled closets on the east and west corridors are provided with double doors to the closet and the stationary leaf does not have an automatic latching device and must be latched manually to keep the doors closed.

It was observed that the stationary leaf of both of these rooms was manually latched at the time of the survey. Staff B stated that the doors can be manually latch only and is aware of 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 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 would prevent these exits from being arranged so that they are readily available and accessible, affecting the exit from the facility in one of two smoke zones. This facility has a capacity of 40 and a census of 21 at the time of the survey.

Findings Include:

On 1/3/2010 between 11:35 AM and 4:45 PM the following is observed:

The exit stairs on the northeast and northwest corridors discharge to the roof on the 2nd floor. This roof does meet the requirement for exit discharge as follows:

1) The exit discharge path from the roof does not have a hard surface to the public way. The exit discharge is through a grassy area approximately 200 feet from a hard surface that would lead to a public way.
2) There is was no plan presented for snow and ice removal from the exit path across the roofing surface.
3) There is inadequate marking of the direction of egress to a public way once leaving the stairway.

Staff C and D were present and are aware of the findings.

NFPA Standard: Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1

NFPA Standard: Exits shall terminate directly at a public way or an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. 2000 NFPA 101, 7.7.1.

NFPA Standard: The exit discharge shall be arranged and marked to make clear the direction of egress to a public way. Stairs shall be arranged so as to make clear the direction of egress to a public way. Stairs that continue beyond the level of exit discharge shall be interrupted at the level of exit discharge by partitions, doors, or other effective means. 2000 NFPA 101, 7.7.3.

NFPA Standard: Where approved by the authority having jurisdiction, exits shall be permitted to discharge to the roofs or other sections of the building or an adjoining building where the following criteria are met:
(1) The roof has a fire resistance rating not less than required for the exit enclosure.
(2) There is a continuous and safe means of egress from the roof. 2000 NFPA 101, 7.7.6.

Based on observation and staff interview the facility fails to assure there is sufficient normal illumination for the exit north exit discharge paths. This deficient practice fails to ensure that all areas of egress will not be left in total darkness, affecting one of two smoke zones. The facility has a capacity of 40 and a census of 21 at the time of the survey.

Findings include:

During the tour on 1/3/2011 between 11:35 AM and 4:45 PM the following is observed:

1) The overhead lights above each door at the north stairway exit discharges at the roof level has one (1) bulb providing light to the walking surface.
2) The exit discharge path from the roof through the grassy area does not have normal illumination provided.

Staff C and D were present and acknowledge the findings.

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 observation and staff interview the facility failed to provide adequate emergency lighting as required for the north exit discharge. The deficient practice could leave the exit discharge path without illumination during a disruption of normal power or in the event of an emergency. This deficiency affects all residents in all one of two smoke zones. The facility has a capacity of 40 and a census of 21 at the time of the survey.

Findings Include:

During the tour on 1/3/2011 between 11:35 AM and 4:45 PM the following is observed:

Inadequate emergency lighting is provided for the exit discharge paths across roof surface and the grassy area exit discharge path.

Staff C acknowledge that the only emergency lighting provided by the generator was above the exit door to the north 2nd floor roof and that no other fixtures providing emergency lighting are provided to illuminate the exit discharge paths to the public way.

NFPA Standard: Emergency lighting for means of egress shall be provided in accordance with Section 7.9 for the following: buildings or structures where required by the occupancy chapters, underground and windowless structures as required by Section 11.7, high-rise buildings as required by other sections of this Code, doors equipped with delayed egress locks, and stair shaft and vestibules of smoke proof enclosures. For the purposes of this requirement, exit access shall include designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit and exit discharge shall include designated stairs, ramps, aisles, walkways, and escalators leading to a public way. 2000 NFPA 101, 7.9.1.1.

NFPA Standard: Emergency illumination shall be provided for not less than 11/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 foot-candle. 2000 NFPA 101, 7.9.2.1.

Based on record review and staff interview, the facility is not conducting fire drills as required quarterly on each shift. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency and affects two of two smoke zones. This facility has a capacity of 40 and a census of 21 at the time of the survey.

Findings Include:

During the tour on 1/3/2011 between 11:35 AM and 4:45 PM the following is observed:

1) Review of the facility's fire drill records for the previous 12 months revealed that fire drills have not been conducted on the 6 PM to 6 AM shift during the last 1st, 2nd and 3rd quarters of 2010.
2) Review of the facility's fire drill records for the previous 12 months revealed that a fire drill had not been conducted on the 6 AM to 6 PM shift during the 4th quarter of 2010.

Staff B indicated that drills are conducted at the same time as the other health care facility sharing this building and did not realize that these drills had not been documented.

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. The fire alarm shall be transmitted the day before or the day after the coded drill. 2000 NFPA 101, 19.7.1.2.