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Based on observations and staff interview the facility failed to install the smoke detection in accordance with NFPA 101 Life Safety Code (2012) section 19.3.4.1, 9.6.1.3 and NFPA 72 National Fire Alarm Code (2010) section 17.7.4.1. This deficient practice could affect the ability of the alarm system to sound in a timely manner during a fire event which could affect an undetermined amount of staff and visitors.

Findings include:

At 10:20 am on 09/26/17, observations revealed a smoke detector within 36 inches of an HVAC diffuser in the Physicians office.

This deficient condition was confirmed by the Physical Plant Director.

Spaces (other than patient sleeping rooms, treatment rooms and hazardous areas), waiting areas, nurse ' s stations, gift shops, and cooking facilities, open to the corridor are in accordance with the criteria under 18.3.6.1 and 19.3.6.1. 18.3.6.1, 19.3.6.1

Findings include:

At 10:25 am on 09/26/17 observations revealed the space open to the corridor adjacent to the treatment room contained combustible storage.


This deficient condition was confirmed by the Physical Plant Director.

Based on record review and staff interview the facility failed to maintain smoke dampers in accordance with The Standard for Fire Doors and Other Opening Protective's, NFPA 80 , 2010 edition section 19.4.1.1. This deficient practice could allow smoke to travel throughout smoke compartments affecting the exiting capabilities of all patients and an undetermined amount of staff and visitors.

Findings include:

At 9:40 am on 09/26/17 observations revealed the cable bundles and conduit that penetrated the wall above the cross corridor doors were not properly fire stopped.

This deficient condition was confirmed by the Physical Plant Director.

Based on record review and staff interview the facility failed to provide documentation of fire drills at least quarterly on each shift as required by the Life Safety Code (NFPA 101) 2012 edition, section 19.7.1.4 to 19.7.1.7. This deficient practice could reduce the ability of staff to conduct a safe and timely response to a fire emergency, which would affect all residents and an undetermined amount of staff and visitors.

Findings include:

On 09/26/2017 at 9 AM, documentation reviewed revealed Fire drills were not performed correctly during these times:

1) 1st quarter 2nd shift of 2017
2) 2nd quarter 1st and 2nd shift of 2017



This deficient practice was confirmed by the facility Maintenance staff at the time of discovery and at the exit conference.