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Based on observation and staff interview, the facility failed to provide approved readily visible signs to appropriately mark all exit access. The deficient practice could affect all residents, visitors, and staff in 1 of 9 smoke zones. The hospital has a capacity of 18 with a census of 9 residents and the LTCU a capacity of 38 with a census of 28 at the time of the survey. The entire building was inspected due to no complete 2 hour fire separation.
Findings include.

During the survey conducted on 9/29/16 the following deficiency is noted:

1. During the survey at approximately 3:30 PM it is observed that the door to the enclosed courtyard near the Assisted Living dietary dining area were not marked with " No Exit " signage.

Maintenance Staff was present and acknowledged the missing signage on the courtyard door.
NFPA Standard: Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that read as follows: NO EXIT. Such a sign shall have the word NO in letters 2 in. high with a stroke width of 3/8 " and the word EXIT in letter 1 " high with the EXIT below the word NO. NFPA 101 7.10.8.1

Base on observation and staff interview, the facility fails to assure that spaces between penetrating items and smoke barriers are filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. This deficient practice would not prevent the passage of smoke to other areas of the building, affecting approximately no residents and all visitors and staff in 4 of 9 smoke zones. The hospital has a capacity of 18 with a census of 9 residents and the LTCU a capacity of 38 with a census of 28 at the time of the survey. The entire building was inspected due to no complete 2 hour fire separation.
Findings include:

During the survey conducted on 9/29/16 the following deficiencies are noted:


1. During the survey at approximately 2:15 PM it is observed that there are unsealed penetrations, in an approximate 2 " hole, by IT wires in the wall above the smoke barrier doors near dietary.
2. During the survey at approximately 1:55 PM it is observed that there are unsealed penetrations, in an approximate 2 " hole, by IT wires in the wall above the smoke barrier doors near the clinic.

Maintenance and Staff A was present and acknowledged the penetrations in the smoke barrier walls.

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
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 staff interview, the facility failed to properly inspect and maintain the smoke barrier doors in accordance with NFPA 101. This deficient practice could affect all residents, visitors, and staff in 4 of 9 smoke zones. The hospital has a capacity of 18 with a census of 9 residents and the LTCU a capacity of 38 with a census of 28 at the time of the survey. The entire building was inspected due to no complete 2 hour fire separation.
Findings include:
During the survey conducted on 9/29/16 the following deficiencies are noted:

1. During the survey at approximately 2:20 PM it is observed that the smoke barrier doors to the dietary dining room did not properly close and latch was catching when tested.
2. During the survey at approximately 2:25 PM it is observed that the automatic closing device on the smoke barrier door to the Assisted Living dining room did not properly function when tested and the door would not close on its own.

Maintenance staff was present and acknowledged that the smoke barrier door closing device to the Assisted Living dining room was not functional and the Dietary dining room were not completely closing.
NFPA Standard: Doors shall be self-closing or automatic closing in accordance with 2000 NFPA 101 19.2.2.2.6.

Based on observation and staff interview, this facility is not providing proper signage for the delayed egress doors in the path of the means of egress. This deficient practice could affect the ability of people to properly exit the facility in the event of a fire affecting approximately 16 residents, and all visitors and staff in 1 of 9 smoke zones. The hospital has a capacity of 18 with a census of 9 residents and the LTCU a capacity of 38 with a census of 28 at the time of the survey. The entire building was inspected due to no complete 2 hour fire separation.
Findings include:
During the survey conducted on 9/29/16 the following deficiency is noted:


1. During the survey at approximately 2:45 PM it is observed that the delayed egress door near rooms 107 and 108 in the Assisted Living hall was not marked by any of the proper signage of " In Emergency - push the panic bar for 15 seconds to release the lock " .

Maintenance Staff was present and acknowledged the missing signage on the delayed egress door.

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

Base on observation and staff interview, the facility failed to test and maintain the emergency lights to provide a means of illumination at each exit discharge, so that failure of normal lighting would not leave the area to public way in darkness. This deficient practice could affect approximately 16 residents, and all visitors and staff in 1 of 9 smoke zones. The hospital has a capacity of 18 with a census of 9 residents and the LTCU a capacity of 38 with a census of 28 at the time of the survey. The entire building was inspected due to no complete 2 hour fire separation.
Findings include:

During the survey conducted on 9/29/16 the following deficiency is noted:


1. During the survey at approximately 2:40 PM it is observed when testing the emergency light in the Assisted Living hall near rooms 107 and 108 the lights did not function and the battery was dead.

Maintenance staff was present and acknowledged the emergency lights near Assisted Living rooms 107 and 108 failed a test.

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 at least quarterly on each shift in accordance with NFPA 101. The deficient practice could affect the abilities of the staff to respond in the event of an actual emergency. This deficient practice could affect all residents, visitors, and staff in 9 of 9 smoke zones. The hospital has a capacity of 18 with a census of 9 residents and the LTCU a capacity of 38 with a census of 28 at the time of the survey. The entire building was inspected due to no complete 2 hour fire separation.
Findings include:

During the survey conducted on 9/29/16 the following deficiency is noted:

1. During document at approximately 10:00 a.m. it is observed that there is no documentation for a fire drill on 3rd shift in the 3rd and 4th quarter of 2015.

Maintenance Staff was present and acknowledged the missing fire drills.
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

Base on observation and staff interview, the facility fails to inspect and maintain the sprinkler system in accordance with NFPA 25. This deficient practice may cause the sprinkler system to improperly function in the event of a fire, affecting all residents, visitors, and staff in 9 of 9 smoke zones. The hospital has a capacity of 18 with a census of 9 residents and the LTCU a capacity of 38 with a census of 28 at the time of the survey. The entire building was inspected due to no complete 2 hour fire separation.
Findings include:


During the survey conducted on 9/29/16 the following deficiencies are noted:


1. During the survey at approximately 1:40 PM it is observed that there is a sprinkler head in the EP room and storage room of the basement that has paint on it.
2. During document review at approximately 11:00 AM it is observed that there were missed weekly inspections of the dry sprinkler system in December of 2015.

Maintenance Staff was present and acknowledged the paint on the sprinkler heads and missed weekly inspections.

NFPA Standard: Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. 1998 NFPA 25, 2-2.1.1
NFPA Standard: Gauges on dry and preaction systems shall be inspected weekly to ensure that normal air or nitrogen and water pressures are being maintained. NFPA 25 5.2.4.2