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Based upon 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. The deficient practice would not prevent the passage of smoke to other areas of the building, affecting all 25 residents in 3 of 5 smoke zones. The facility has a capacity of 25 with a census of 10 at the time of the survey.

Findings include:

During the tour conducted on 03/12/2013, between 10:00 a.m. and 3:30 p.m., it is observed:

-- 1. Smoke barrier wall near Resident Room 327 has unsealed gaps around wires and cables.

-- 2. Smoke barrier wall near Surgery has unsealed gaps around wires and cables.

Maintenance Staff A was present and acknowledged the presence of unsealed gaps in 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

Based upon a review of records and staff interview, the facility fails to assure that the fire alarm is continuously maintained in accordance with NFPA 70. The deficient practice could result in insufficient warning of a fire or other emergency for occupants of the building, affecting all 25 residents, staff and visitors in 5 of 5 smoke zones. The facility has a capacity of 25 with a census of 10 at the time of the survey.

Findings include:

During the tour conducted on 03/12/2013, between 10:00 a.m. and 3:30 p.m., a review of records for the past 5 quarters revealed that the fire alarm system is past due for annual maintenance and testing. The last available annual report of maintenance and testing of the fire alarm system was dated 02-20-2012.

Staff A and B were present and acknowledged the results of the record review.

NFPA Standard: Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2. 1999 NFPA 72, 7-2.2

NFPA Standard: A permanent record of all inspections, testing, and maintenance shall be maintained that includes periodic tests and applicable information, per 1999 NFPA 72, 7-5.2.2 and figure 7-5.2.2; A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70. 2000 NFPA 101, 9.6.1.4

Based upon a review of records, observation, and staff interview, the facility fails to assure that the automatic sprinkler system is inspected, tested and maintained in accordance with NFPA 25. The deficient practice could result in the unexpected failure of the automatic fire sprinkler system, affecting all 25 residents, staff and visitors in 5 of 5 smoke zones. The facility has a capacity of 25 with a census of 10 at the time of the survey.

Findings include:

During the tour conducted on 03/12/2013, between 10:00 a.m. and 3:30 p.m., a review of records for the last five quarters, revealed the following:

-- 1. No documented monthly visual inspections of the automatic sprinkler system.

-- 2. Sprinkler heads located in the Laundry (Room 314), Resident Rooms 116 & 117, and near the Nurses Station, have an accumulation of lint, dust and other materials.

Maintenance Staff A was present and acknowledged the results of the records review. Maintenance Staff A stated that he was unaware of the requirement for documentation of the monthly visual inspections. Maintenance Staff A acknowledged that sprinkler heads have an accumulation of debris.

NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1

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 Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. 1999 NFPA 13, 12.1

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

Based upon observation and staff interview, the facility fails to assure that electrical wiring and equipment is in accordance with NFPA 70. The deficient practice increases the risk of an electrical fire, affecting 6 residents, staff and visitors in 3 of 5 smoke zones. The facility has a capacity of 25 with a census of 10 at the time of this survey.

Findings include:

During the tour conducted on 03/12/2013, between 10:00 a.m. and 3:30 p.m., it is observed:

-- 1. Flexible cords and cables (power strips) used to power medical equipment:
a. In the Emergency Room, for portable diagnostic medical equipment.
b. Near the Nurses Station, crash cart with multiple power strips.

-- 2. Electrical outlets near water sources not protected by Ground-Fault Circuit-Interrupter (GFCI) protection:
a. Hand sink in Central Supply.
b. Hand sink in Kitchen (Rm 305).

Maintenance Staff A was present and acknowledged the inappropriate use of flexible cords and cables and that the outlets referenced above were not protected by GFCI breakers.

NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8.

NFPA Standard: Flexible cord shall be used only in continuous lengths without splice or tap where initially installed in applications permitted by Section 400-7(a). 1999 NFPA 70, article 400-9

NFPA Standard: All 125-volt, single-phase, 15- and 20-ampere receptacles installed in bathrooms, garages, storage areas, work areas, and area of similar use shall have Ground-Fault Circuit-Interrupter (GFCI) protection. 1999 NFPA 70, 210-8.