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Based on observation and interview, the facility failed to ensure the corridor walls above the drop ceiling on the 200 wing were able to resist the passage of fire/smoke.

The findings include:

During the Life Safety Code tour on April 22, 2010, at 3:30 PM, with the Director of Maintenance, an inspection above the corridor drop ceiling in the unsprinklered 200 wing next to room 213 revealed wiring and water piping penetrating the corridor wall. Penetrations of corridor walls above drop ceilings in unsprinklered buildings must be properly sealed. The gaps around this wiring and piping could not prevent the passage of fire/smoke in a fire situation. An interview revealed the Director of Maintenance was not aware these types of penetrations had not been properly sealed.

Based on observation and interview, the facility failed to ensure that corridor doors were maintained according to NFPA standards. Nine (9) roller latches were observed on doors on the 200 wing of the facility.

The findings include:

During the Life Safety Code tour on April 22, 2010, at 3:10 PM, with the Director of Maintenance, a roller latch was noted on room 201 in the 200 corridor. Roller latches are not considered reliable and are prohibited on corridor doors. An interview revealed the Director of Maintenance was not aware roller latches were prohibited on corridor doors. Eight other corridor doors were noted to have roller latches in the 200 corridor. At 3:45 PM, the front business office was noted to have a wedge holding the door open. A wedge is not an approved device to hold doors open. An interview revealed the Director of Maintenance had previously made staff aware that wedges should not be used to hold doors open.

Reference: NFPA 101 (2000 Edition).

19.3.6.3.3*
Hold-open devices that release when the door is pushed or pulled shall be permitted

A.19.3.6.3.3
Doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches

19.3.6.3.4
Door-closing devices shall not be required on doors in corridor wall openings other than those serving required exits, smoke barriers, or enclosures of vertical openings and hazardous areas.

Based on observation and interview, the facility failed to maintain smoke barriers with at least a one-half hour fire resistance rating as required. The facility failed to ensure that penetrations above fire/smoke barrier doors were properly sealed.

The findings include:

During the Life Safety Code survey on April 22, 2010, at 3:40 PM, with the Director of Maintenance, unsealed penetrations of electrical wiring, conduit, and piping were noted above the fire/smoke barrier cross corridor doors between the 100 and 200 corridor. An interview revealed the Director of Maintenance was not aware these had not been properly sealed. During the survey unsealed penetrations of electrical wiring, conduit, and piping were noted above three other cross corridor fire/smoke barrier doors in the existing building.

Reference: NFPA 101 (2000 Edition).

8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(a) The space between the penetrating item and the smoke barrier shall
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(b) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(c) Where designs take transmission of vibration into consideration, any vibration isolation shall
1. Be made on either side of the smoke barrier, or
2. Be made by an approved device designed for the specific purpose.

Based on observation and interview, the facility failed to maintain smoke barriers with at least a one-half hour fire resistance rating as required. Unsealed penetrations were noted above six (6) sets of fire/smoke barrier doors on the first, second, and third floors of the facility. This condition affected all residents, staff, and any other occupants of the building. The facility has the capacity for 42 beds and had a patient census of 26 on the day of the survey.

The findings include:

During the Life Safety Code survey on April 22, 2010, at 1:15 PM, with the Director of Maintenance, unsealed penetrations of sprinkler piping, electrical conduit, and ductwork was noted above two sets of fire/smoke barrier cross corridor doors on the second floor. The Director of Maintenance stated no one had inspected these areas since this part of the facility was opened in May 2008. The Director of Maintenance was not aware these areas had not been properly sealed. During the survey unsealed penetrations were also noted above four sets of cross corridor doors located on the first and third floors of the facility.

Reference: NFPA 101 (2000 Edition).

8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(a) The space between the penetrating item and the smoke barrier shall
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(b) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(c) Where designs take transmission of vibration into consideration, any vibration isolation shall
1. Be made on either side of the smoke barrier, or
2. Be made by an approved device designed for the specific purpose.

Based on observation and interview, the facility failed to ensure that two (2) sets of double doors to hazardous areas on the second and third floors of the facility were equipped with door closing devices as required. This condition affected twenty-four (24) residents residing on the second and third floors, staff, and any other occupants of the building. The facility has the capacity for 42 beds and had a census of 26 on the day of the survey.

The findings include:

During the Life Safety Code survey on April 22, 2010, at 1:10 PM, with the Director of Maintenance, double doors to a mechanical room on the second floor corridor were noted not to be equipped with door closures. The mechanical room was noted to contain combustible storage. Rooms that are considered to be hazardous area are required to have a door closing device. An interview revealed the Director of Maintenance was told these doors did not require door closures while the building was being constructed. During the survey the third floor mechanical room doors were noted not to be equipped with door closing devices.

Reference: NFPA 101 (2000 Edition).

7.2.1.8.1*
A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

7.2.1.8.2
In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.

Based on observation and interview, the facility failed to ensure three (3) hazardous area doors were equipped with door closing devices as required.

The findings include:

During the Life Safety Code survey on April 22, 2010, at 3:15 PM, with the Director of Maintenance, storage room door 206 in the 200 corridor was noted not to be equipped with a door closing device as required. Rooms that are considered to be a hazardous area are required to have a door closing device. An interview with the Director of Maintenance revealed this room was previously converted to a storage room. During the survey room 202 and the materials management room doors were noted not to be fitted with a door closing device.

Reference: NFPA 101 (2000 Edition).

7.2.1.8.1*
A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

7.2.1.8.2
In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.

Based on interview and record review, the facility failed to perform the minimum number of fire drills as required during the second shift. This condition affected all second shift staff and all of the residents. The facility has the capacity for 42 beds and had a census of 26 on the day of the survey.

The findings include:

During the Life Safety Code survey on April 22, 2010, at 6:10 PM, with the Director of Maintenance, a record review revealed the facility has two shifts. The last fire drill on the second shift was performed on November 9, 2009, approximately five and one-half months from the date of the survey. An interview revealed the Director of Maintenance conducts the fire drills. The Director of Maintenance stated he needed to be at home during the missed fire drill period. The Director of Maintenance stated other people at the facility were currently being trained to perform fire drills if needed.

Based on observation, interview, and record review, the facility failed to ensure that the building fire alarm system functioned and was maintained as required by NFPA standards.

The findings include:

During the Life Safety Code survey on April 22, 2010, at 3:50 PM, with the Director of Maintenance, a test of the fire alarm automatic dialer panel located near the first floor generator room revealed that, when placed in trouble from phone line failure, the unit did not send a trouble signal to a continuously occupied location within the facility. The main fire alarm control panel and other panels in the facility revealed all systems were normal. The fire alarm monitoring company did notify the facility of this phone line failure. An interview revealed the Director of Maintenance was not aware a phone line failure signal should be located in an area of the facility where the signal is likely to be heard.

Reference: NFPA 72 (1999 Edition).

1-5.4.4 Distinctive Signals.
Fire alarms, supervisory signals, and trouble signals shall be distinctively and descriptively annunciated.

1-5.4.6 Trouble Signals.
Trouble signals and their restoration to normal shall be indicated within 200 seconds at the locations identified in 1-5.4.6.1 or 1-5.4.6.2. Trouble signals required to indicate at the protected premises shall be indicated by distinctive audible signals. These audible trouble signals shall be distinctive from alarm signals. If an intermittent signal is used, it shall sound at least once every 10 seconds, with a minimum duration of 1/2 second. An audible trouble signal shall be permitted to be common to several supervised circuits. The trouble signal(s) shall be located in an area where it is likely to be heard.

3-8.1* Fire Alarm Control Units.
Fire alarm systems shall be permitted to be either integrated systems combining all detection, notification, and auxiliary functions in a single system or a combination of component subsystems. Fire alarm system components shall be permitted to share control equipment or shall be able to operate as stand alone subsystems, but, in any case, they shall be arranged to function as a single system. All component subsystems shall be capable of simultaneous, full load operation without degradation of the required, overall system performance.

5-5.3.2.1.6.2
The following requirements shall apply to all combinations in 5-5.3.2.1.6.1:
(1) Both channels shall be supervised in a manner approved for the means of transmission employed.
(3) The failure of either channel shall send a trouble signal on the other channel within 4 minutes.
(8) Failure of telephone lines (numbers) or cellular service shall be
annunciated locally.

5-2.6.1.4
Upon receipt of trouble signals or other signals pertaining solely to matters of equipment maintenance of the fire alarm systems, the central station shall perform the following actions:
(1) *Communicate immediately with persons designated by the subscriber
A-5-2.6.1.4(1)
The term immediately in this context is intended to mean " without unreasonable delay. " Routine handling should take a maximum of 4 minutes from receipt of a trouble signal by the central station until initiation of the investigation by telephone.

Based on interview and record review, the facility failed to ensure the building fire alarm system was maintained as required by NFPA standards. The facility failed to ensure that sensitivity testing was conducted on the smoke and heat detectors in the facility. This condition affected all residents, staff, and any other occupants of the building. The facility has the capacity for 42 beds and had a census of 26 on the day of the survey.

The findings include:

During the Life Safety Code tour conducted on April 22, 2010, at 5:20 PM, with the Director of Maintenance, there were no reports available regarding the sensitivity testing of the smoke and heat detectors. A sensitivity report entails the testing of components associated with the fire alarm system such as smoke detectors and heat detectors. Sensitivity testing is required every two years. An interview revealed the Director of Maintenance was not aware smoke and heat detectors required sensitivity testing every two years.

Reference: NFPA 72 (1999 Edition).

7-3.2.1*
Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.
7-3.2.2
Test frequency of interfaced equipment shall be the same as specified by the applicable NFPA standards for the equipment being supervised.
7-3.2.3
For restorable fixed-temperature, spot-type heat detectors, two or more detectors shall be tested on each initiating circuit annually. Different detectors shall be tested each year, with records kept by the building owner specifying which detectors have been tested. Within 5 years, each detector shall have been tested.

Based on observation, interview, and record review, the facility failed to ensure the emergency generator located in the facility was being maintained according to NFPA standards.

The findings include:

During the Life Safety Code survey on April 22, 2010, at 4:05 PM, with the Director of Maintenance, a generator room located on the first floor was observed not to have emergency battery-operated lighting. The battery charger to the generator was noted to be wired incorrectly. The annunciator panel to the generator was noted to be on a wall outside of the generator room and not in an area where it was likely to be heard. An interview revealed the Director of Maintenance was not aware of these requirements. At 4:40 PM, a review of generator records revealed there was no written weekly maintenance or operational testing schedule associated with the generator. An interview revealed the Director of Maintenance was aware there should be a written maintenance and operational testing schedule. The Director of Maintenance stated maintenance and operational testing was performed on the generator but the facility did not keep a record of it. The Director of Maintenance was not aware if the manufacturer of the generator required a periodic full load test of the generator. Conducting a full load test ensures the generator will operate as intended.

Reference: NFPA 110 (1999 Edition).

6-1.1*
The routine maintenance and operational testing program shall be based on the manufacturer's recommendations, instruction manuals, and the minimum requirements of this chapter and the authority having jurisdiction
6-3.3
A written schedule for routine maintenance and operational testing of the EPSS shall be established
6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
6-4.5
Level 1 and Level 2 transfer switches shall be operated monthly. The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.

5-12.6
The starting battery units shall be located as close as practicable to the prime mover starter to minimize voltage drop. Battery cables shall be sized to minimize voltage drop in accordance with the manufacturer ' s recommendations and accepted engineering practices.
Battery charger output wiring shall be permanently connected. Connections shall not be made at the battery terminals.

6-4.6* EPSS circuit breakers for Level 1 system usage, including main and feed breakers between the EPS and the transfer switch load terminals, shall be exercised annually with the EPS in the " off " position.

Exception: Medium- and high-voltage circuit breakers for Level 1 system usage
shall be exercised every 6 months and shall be tested under simulated
overload conditions every 2 years.


5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

Reference: NFPA 101 (2000 Edition).

7.9.3 Periodic Testing of Emergency Lighting Equipment.
A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Reference: NFPA 99 (1999 Edition).

3-4.1.1.15 + Alarm Annunciator.
A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
a. Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
b. Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]

Based on observation, interview, and record review, the facility failed to ensure the emergency generator located outside of the facility was being maintained according to NFPA standards. The facility failed to document the monthly testing of the emergency generator as required. This condition affected all staff, residents, and any other occupants of the building. The facility has the capacity for 42 beds and had a census of 26 on the day of the survey.

The findings include:

During the Life Safety Code survey on April 22, 2010, at 11:45 AM, with the Director of Maintenance, a generator room located outside of the facility was observed not to have emergency battery-operated lighting. An interview revealed the Director of Maintenance was not aware of this requirement. At 4:40 PM, an interview revealed the Director of Maintenance was not aware that the generator's transfer switch was required to be exercised and recorded monthly. A record review revealed a monthly maintenance and operational testing schedule had begun in February 2010. A weekly written maintenance schedule is required for the generator. An interview revealed the Director of Maintenance was aware there should be a written maintenance and operational testing program for the generator. The Director of Maintenance stated maintenance and operational testing was performed on the generator before February 2010, but the facility did not keep a record of this testing. The Director of Maintenance was not aware if the manufacturer of the generator required a periodic full load test of the generator. Conducting a full load test ensures the generator will operate as intended.

Reference: NFPA 110 (1999 Edition).

6-1.1*
The routine maintenance and operational testing program shall be based on the manufacturer ' s recommendations, instruction manuals, and the minimum requirements of this chapter and the authority having jurisdiction
6-3.3
A written schedule for routine maintenance and operational testing of the EPSS shall be established
6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
6-4.5
Level 1 and Level 2 transfer switches shall be operated monthly. The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.

5-12.6
The starting battery units shall be located as close as practicable to the prime mover starter to minimize voltage drop. Battery cables shall be sized to minimize voltage drop in accordance with the manufacturer ' s recommendations and accepted engineering practices.
Battery charger output wiring shall be permanently connected. Connections shall not be made at the battery terminals.

6-4.6* EPSS circuit breakers for Level 1 system usage, including main and feed breakers between the EPS and the transfer switch load terminals, shall be exercised annually with the EPS in the " off " position.

Exception: Medium- and high-voltage circuit breakers for Level 1 system usage shall be
exercised every 6 months and shall be tested under simulated overload conditions
every 2 years.

5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

Reference: NFPA 101 (2000 Edition).

7.9.3 Periodic Testing of Emergency Lighting Equipment.
A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Based on observation and interview, the facility failed to ensure the corridor walls above the drop ceiling on the 200 wing were able to resist the passage of fire/smoke.

The findings include:

During the Life Safety Code tour on April 22, 2010, at 3:30 PM, with the Director of Maintenance, an inspection above the corridor drop ceiling in the unsprinklered 200 wing next to room 213 revealed wiring and water piping penetrating the corridor wall. Penetrations of corridor walls above drop ceilings in unsprinklered buildings must be properly sealed. The gaps around this wiring and piping could not prevent the passage of fire/smoke in a fire situation. An interview revealed the Director of Maintenance was not aware these types of penetrations had not been properly sealed.

Based on observation and interview, the facility failed to ensure that corridor doors were maintained according to NFPA standards. Nine (9) roller latches were observed on doors on the 200 wing of the facility.

The findings include:

During the Life Safety Code tour on April 22, 2010, at 3:10 PM, with the Director of Maintenance, a roller latch was noted on room 201 in the 200 corridor. Roller latches are not considered reliable and are prohibited on corridor doors. An interview revealed the Director of Maintenance was not aware roller latches were prohibited on corridor doors. Eight other corridor doors were noted to have roller latches in the 200 corridor. At 3:45 PM, the front business office was noted to have a wedge holding the door open. A wedge is not an approved device to hold doors open. An interview revealed the Director of Maintenance had previously made staff aware that wedges should not be used to hold doors open.

Reference: NFPA 101 (2000 Edition).

19.3.6.3.3*
Hold-open devices that release when the door is pushed or pulled shall be permitted

A.19.3.6.3.3
Doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches

19.3.6.3.4
Door-closing devices shall not be required on doors in corridor wall openings other than those serving required exits, smoke barriers, or enclosures of vertical openings and hazardous areas.

Based on observation and interview, the facility failed to maintain smoke barriers with at least a one-half hour fire resistance rating as required. The facility failed to ensure that penetrations above fire/smoke barrier doors were properly sealed.

The findings include:

During the Life Safety Code survey on April 22, 2010, at 3:40 PM, with the Director of Maintenance, unsealed penetrations of electrical wiring, conduit, and piping were noted above the fire/smoke barrier cross corridor doors between the 100 and 200 corridor. An interview revealed the Director of Maintenance was not aware these had not been properly sealed. During the survey unsealed penetrations of electrical wiring, conduit, and piping were noted above three other cross corridor fire/smoke barrier doors in the existing building.

Reference: NFPA 101 (2000 Edition).

8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(a) The space between the penetrating item and the smoke barrier shall
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(b) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(c) Where designs take transmission of vibration into consideration, any vibration isolation shall
1. Be made on either side of the smoke barrier, or
2. Be made by an approved device designed for the specific purpose.

Based on observation and interview, the facility failed to maintain smoke barriers with at least a one-half hour fire resistance rating as required. Unsealed penetrations were noted above six (6) sets of fire/smoke barrier doors on the first, second, and third floors of the facility. This condition affected all residents, staff, and any other occupants of the building. The facility has the capacity for 42 beds and had a patient census of 26 on the day of the survey.

The findings include:

During the Life Safety Code survey on April 22, 2010, at 1:15 PM, with the Director of Maintenance, unsealed penetrations of sprinkler piping, electrical conduit, and ductwork was noted above two sets of fire/smoke barrier cross corridor doors on the second floor. The Director of Maintenance stated no one had inspected these areas since this part of the facility was opened in May 2008. The Director of Maintenance was not aware these areas had not been properly sealed. During the survey unsealed penetrations were also noted above four sets of cross corridor doors located on the first and third floors of the facility.

Reference: NFPA 101 (2000 Edition).

8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(a) The space between the penetrating item and the smoke barrier shall
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(b) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(c) Where designs take transmission of vibration into consideration, any vibration isolation shall
1. Be made on either side of the smoke barrier, or
2. Be made by an approved device designed for the specific purpose.

Based on observation and interview, the facility failed to ensure that two (2) sets of double doors to hazardous areas on the second and third floors of the facility were equipped with door closing devices as required. This condition affected twenty-four (24) residents residing on the second and third floors, staff, and any other occupants of the building. The facility has the capacity for 42 beds and had a census of 26 on the day of the survey.

The findings include:

During the Life Safety Code survey on April 22, 2010, at 1:10 PM, with the Director of Maintenance, double doors to a mechanical room on the second floor corridor were noted not to be equipped with door closures. The mechanical room was noted to contain combustible storage. Rooms that are considered to be hazardous area are required to have a door closing device. An interview revealed the Director of Maintenance was told these doors did not require door closures while the building was being constructed. During the survey the third floor mechanical room doors were noted not to be equipped with door closing devices.

Reference: NFPA 101 (2000 Edition).

7.2.1.8.1*
A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

7.2.1.8.2
In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.

Based on observation and interview, the facility failed to ensure three (3) hazardous area doors were equipped with door closing devices as required.

The findings include:

During the Life Safety Code survey on April 22, 2010, at 3:15 PM, with the Director of Maintenance, storage room door 206 in the 200 corridor was noted not to be equipped with a door closing device as required. Rooms that are considered to be a hazardous area are required to have a door closing device. An interview with the Director of Maintenance revealed this room was previously converted to a storage room. During the survey room 202 and the materials management room doors were noted not to be fitted with a door closing device.

Reference: NFPA 101 (2000 Edition).

7.2.1.8.1*
A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

7.2.1.8.2
In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.

Based on interview and record review, the facility failed to perform the minimum number of fire drills as required during the second shift. This condition affected all second shift staff and all of the residents. The facility has the capacity for 42 beds and had a census of 26 on the day of the survey.

The findings include:

During the Life Safety Code survey on April 22, 2010, at 6:10 PM, with the Director of Maintenance, a record review revealed the facility has two shifts. The last fire drill on the second shift was performed on November 9, 2009, approximately five and one-half months from the date of the survey. An interview revealed the Director of Maintenance conducts the fire drills. The Director of Maintenance stated he needed to be at home during the missed fire drill period. The Director of Maintenance stated other people at the facility were currently being trained to perform fire drills if needed.

Based on observation, interview, and record review, the facility failed to ensure that the building fire alarm system functioned and was maintained as required by NFPA standards.

The findings include:

During the Life Safety Code survey on April 22, 2010, at 3:50 PM, with the Director of Maintenance, a test of the fire alarm automatic dialer panel located near the first floor generator room revealed that, when placed in trouble from phone line failure, the unit did not send a trouble signal to a continuously occupied location within the facility. The main fire alarm control panel and other panels in the facility revealed all systems were normal. The fire alarm monitoring company did notify the facility of this phone line failure. An interview revealed the Director of Maintenance was not aware a phone line failure signal should be located in an area of the facility where the signal is likely to be heard.

Reference: NFPA 72 (1999 Edition).

1-5.4.4 Distinctive Signals.
Fire alarms, supervisory signals, and trouble signals shall be distinctively and descriptively annunciated.

1-5.4.6 Trouble Signals.
Trouble signals and their restoration to normal shall be indicated within 200 seconds at the locations identified in 1-5.4.6.1 or 1-5.4.6.2. Trouble signals required to indicate at the protected premises shall be indicated by distinctive audible signals. These audible trouble signals shall be distinctive from alarm signals. If an intermittent signal is used, it shall sound at least once every 10 seconds, with a minimum duration of 1/2 second. An audible trouble signal shall be permitted to be common to several supervised circuits. The trouble signal(s) shall be located in an area where it is likely to be heard.

3-8.1* Fire Alarm Control Units.
Fire alarm systems shall be permitted to be either integrated systems combining all detection, notification, and auxiliary functions in a single system or a combination of component subsystems. Fire alarm system components shall be permitted to share control equipment or shall be able to operate as stand alone subsystems, but, in any case, they shall be arranged to function as a single system. All component subsystems shall be capable of simultaneous, full load operation without degradation of the required, overall system performance.

5-5.3.2.1.6.2
The following requirements shall apply to all combinations in 5-5.3.2.1.6.1:
(1) Both channels shall be supervised in a manner approved for the means of transmission employed.
(3) The failure of either channel shall send a trouble signal on the other channel within 4 minutes.
(8) Failure of telephone lines (numbers) or cellular service shall be
annunciated locally.

5-2.6.1.4
Upon receipt of trouble signals or other signals pertaining solely to matters of equipment maintenance of the fire alarm systems, the central station shall perform the following actions:
(1) *Communicate immediately with persons designated by the subscriber
A-5-2.6.1.4(1)
The term immediately in this context is intended to mean " without unreasonable delay. " Routine handling should take a maximum of 4 minutes from receipt of a trouble signal by the central station until initiation of the investigation by telephone.

Based on interview and record review, the facility failed to ensure the building fire alarm system was maintained as required by NFPA standards. The facility failed to ensure that sensitivity testing was conducted on the smoke and heat detectors in the facility. This condition affected all residents, staff, and any other occupants of the building. The facility has the capacity for 42 beds and had a census of 26 on the day of the survey.

The findings include:

During the Life Safety Code tour conducted on April 22, 2010, at 5:20 PM, with the Director of Maintenance, there were no reports available regarding the sensitivity testing of the smoke and heat detectors. A sensitivity report entails the testing of components associated with the fire alarm system such as smoke detectors and heat detectors. Sensitivity testing is required every two years. An interview revealed the Director of Maintenance was not aware smoke and heat detectors required sensitivity testing every two years.

Reference: NFPA 72 (1999 Edition).

7-3.2.1*
Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.
7-3.2.2
Test frequency of interfaced equipment shall be the same as specified by the applicable NFPA standards for the equipment being supervised.
7-3.2.3
For restorable fixed-temperature, spot-type heat detectors, two or more detectors shall be tested on each initiating circuit annually. Different detectors shall be tested each year, with records kept by the building owner specifying which detectors have been tested. Within 5 years, each detector shall have been tested.

Based on observation, interview, and record review, the facility failed to ensure the emergency generator located in the facility was being maintained according to NFPA standards.

The findings include:

During the Life Safety Code survey on April 22, 2010, at 4:05 PM, with the Director of Maintenance, a generator room located on the first floor was observed not to have emergency battery-operated lighting. The battery charger to the generator was noted to be wired incorrectly. The annunciator panel to the generator was noted to be on a wall outside of the generator room and not in an area where it was likely to be heard. An interview revealed the Director of Maintenance was not aware of these requirements. At 4:40 PM, a review of generator records revealed there was no written weekly maintenance or operational testing schedule associated with the generator. An interview revealed the Director of Maintenance was aware there should be a written maintenance and operational testing schedule. The Director of Maintenance stated maintenance and operational testing was performed on the generator but the facility did not keep a record of it. The Director of Maintenance was not aware if the manufacturer of the generator required a periodic full load test of the generator. Conducting a full load test ensures the generator will operate as intended.

Reference: NFPA 110 (1999 Edition).

6-1.1*
The routine maintenance and operational testing program shall be based on the manufacturer's recommendations, instruction manuals, and the minimum requirements of this chapter and the authority having jurisdiction
6-3.3
A written schedule for routine maintenance and operational testing of the EPSS shall be established
6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
6-4.5
Level 1 and Level 2 transfer switches shall be operated monthly. The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.

5-12.6
The starting battery units shall be located as close as practicable to the prime mover starter to minimize voltage drop. Battery cables shall be sized to minimize voltage drop in accordance with the manufacturer ' s recommendations and accepted engineering practices.
Battery charger output wiring shall be permanently connected. Connections shall not be made at the battery terminals.

6-4.6* EPSS circuit breakers for Level 1 system usage, including main and feed breakers between the EPS and the transfer switch load terminals, shall be exercised annually with the EPS in the " off " position.

Exception: Medium- and high-voltage circuit breakers for Level 1 system usage
shall be exercised every 6 months and shall be tested under simulated
overload conditions every 2 years.


5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

Reference: NFPA 101 (2000 Edition).

7.9.3 Periodic Testing of Emergency Lighting Equipment.
A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Reference: NFPA 99 (1999 Edition).

3-4.1.1.15 + Alarm Annunciator.
A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
a. Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
b. Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]

Based on observation, interview, and record review, the facility failed to ensure the emergency generator located outside of the facility was being maintained according to NFPA standards. The facility failed to document the monthly testing of the emergency generator as required. This condition affected all staff, residents, and any other occupants of the building. The facility has the capacity for 42 beds and had a census of 26 on the day of the survey.

The findings include:

During the Life Safety Code survey on April 22, 2010, at 11:45 AM, with the Director of Maintenance, a generator room located outside of the facility was observed not to have emergency battery-operated lighting. An interview revealed the Director of Maintenance was not aware of this requirement. At 4:40 PM, an interview revealed the Director of Maintenance was not aware that the generator's transfer switch was required to be exercised and recorded monthly. A record review revealed a monthly maintenance and operational testing schedule had begun in February 2010. A weekly written maintenance schedule is required for the generator. An interview revealed the Director of Maintenance was aware there should be a written maintenance and operational testing program for the generator. The Director of Maintenance stated maintenance and operational testing was performed on the generator before February 2010, but the facility did not keep a record of this testing. The Director of Maintenance was not aware if the manufacturer of the generator required a periodic full load test of the generator. Conducting a full load test ensures the generator will operate as intended.

Reference: NFPA 110 (1999 Edition).

6-1.1*
The routine maintenance and operational testing program shall be based on the manufacturer ' s recommendations, instruction manuals, and the minimum requirements of this chapter and the authority having jurisdiction
6-3.3
A written schedule for routine maintenance and operational testing of the EPSS shall be established
6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
6-4.5
Level 1 and Level 2 transfer switches shall be operated monthly. The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.

5-12.6
The starting battery units shall be located as close as practicable to the prime mover starter to minimize voltage drop. Battery cables shall be sized to minimize voltage drop in accordance with the manufacturer ' s recommendations and accepted engineering practices.
Battery charger output wiring shall be permanently connected. Connections shall not be made at the battery terminals.

6-4.6* EPSS circuit breakers for Level 1 system usage, including main and feed breakers between the EPS and the transfer switch load terminals, shall be exercised annually with the EPS in the " off " position.

Exception: Medium- and high-voltage circuit breakers for Level 1 system usage shall be
exercised every 6 months and shall be tested under simulated overload conditions
every 2 years.

5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

Reference: NFPA 101 (2000 Edition).

7.9.3 Periodic Testing of Emergency Lighting Equipment.
A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.