HospitalInspections.org

Based on observation and interview, the facility failed to maintain the two hour fire wall in one area of the building. This deficient practice affects all occupants located on both sides of the wall. The facility has a certified capacity of 25 with the current census of 6 residents.

Findings include:

Observation and interview on 5/2/11, revealed a 1/2 inch penetration around conduit in the two hour fire wall by room #190A. Maintenance Staff A verified this finding.


NFPA Standard: Health care occupancies in buildings housing other occupancies shall be completely separated from them by construction having a fire resistance rating of not less than 2 hours as provided for additions in 19.1.1.4. 2000 NFPA 101, 19.1.2.3

Based on observation and interview, this facility is not assuring that two of seven 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 all occupants of the building, including staff, visitors and residents in four of nine smoke zones. This facility has a capacity of 25 with a census of 6 residents.

Findings include:

Observation and interview on 5/2/11, revealed open conduit and a one inch penetration in the smoke barrier by room #55 and open conduit and a four inch penetration around duct work in the smoke barrier by room #204. According to the facility layout, this was a required barrier. Maintenance Staff A confirmed these observations.

NFPA standard: Requires smoke walls to have a fire resistance rating of at least a half hour and to be continuous from floor to roof deck and from outside wall to outside wall. 2000 NFPA 101, 19.3.7.3

Based on observation and interview, the facility is not providing clear and unobstructed exit for one area. This deficient practice affects all occupants located inside of the area. This facility has a capacity of 25 with a census of 6.

Findings include:

Observation and interview on 5/2/11, revealed the door to the Employee Dining room had a keyed deadbolt on the door along with a door knob with a locking mechanism. Maintenance Staff A verified the observation.

NFPA Standard: Exits shall be located and exit access shall be arranged so that exits are readily accessible at all times. 2000 NFPA 101, 7.5.1.1

Based on record review and interview, the facility failed to document the emergency egress lighting monthly and annually. This deficient practice affects nine of nine smoke compartments and all occupants of the facility. This facility has a capacity of 25 and a census of 6 residents.

Findings include:

Observation of the facility's maintenance records and interview on 5/2/11, revealed the absence of documentation regarding the testing of the emergency battery lighting system. According to Maintenance Staff A, the lights were tested monthly, but there was no documentation to show that the monthly tests were conducted for 30 seconds or that an annual test was completed for 90 minutes under load.

NFPA standard: Requires a documented monthly test of battery-powered emergency lighting for at least 30 seconds, and an annual test for a duration of 1-1/2 hours. 2000 NFPA 101, 7.9.3

Based on observation and interview, the facility did not provide a directional exit sign at one smoke door. This deficient practice effects residents, staff and visitors in this smoke zone. This facility has a capacity of 25 and census of 6 residents.

Findings include:

Observation and interview on 5/2/11, revealed the West side of the smoke doors by room #132 did not have a directional exit sign. According to the facility layout, which is used in conjunction with the emergency procedures, this designated exit is a required exit. This was verifed by Maintenance Staff A.

Based upon record review and interview, the facility failed to hold fire drills under varied conditions at different times of the day for two of four quarters reviewed. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This facility has a capacity of 25 with a census of 6.

Findings include:

Record review and interview on 5/2/11, showed the facility fire drill documentation did not have drills for the second quarter of 2010 on the 2nd shift and fourth quarter of 2010 on the 1st shift. Maintenance Staff A verified the documentation.

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. 2000 NFPA 101, 19.7.1.2

Based on observation and interview, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association 72. This deficient practice affects all occupants in the building. The facility has a certified capacity of 25 with the current census of 6.

Findings include:

Observation and interview on 5/2/11, revealed the fire alarm control panel was located in the Employee Dining room and did not have a smoke detector in the room. This was verified by Maintenance Staff A.




NFPA Standard: Fire safety functions shall not interfere with other operations of the fire alarm system. 1999 NFPA 72, 3-9.2.2

NFPA Standard: A fire alarm and control system, where required by Code, shall be arranged to actuate automatically the control functions necessary to make the protected premises safer for building occupants. 2000 NFPA 101, 9.6.5.1

NFPA standard: In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit(s) to provide notification of fire at that location. Exception: Where ambient conditions prohibit installation of automatic smoke detection, automatic heat detection shall be permitted. 1999 NFPA 72, 5.6

A)
Based on record review and interview, the facility failed to maintain the sprinkler system in accordance with the National Fire Protection Association (NFPA), Standard 25, by ensuring the 5 year Flow test had been performed. This deficient practice affects all occupants in the building. The facility has a capacity of 25 with the census of 6 residents.

Findings include:

Record review and interview on 5/2/11, revealed documentation from American Fire Protection dated September 2010 indicating the 5 year Flow test was overdue. The facility could not find documentation the test had been performed. Maintenance Staff A verified this finding.


B)

Based on record review and interview the faciltiy failed to correct all deficiencies on the last documented sprinkler system inspection. This deficient practice affects all occupants in the building. The facility has a capacity of 25 with the current census of 6 residents.

Findings include:

Record review and interview on 5/2/11, revealed two deficiencies on the last inspection report from American Fire Protection dated September 2010 had not been corrected. Maintenance Staff A verified this finding.

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 performance and protection as designed. NFPA 13, 12.1

Based on observation and interview, the facility failed to maintain the two hour fire wall in one area of the building. This deficient practice affects all occupants located on both sides of the wall. The facility has a certified capacity of 25 with the current census of 6 residents.

Findings include:

Observation and interview on 5/2/11, revealed a 1/2 inch penetration around conduit in the two hour fire wall by room #190A. Maintenance Staff A verified this finding.


NFPA Standard: Health care occupancies in buildings housing other occupancies shall be completely separated from them by construction having a fire resistance rating of not less than 2 hours as provided for additions in 19.1.1.4. 2000 NFPA 101, 19.1.2.3

Based on observation and interview, this facility is not assuring that two of seven 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 all occupants of the building, including staff, visitors and residents in four of nine smoke zones. This facility has a capacity of 25 with a census of 6 residents.

Findings include:

Observation and interview on 5/2/11, revealed open conduit and a one inch penetration in the smoke barrier by room #55 and open conduit and a four inch penetration around duct work in the smoke barrier by room #204. According to the facility layout, this was a required barrier. Maintenance Staff A confirmed these observations.

NFPA standard: Requires smoke walls to have a fire resistance rating of at least a half hour and to be continuous from floor to roof deck and from outside wall to outside wall. 2000 NFPA 101, 19.3.7.3

Based on observation and interview, the facility is not providing clear and unobstructed exit for one area. This deficient practice affects all occupants located inside of the area. This facility has a capacity of 25 with a census of 6.

Findings include:

Observation and interview on 5/2/11, revealed the door to the Employee Dining room had a keyed deadbolt on the door along with a door knob with a locking mechanism. Maintenance Staff A verified the observation.

NFPA Standard: Exits shall be located and exit access shall be arranged so that exits are readily accessible at all times. 2000 NFPA 101, 7.5.1.1

Based on record review and interview, the facility failed to document the emergency egress lighting monthly and annually. This deficient practice affects nine of nine smoke compartments and all occupants of the facility. This facility has a capacity of 25 and a census of 6 residents.

Findings include:

Observation of the facility's maintenance records and interview on 5/2/11, revealed the absence of documentation regarding the testing of the emergency battery lighting system. According to Maintenance Staff A, the lights were tested monthly, but there was no documentation to show that the monthly tests were conducted for 30 seconds or that an annual test was completed for 90 minutes under load.

NFPA standard: Requires a documented monthly test of battery-powered emergency lighting for at least 30 seconds, and an annual test for a duration of 1-1/2 hours. 2000 NFPA 101, 7.9.3

Based on observation and interview, the facility did not provide a directional exit sign at one smoke door. This deficient practice effects residents, staff and visitors in this smoke zone. This facility has a capacity of 25 and census of 6 residents.

Findings include:

Observation and interview on 5/2/11, revealed the West side of the smoke doors by room #132 did not have a directional exit sign. According to the facility layout, which is used in conjunction with the emergency procedures, this designated exit is a required exit. This was verifed by Maintenance Staff A.

Based upon record review and interview, the facility failed to hold fire drills under varied conditions at different times of the day for two of four quarters reviewed. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This facility has a capacity of 25 with a census of 6.

Findings include:

Record review and interview on 5/2/11, showed the facility fire drill documentation did not have drills for the second quarter of 2010 on the 2nd shift and fourth quarter of 2010 on the 1st shift. Maintenance Staff A verified the documentation.

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. 2000 NFPA 101, 19.7.1.2

Based on observation and interview, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association 72. This deficient practice affects all occupants in the building. The facility has a certified capacity of 25 with the current census of 6.

Findings include:

Observation and interview on 5/2/11, revealed the fire alarm control panel was located in the Employee Dining room and did not have a smoke detector in the room. This was verified by Maintenance Staff A.




NFPA Standard: Fire safety functions shall not interfere with other operations of the fire alarm system. 1999 NFPA 72, 3-9.2.2

NFPA Standard: A fire alarm and control system, where required by Code, shall be arranged to actuate automatically the control functions necessary to make the protected premises safer for building occupants. 2000 NFPA 101, 9.6.5.1

NFPA standard: In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit(s) to provide notification of fire at that location. Exception: Where ambient conditions prohibit installation of automatic smoke detection, automatic heat detection shall be permitted. 1999 NFPA 72, 5.6

A)
Based on record review and interview, the facility failed to maintain the sprinkler system in accordance with the National Fire Protection Association (NFPA), Standard 25, by ensuring the 5 year Flow test had been performed. This deficient practice affects all occupants in the building. The facility has a capacity of 25 with the census of 6 residents.

Findings include:

Record review and interview on 5/2/11, revealed documentation from American Fire Protection dated September 2010 indicating the 5 year Flow test was overdue. The facility could not find documentation the test had been performed. Maintenance Staff A verified this finding.


B)

Based on record review and interview the faciltiy failed to correct all deficiencies on the last documented sprinkler system inspection. This deficient practice affects all occupants in the building. The facility has a capacity of 25 with the current census of 6 residents.

Findings include:

Record review and interview on 5/2/11, revealed two deficiencies on the last inspection report from American Fire Protection dated September 2010 had not been corrected. Maintenance Staff A verified this finding.

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 performance and protection as designed. NFPA 13, 12.1