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Based on observations and interview, it was determined the facility failed to maintain smoke barriers that would resist the passage of smoke between smoke compartments in accordance with NFPA standards. The deficiency had the potential to affect six (6) of seven (7) smoke compartments, residents, staff and visitors. The facility has one hundred forty (140) certified beds with a census of one hundred one (101) on the day of the survey.


The findings include:

Observations, on 07/24/12 between 10:00 AM and 11:00 AM, with the Director of Plant Operations revealed the smoke partitions, extending above the ceiling had multiple penetrations of pipes and wires. The penetrations were not filled with a material rated equal to the partition and could not resist the passage of smoke. The penetrations and unrated material were noted in the following locations:

1) Quik foam was used to seal a penetration located in Unit 2 West over the Patients Effects Room.
2) Penetration by pipes and wires located above cross corridor door #4.
3) Penetration around the sprinkler pipe located above cross corridor door #6.
4) A sleeve through the smoke partition for data cables was not sealed inside the sleeve, located above cross corridor door #14.


Interview, on 07/24/12 between 10:00 AM and 11:00 AM, with the Director of Plant Operations revealed he was not aware of the penetrations, and was not aware of who had installed the unrated Qwik Foam.



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, it was determined the facility failed to meet the requirements of Protection of Hazards, in accordance with NFPA Standards. The deficiency had the potential to affect one (1) of seven (7) smoke compartments, residents, staff and visitors. The facility has one hundred forty (140) certified beds with a census of one-hundred one (101) on the day of the survey.


The findings include:

Observation, on 07/24/12 at 1:10 PM, with the Director of Plant Services revealed the mechanical closet located in Unit 1 West had a twelve (12) inch hole in the wall over the door to the corridor. The hole was caused by duct work that was no longer used and had not been sealed.

Interview, on 07/24/12 at 1:10 PM, with the Director of Plant Services revealed he did not realize the hole was over the door when he would check for penetrations in the mechanical room.

Reference:

NFPA 101 (2000 Edition).

19.3.2 Protection from Hazards.
19.3.2.1 Hazardous Areas. Any hazardous areas
shall be safeguarded by a fire barrier having a
1-hour fire resistance rating or shall be provided
with an automatic extinguishing system in
accordance with 8.4.1. The automatic
extinguishing shall be permitted to be in
accordance with 19.3.5.4. Where the sprinkler
option is used, the areas shall be separated
from other spaces by smoke-resisting partitions
and doors. The doors shall be self-closing or
automatic-closing. Hazardous areas shall
include, but shall not be restricted to, the
following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2
(9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2),
including repair shops, used for storage of
combustible supplies
and equipment in quantities deemed hazardous
by the authority having jurisdiction
(8) Laboratories employing flammable or
combustible materials in quantities less than
those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be
permitted to have nonrated, factory or field-applied
protective plates extending not more than
48 in. (122 cm) above the bottom of the door.

Based on observation and interview, it was determined the facility failed to ensure the exits were maintained in accordance with NFPA standards. The deficiency had the potential to affect four (4) of seven (7) smoke compartments, residents, staff, and visitors. The facility has one hundred forty (140) certified beds with a census of one hundred one (101) on the day of the survey.


The findings include:

Observation, on 07/24/12 between 10:00 AM and 4:00 PM, with the Director of Plant Services revealed the following exits did not have a durable surface to a public way; Fire Exit at door # P, Unit 1 East Exit , Unit 1 West Exit , Unit 3 Playground Exit , Unit 5 Exit near room #513, Unit 5 Exit near room #505, and Unit 5 Day Room Exit.

Interview, on 7/24/12 between 10:00 AM and 4:00 PM, with the Director of Plant Services revealed the facility had talked to Joint Commission about the exits. After talking with Joint Commission, the facility was under the impression they did not need durable surface to the public way from these exits.

Reference: NFPA 101 (2000 edition)

7.1.10.1* Means of egress shall be continuously maintained
free of all obstructions or impediments to full instant use in
the case of fire or other emergency.
7.5.1.1 Exits shall be located and exit access shall be arranged
so that exits are readily accessible at all times.
7.7.1* Exits shall terminate directly at a public way or at an
exterior exit discharge. Yards, courts, open spaces, or other
portions of the exit discharge shall be of required width and
size to provide all occupants with a safe access to a public way.
Exception No. 1: This requirement shall not apply to interior exit discharge
as otherwise provided in 7.7.2.
Exception No. 2: This requirement shall not apply to rooftop exit discharge
as otherwise provided in 7.7.6.
Exception No. 3: Means of egress shall be permitted to terminate in an
exterior area of refuge as provided in Chapters 22 and 23.

Reference: CMS S&C letter 5-38

Based on observation and interview, it was determined the facility failed to ensure exits were equipped with lighting in accordance with NFPA standards. The deficiency had the potential to affect one (1) of seven (7) smoke compartments, residents, staff and visitors. The facility has one hundred forty (140) certified beds with a census of one hundred one (101) on the day of the survey.

The findings include:

Observation, on 07/24/12 at 4:00 PM, with the Director of Plant Operations revealed the exterior exit in the Unit 5 Day Room, to have a light fixture with only one light bulb outside to illuminate the egress path.

Interview, on 07/12/12 at 4:00 PM, with the Director of Plant Services revealed he had just become aware of the requirements for egress lighting and was in the process of making changes regarding egress lighting to meet NFPA requirements.


Reference: NFPA 101 (2000 edition)
7.8.1.4* Required illumination shall be arranged so that the
failure of any single lighting unit does not result in an illumination
level of less than 0.2 ft-candle (2 lux) in any designated
area.

Based on interview and fire drill record review, it was determined the facility failed to ensure fire drills were conducted quarterly on each shift at unexpected times, in accordance with NFPA standards. The deficiency had the potential to affect seven (7) of seven (7) smoke compartments, residents, staff and visitors. The facility has one hundred forty (140) certified beds with a census of one hundred one (101) on the day of the survey.

The findings include:

Fire Drill review, on 07/24/12 at 11:14 AM, with the Director of Plant Operations revealed the facility failed to conduct fire drills at unexpected times on second and third shift. Fire drills on second shift were conducted at 3:06 PM, 3:05 PM, 3:10 PM, and 3:19 PM throughout the last four (4) quarters. Third shift fire drills were conducted at 6:00 AM, 6:00 AM, 5:30 AM, and 6:30 AM throughout the last four (4) quarters.

Interview, on 07/24/12 at 11:14 AM, with the Director of Plant Operations revealed he was not aware the fire drills were not being conducted in accordance with NFPA standards.


Reference: NFPA Standard NFPA 101 19.7.1.2.
Fire drills shall be conducted at least quarterly on each shift and at unexpected times under varied conditions on all shifts.

Based on interview and fire alarm inspection review, the facility failed to test the fire alarm system quarterly per NFPA standards. The deficiency had the potential to affect seven (7) of seven (7) smoke compartments, residents, staff, and visitors. The facility has one hundred forty (140) certified beds with a census of one hundred one (101) on the day of the survey.

The findings include:

Fire alarm inspection review, on 07/24/12 at 11:00 AM, with the Director of Plant Operations revealed the facility failed to conduct a fire alarm inspection in the 3rd quarter of 2011. However a fire alarm inspection was conducted on 10/03/11, and again on 12/20/11.

Interview, on 07/24/12 at 11:00 AM, with the Director of Plant Operations revealed the facility had a contract with a company to complete the fire alarm tests as required, but did not have a system in place to monitor the fire alarm testing company to ensure they are conducting the tests in accordance with NFPA standards.

Actual NFPA Standard: NFPA 101, 9.6.1.4. A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.

Based on observation, interview, and sprinkler testing record review it was determined the facility failed to maintain the sprinkler system in accordance with NFPA standards. The deficiency had the potential to affect seven (7) of seven (7) smoke compartments, residents, staff and visitors. The facility has one hundred forty (140) certified beds with a census of one hundred one (101) on the day of the survey.


The findings Include:

Observation and record review, on 07/24/12 at 11:16 AM, with the Director of Plant Operations revealed the sprinkler system had no internal pipe inspection within the last 5 years Also two (2) of the systems six (6) gauges have not been calibrated within the last five (5) years.

Interview, on 07/24/12 at 11:16 AM, with the Director of Plant Operations revealed he was under the impression the sprinkler contractor would know the testing frequency for all parts of the sprinkler system and keep the facility in compliance.

Observation and record review, on 07/24/12 between 2:00 PM and 3:30 PM, with the Director of Plant Operations revealed the sprinkler heads located in the gymnasium storage room, Intake Office, and Unit 4 Nurse Lounge were missing the escutcheon (trim piece) and allowing the ceiling tile to bag down and possibly obstruct the sprinkler head discharge pattern development.

Interview, on 07/24/12 at 11:16 AM, with the Director of Plant Operations revealed he had not noticed the escutcheons were missing.

Observation and record review, on 07/24/12 at 11:16 AM, with the Director of Plant Operations revealed the sprinkler heads located in the Dish Room to be covered in green corrosion.

Interview, on 07/24/12 at 11:16 AM, with the Director of Plant Operations revealed he had not noticed the green corrosion on the sprinkler heads in the Dish Room.






Reference: NFPA 13 (1999 Edition)
5-5.5.2* Obstructions to Sprinkler Discharge
Pattern Development.
5-5.5.2.1 Continuous or noncontiguous
obstructions less Than or equal to 18 in.
(457 mm) below the sprinkler deflector
That prevent the pattern from fully developing
shall comply With 5-5.5.2.


2-2.1.1* 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.
hydraulic design basis, the system area of operation shall be
permitted to be reduced without revising the density as indicated
in Figure 7-2.3.2.4 when all of the following conditions
are satisfied:
(1) Wet pipe system
(2) Light hazard or ordinary hazard occupancy
(3) 20-ft (6.1-m) maximum ceiling height
The number of sprinklers in the design area shall never be
less than five. Where quick-response sprinklers are used on a
sloped ceiling, the maximum ceiling height shall be used for
determining the percent reduction in design area. Where
quick-response sprinklers are installed, all sprinklers within a
compartment shall be of the quick response type.
Exception: Where circumstances require the use of other than ordinary
temperature-rated sprinklers, standard response sprinklers shall be
permitted to be used.


Reference: NFPA 25 (1998 Edition).


10-2.2* Obstruction Prevention.
Systems shall be examined internally for obstructions where conditions exist that could cause obstructed piping. If the condition has not been corrected or the condition is one that could result in obstruction of piping despite any previous flushing procedures that have been performed, the system shall be examined internally for obstructions every 5 years. This investigation shall be accomplished by examining the interior of a dry valve or preaction valve and by removing two cross main flushing connections.

10-2.3* Flushing Procedure.
If an obstruction investigation carried out in accordance with 10-2.1 indicates the presence of sufficient material to obstruct sprinklers, a complete flushing program shall be conducted. The work shall be done by qualified personnel.

Reference: NFPA 25 (1998 Edition).

2-1 General. This chapter provides the minimum requirements
for the routine inspection, testing, and maintenance of
sprinkler systems. Table 2-1 shall be used to determine the
minimum required frequencies for inspection, testing, and
maintenance.
Exception: Valves and fire department connections shall be inspected,
tested, and maintained in accordance with Chapter 9.

Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance
Item Activity Frequency Reference
Gauges (dry, preaction deluge systems) Inspection Weekly/monthly 2-2.4.2
Control valves Inspection Weekly/monthly Table 9-1
Alarm devices Inspection Quarterly 2-2.6
Gauges (wet pipe systems) Inspection Monthly 2-2.4.1
Hydraulic nameplate Inspection Quarterly 2-2.7
Buildings Inspection Annually (prior to freezing
weather)
2-2.5
Hanger/seismic bracing Inspection Annually 2-2.3
Pipe and fittings Inspection Annually 2-2.2
Sprinklers Inspection Annually 2-2.1.1
Spare sprinklers Inspection Annually 2-2.1.3
Fire department connections Inspection Table 9-1
Valves (all types) Inspection Table 9-1
Alarm devices Test Quarterly 2-3.3
Main drain Test Annually Table 9-1
Antifreeze solution Test Annually 2-3.4
Gauges Test 5 years 2-3.2
Sprinklers - extra-high temp. Test 5 years 2-3.1.1 Exception No. 3
Sprinklers - fast response Test At 20 years and every 10 years
thereafter
2-3.1.1 Exception No. 2
Sprinklers Test At 50 years and every 10 years
thereafter
2-3.1.1
Valves (all types) Maintenance Annually or as needed Table 9-1
Obstruction investigation Maintenance 5 years or as needed Chapter 10

Based on observation and interview, it was determined the facility failed to ensure the use of approved ashtrays in the designated smoking area, in accordance with NFPA standards. The deficiency had the potential to affect two (2) of seven (7) smoke compartments, residents, staff and visitors. The facility has one hundred forty (140) certified beds with a census of one hundred one (101) on the day of the survey.

The findings include:

Observation, on 07/24/12 between 1:00 PM and 2:00 PM, with the Director of Plant Services revealed the ashtrays located in the Unit 1 West, and Unit 2 West smoking areas were not of the approved type. They did not have a metal container with a self-closing lid.

Interview, on 07/24/12 between 1:00 PM and 2:00 PM, with the Director of Plant Services revealed he was not aware of the requirement for self-closing ashtrays.

Reference: NFPA 101 (2000 edition)
19.7.4* Smoking. Smoking regulations shall be adopted and
shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment
where flammable liquids, combustible gases, or
oxygen is used or stored and in any other hazardous location,
and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international
symbol for no smoking.
Exception: In health care occupancies where smoking is prohibited
and signs are prominently placed at all major entrances, secondary
signs with language that prohibits smoking shall not be required.
(2) Smoking by patients classified as not responsible shall be
prohibited.
Exception: The requirement of 19.7.4(2) shall not apply where the patient
is under direct supervision.
(3) Ashtrays of noncombustible material and safe design
shall be provided in all areas where smoking is permitted.
(4) Metal containers with self-closing cover devices into
which ashtrays can be emptied shall be readily available
to all areas where smoking is permitted.

Based on observation and interview it was determined the facility failed to ensure, portable space heaters used in the facility were in accordance with NFPA standards. The deficiency had the potential to affect three (3) of seven (7) smoke compartments, residents, staff and visitors. The facility has one hundred forty (140) beds with a census of one hundred one (101) on the day of the survey.

The findings include:

Observation, on 07/24/12 between 12:50 PM and 4:00 PM, with the Director of Plant Services revealed portable space heaters located in the following areas; Unit 1 East Mangers Office, Medical Directors Office, Staffing Coordinators Office, two (2) in the Marketing Office, and the Director of Medical Records Office.

Interview, on 07/24/12 between 12:50 PM and 4:00 PM, with the Director of Plant Services revealed he was not aware the heaters could not exceed 212?F in non-sleeping, staff, and employee areas.


Reference: NFPA 101 (2000 edition)
19.7.8 Portable Space-Heating Devices. Portable space-heating
devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used
in non-sleeping staff and employee areas where the heating elements of
such devices do not exceed 212?F (100?C).

Based on observation and interview, it was determined the facility failed to maintain doors within a required means of egress in accordance with NFPA standards. The deficiency had the potential to affect one (1) of three (3) smoke compartments, residents, staff and visitors. The facility has one hundred forty (140) certified beds with a census of one hundred one (101) on the day of the survey.

The findings include:

Observation, on 07/24/12 between 12:50 PM and 4:00 PM, with the Director of Plant Services revealed unapproved door hold open devices (flip down type) were installed on doors to the following rooms; Unit 1 West: Nurses Lounge, Med Room, and Therapist Office, also, Unit 2 West Pharmacy, and Therapist Office. Further observation revealed more unapproved door stops located on the Medical Directors Office, Mail Room, Kitchen Door, Unit 3 Central Supply, and Clean Linen

Interview, on 07/24/12 between 12:50 PM and 4:00 PM, with the Director of Plant Services revealed he was not aware the door hold open devices could not be used.


Reference: NFPA 101 (2000 Edition)

19.2.2.2.4
Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.

Based on observation and interview, it was determined the facility failed to ensure emergency generators were maintained in accordance with NFPA standards. The deficiency had the potential to affect seven (7) of seven (7) smoke compartments, residents, staff, and visitors. The facility has one hundred forty (140) certified beds with a census of one hundred one (101) on the day of the survey.

The findings include:

Observation, on 7/24/12 at 11:28 AM, with the Director of Plant Services revealed the facility was equipped with an emergency generator. However, the generator was not equipped with an annunciation panel that could be readily observed by staff at a regular work station to inform staff of alarm conditions with the generators.

Interview, on 7/24/12 at 11:28 AM, with the Director of Plant Services revealed he was not aware the generator needed an annunciation panel to inform staff of alarm conditions with the generators.


Observation, on 07/24/12 at 11:26 AM, with the Director of Plant Operations revealed the facility did not have any battery-powered lighting installed in the room where the transfer switch for the emergency generator was located. The room where the transfer switch for the emergency generator is located must have battery-powered lighting in case there was a failure of the emergency generator and staff must operate the transfer switch manually.

Interview, on 07/24/12 at 11:26 AM, with the Director of Plant Operations revealed he was not aware of the requirement for the battery backup lighting. Observations were confirmed with the Administrator during the exit conference.


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]


Reference: NFPA 110 (1999 Edition).

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.

Based on observation and interview, it was determined the facility failed to ensure electrical wiring was maintained in accordance with NFPA standards. The deficiency had the potential to affect six (6) of seven (7) smoke compartments, residents, staff, and visitors. The facility has one hundred forty (140) certified beds with a census of one hundred one (101) on the day of the survey.

The findings include:

Observations, on 07/24/12 between 10:00 AM and 4:00 PM, with the Director of Plant Operations revealed:

1) An open electrical junction box located above the ceiling at cross corridor door #4, #11, and #12.
2) A power strip was plugged into another power strip located in the Pharmacy.
3) An extension cord was in use to a Christmas Tree, and a coffee pot was plugged into a power strip located in the Fiscal Accounting Office.
4) A refrigerator and a microwave were plugged into a power strip located in the Risk Management Office, also in the Director of Nursing Office.
5) A portable de-humidifier was plugged into a power strip located in the Main Lobby.
6) A power strip was plugged into another power strip located in the Receptionist Office.
7) A refrigerator and a toaster were plugged into a power strip located in the Medical Records Storage Room.
8) A refrigerator was plugged into a power strip located in the Unit 5 Clinical Director Office.


Interview, on 07/24/12 between 10:00 AM and 4:00 PM, with the Maintenance Director revealed he was not aware of the misuse of power strips, and extension cords. Further interview revealed they had recently done some work over the ceilings changing some exit signs, and the covers for the junction boxes must have just been overlooked.

Reference: NFPA 99 ( 1999 edition)
3-3.2.1.2 D

Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.


Reference: NFPA 70 (1999 edition)

370.28(c) Covers.

All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 370-22, Exception.

Based on interview and facility policy and procedure review, the facility failed to develop a fire watch policy in accordance with NFPA standards. The deficiency had the potential to affect seven (7) of seven (7) smoke compartments, residents, staff, and visitors. The facility has one hundred forty (140) beds with a census of one hundred one (101) on the day of the survey.


The findings include:

Policy and Procedure review, on 7/24/12 at 11:08 AM, with the Director of Plant Operations revealed the facility failed to provide a written policy outlining an approved fire watch system in the event the sprinkler system is shut down for four (4) or more hours in a twenty four (24) hour period.

Interview, on 7/24/12 at 11:08 AM, with the Director of Plant Operations revealed he was unaware the facility was required to have a written policy for the facilities fire watch system.

Reference; NFPA 101 (2000 edition)
9.7.6* Sprinkler System Shutdown.
9.7.6.1
Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.

Based on interview and facility policy and procedure review, the facility failed to develop a fire watch policy in accordance with NFPA standards. The deficiency had the potential to affect seven (7) of seven (7) smoke compartments, residents, staff, and visitors. The facility has one hundred forty (140) beds with a census of one hundred one (101) on the day of the survey.


The findings include:

Policy and Procedure review, on 7/24/12 at 11:08 AM, with the Director of Plant Operations revealed the facility failed to provide a written policy outlining an approved fire watch system in the event the fire alarm system is shut down for four (4) or more hours in a twenty four (24) hour period.

Interview, on 7/24/12 at 11:08 AM, with the Director of Plant Operations revealed he was unaware the facility was required to have a written policy for the facilities fire watch system.


Reference; NFPA 101 (2000 edition)
9.6.1.8*
Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

Based on observations and interview, it was determined the facility failed to maintain smoke barriers that would resist the passage of smoke between smoke compartments in accordance with NFPA standards. The deficiency had the potential to affect six (6) of seven (7) smoke compartments, residents, staff and visitors. The facility has one hundred forty (140) certified beds with a census of one hundred one (101) on the day of the survey.


The findings include:

Observations, on 07/24/12 between 10:00 AM and 11:00 AM, with the Director of Plant Operations revealed the smoke partitions, extending above the ceiling had multiple penetrations of pipes and wires. The penetrations were not filled with a material rated equal to the partition and could not resist the passage of smoke. The penetrations and unrated material were noted in the following locations:

1) Quik foam was used to seal a penetration located in Unit 2 West over the Patients Effects Room.
2) Penetration by pipes and wires located above cross corridor door #4.
3) Penetration around the sprinkler pipe located above cross corridor door #6.
4) A sleeve through the smoke partition for data cables was not sealed inside the sleeve, located above cross corridor door #14.


Interview, on 07/24/12 between 10:00 AM and 11:00 AM, with the Director of Plant Operations revealed he was not aware of the penetrations, and was not aware of who had installed the unrated Qwik Foam.



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, it was determined the facility failed to meet the requirements of Protection of Hazards, in accordance with NFPA Standards. The deficiency had the potential to affect one (1) of seven (7) smoke compartments, residents, staff and visitors. The facility has one hundred forty (140) certified beds with a census of one-hundred one (101) on the day of the survey.


The findings include:

Observation, on 07/24/12 at 1:10 PM, with the Director of Plant Services revealed the mechanical closet located in Unit 1 West had a twelve (12) inch hole in the wall over the door to the corridor. The hole was caused by duct work that was no longer used and had not been sealed.

Interview, on 07/24/12 at 1:10 PM, with the Director of Plant Services revealed he did not realize the hole was over the door when he would check for penetrations in the mechanical room.

Reference:

NFPA 101 (2000 Edition).

19.3.2 Protection from Hazards.
19.3.2.1 Hazardous Areas. Any hazardous areas
shall be safeguarded by a fire barrier having a
1-hour fire resistance rating or shall be provided
with an automatic extinguishing system in
accordance with 8.4.1. The automatic
extinguishing shall be permitted to be in
accordance with 19.3.5.4. Where the sprinkler
option is used, the areas shall be separated
from other spaces by smoke-resisting partitions
and doors. The doors shall be self-closing or
automatic-closing. Hazardous areas shall
include, but shall not be restricted to, the
following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2
(9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2),
including repair shops, used for storage of
combustible supplies
and equipment in quantities deemed hazardous
by the authority having jurisdiction
(8) Laboratories employing flammable or
combustible materials in quantities less than
those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be
permitted to have nonrated, factory or field-applied
protective plates extending not more than
48 in. (122 cm) above the bottom of the door.

Based on observation and interview, it was determined the facility failed to ensure the exits were maintained in accordance with NFPA standards. The deficiency had the potential to affect four (4) of seven (7) smoke compartments, residents, staff, and visitors. The facility has one hundred forty (140) certified beds with a census of one hundred one (101) on the day of the survey.


The findings include:

Observation, on 07/24/12 between 10:00 AM and 4:00 PM, with the Director of Plant Services revealed the following exits did not have a durable surface to a public way; Fire Exit at door # P, Unit 1 East Exit , Unit 1 West Exit , Unit 3 Playground Exit , Unit 5 Exit near room #513, Unit 5 Exit near room #505, and Unit 5 Day Room Exit.

Interview, on 7/24/12 between 10:00 AM and 4:00 PM, with the Director of Plant Services revealed the facility had talked to Joint Commission about the exits. After talking with Joint Commission, the facility was under the impression they did not need durable surface to the public way from these exits.

Reference: NFPA 101 (2000 edition)

7.1.10.1* Means of egress shall be continuously maintained
free of all obstructions or impediments to full instant use in
the case of fire or other emergency.
7.5.1.1 Exits shall be located and exit access shall be arranged
so that exits are readily accessible at all times.
7.7.1* Exits shall terminate directly at a public way or at an
exterior exit discharge. Yards, courts, open spaces, or other
portions of the exit discharge shall be of required width and
size to provide all occupants with a safe access to a public way.
Exception No. 1: This requirement shall not apply to interior exit discharge
as otherwise provided in 7.7.2.
Exception No. 2: This requirement shall not apply to rooftop exit discharge
as otherwise provided in 7.7.6.
Exception No. 3: Means of egress shall be permitted to terminate in an
exterior area of refuge as provided in Chapters 22 and 23.

Reference: CMS S&C letter 5-38

Based on observation and interview, it was determined the facility failed to ensure exits were equipped with lighting in accordance with NFPA standards. The deficiency had the potential to affect one (1) of seven (7) smoke compartments, residents, staff and visitors. The facility has one hundred forty (140) certified beds with a census of one hundred one (101) on the day of the survey.

The findings include:

Observation, on 07/24/12 at 4:00 PM, with the Director of Plant Operations revealed the exterior exit in the Unit 5 Day Room, to have a light fixture with only one light bulb outside to illuminate the egress path.

Interview, on 07/12/12 at 4:00 PM, with the Director of Plant Services revealed he had just become aware of the requirements for egress lighting and was in the process of making changes regarding egress lighting to meet NFPA requirements.


Reference: NFPA 101 (2000 edition)
7.8.1.4* Required illumination shall be arranged so that the
failure of any single lighting unit does not result in an illumination
level of less than 0.2 ft-candle (2 lux) in any designated
area.

Based on interview and fire drill record review, it was determined the facility failed to ensure fire drills were conducted quarterly on each shift at unexpected times, in accordance with NFPA standards. The deficiency had the potential to affect seven (7) of seven (7) smoke compartments, residents, staff and visitors. The facility has one hundred forty (140) certified beds with a census of one hundred one (101) on the day of the survey.

The findings include:

Fire Drill review, on 07/24/12 at 11:14 AM, with the Director of Plant Operations revealed the facility failed to conduct fire drills at unexpected times on second and third shift. Fire drills on second shift were conducted at 3:06 PM, 3:05 PM, 3:10 PM, and 3:19 PM throughout the last four (4) quarters. Third shift fire drills were conducted at 6:00 AM, 6:00 AM, 5:30 AM, and 6:30 AM throughout the last four (4) quarters.

Interview, on 07/24/12 at 11:14 AM, with the Director of Plant Operations revealed he was not aware the fire drills were not being conducted in accordance with NFPA standards.


Reference: NFPA Standard NFPA 101 19.7.1.2.
Fire drills shall be conducted at least quarterly on each shift and at unexpected times under varied conditions on all shifts.

Based on interview and fire alarm inspection review, the facility failed to test the fire alarm system quarterly per NFPA standards. The deficiency had the potential to affect seven (7) of seven (7) smoke compartments, residents, staff, and visitors. The facility has one hundred forty (140) certified beds with a census of one hundred one (101) on the day of the survey.

The findings include:

Fire alarm inspection review, on 07/24/12 at 11:00 AM, with the Director of Plant Operations revealed the facility failed to conduct a fire alarm inspection in the 3rd quarter of 2011. However a fire alarm inspection was conducted on 10/03/11, and again on 12/20/11.

Interview, on 07/24/12 at 11:00 AM, with the Director of Plant Operations revealed the facility had a contract with a company to complete the fire alarm tests as required, but did not have a system in place to monitor the fire alarm testing company to ensure they are conducting the tests in accordance with NFPA standards.

Actual NFPA Standard: NFPA 101, 9.6.1.4. A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.

Based on observation, interview, and sprinkler testing record review it was determined the facility failed to maintain the sprinkler system in accordance with NFPA standards. The deficiency had the potential to affect seven (7) of seven (7) smoke compartments, residents, staff and visitors. The facility has one hundred forty (140) certified beds with a census of one hundred one (101) on the day of the survey.


The findings Include:

Observation and record review, on 07/24/12 at 11:16 AM, with the Director of Plant Operations revealed the sprinkler system had no internal pipe inspection within the last 5 years Also two (2) of the systems six (6) gauges have not been calibrated within the last five (5) years.

Interview, on 07/24/12 at 11:16 AM, with the Director of Plant Operations revealed he was under the impression the sprinkler contractor would know the testing frequency for all parts of the sprinkler system and keep the facility in compliance.

Observation and record review, on 07/24/12 between 2:00 PM and 3:30 PM, with the Director of Plant Operations revealed the sprinkler heads located in the gymnasium storage room, Intake Office, and Unit 4 Nurse Lounge were missing the escutcheon (trim piece) and allowing the ceiling tile to bag down and possibly obstruct the sprinkler head discharge pattern development.

Interview, on 07/24/12 at 11:16 AM, with the Director of Plant Operations revealed he had not noticed the escutcheons were missing.

Observation and record review, on 07/24/12 at 11:16 AM, with the Director of Plant Operations revealed the sprinkler heads located in the Dish Room to be covered in green corrosion.

Interview, on 07/24/12 at 11:16 AM, with the Director of Plant Operations revealed he had not noticed the green corrosion on the sprinkler heads in the Dish Room.






Reference: NFPA 13 (1999 Edition)
5-5.5.2* Obstructions to Sprinkler Discharge
Pattern Development.
5-5.5.2.1 Continuous or noncontiguous
obstructions less Than or equal to 18 in.
(457 mm) below the sprinkler deflector
That prevent the pattern from fully developing
shall comply With 5-5.5.2.


2-2.1.1* 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.
hydraulic design basis, the system area of operation shall be
permitted to be reduced without revising the density as indicated
in Figure 7-2.3.2.4 when all of the following conditions
are satisfied:
(1) Wet pipe system
(2) Light hazard or ordinary hazard occupancy
(3) 20-ft (6.1-m) maximum ceiling height
The number of sprinklers in the design area shall never be
less than five. Where quick-response sprinklers are used on a
sloped ceiling, the maximum ceiling height shall be used for
determining the percent reduction in design area. Where
quick-response sprinklers are installed, all sprinklers within a
compartment shall be of the quick response type.
Exception: Where circumstances require the use of other than ordinary
temperature-rated sprinklers, standard response sprinklers shall be
permitted to be used.


Reference: NFPA 25 (1998 Edition).


10-2.2* Obstruction Prevention.
Systems shall be examined internally for obstructions where conditions exist that could cause obstructed piping. If the condition has not been corrected or the condition is one that could result in obstruction of piping despite any previous flushing procedures that have been performed, the system shall be examined internally for obstructions every 5 years. This investigation shall be accomplished by examining the interior of a dry valve or preaction valve and by removing two cross main flushing connections.

10-2.3* Flushing Procedure.
If an obstruction investigation carried out in accordance with 10-2.1 indicates the presence of sufficient material to obstruct sprinklers, a complete flushing program shall be conducted. The work shall be done by qualified personnel.

Reference: NFPA 25 (1998 Edition).

2-1 General. This chapter provides the minimum requirements
for the routine inspection, testing, and maintenance of
sprinkler systems. Table 2-1 shall be used to determine the
minimum required frequencies for inspection, testing, and
maintenance.
Exception: Valves and fire department connections shall be inspected,
tested, and maintained in accordance with Chapter 9.

Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance
Item Activity Frequency Reference
Gauges (dry, preaction deluge systems) Inspection Weekly/monthly 2-2.4.2
Control valves Inspection Weekly/monthly Table 9-1
Alarm devices Inspection Quarterly 2-2.6
Gauges (wet pipe systems) Inspection Monthly 2-2.4.1
Hydraulic nameplate Inspection Quarterly 2-2.7
Buildings Inspection Annually (prior to freezing
weather)
2-2.5
Hanger/seismic bracing Inspection Annually 2-2.3
Pipe and fittings Inspection Annually 2-2.2
Sprinklers Inspection Annually 2-2.1.1
Spare sprinklers Inspection Annually 2-2.1.3
Fire department connections Inspection Table 9-1
Valves (all types) Inspection Table 9-1
Alarm devices Test Quarterly 2-3.3
Main drain Test Annually Table 9-1
Antifreeze solution Test Annually 2-3.4
Gauges Test 5 years 2-3.2
Sprinklers - extra-high temp. Test 5 years 2-3.1.1 Exception No. 3
Sprinklers - fast response Test At 20 years and every 10 years
thereafter
2-3.1.1 Exception No. 2
Sprinklers Test At 50 years and every 10 years
thereafter
2-3.1.1
Valves (all types) Maintenance Annually or as needed Table 9-1
Obstruction investigation Maintenance 5 years or as needed Chapter 10

Based on observation and interview, it was determined the facility failed to ensure the use of approved ashtrays in the designated smoking area, in accordance with NFPA standards. The deficiency had the potential to affect two (2) of seven (7) smoke compartments, residents, staff and visitors. The facility has one hundred forty (140) certified beds with a census of one hundred one (101) on the day of the survey.

The findings include:

Observation, on 07/24/12 between 1:00 PM and 2:00 PM, with the Director of Plant Services revealed the ashtrays located in the Unit 1 West, and Unit 2 West smoking areas were not of the approved type. They did not have a metal container with a self-closing lid.

Interview, on 07/24/12 between 1:00 PM and 2:00 PM, with the Director of Plant Services revealed he was not aware of the requirement for self-closing ashtrays.

Reference: NFPA 101 (2000 edition)
19.7.4* Smoking. Smoking regulations shall be adopted and
shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment
where flammable liquids, combustible gases, or
oxygen is used or stored and in any other hazardous location,
and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international
symbol for no smoking.
Exception: In health care occupancies where smoking is prohibited
and signs are prominently placed at all major entrances, secondary
signs with language that prohibits smoking shall not be required.
(2) Smoking by patients classified as not responsible shall be
prohibited.
Exception: The requirement of 19.7.4(2) shall not apply where the patient
is under direct supervision.
(3) Ashtrays of noncombustible material and safe design
shall be provided in all areas where smoking is permitted.
(4) Metal containers with self-closing cover devices into
which ashtrays can be emptied shall be readily available
to all areas where smoking is permitted.

Based on observation and interview it was determined the facility failed to ensure, portable space heaters used in the facility were in accordance with NFPA standards. The deficiency had the potential to affect three (3) of seven (7) smoke compartments, residents, staff and visitors. The facility has one hundred forty (140) beds with a census of one hundred one (101) on the day of the survey.

The findings include:

Observation, on 07/24/12 between 12:50 PM and 4:00 PM, with the Director of Plant Services revealed portable space heaters located in the following areas; Unit 1 East Mangers Office, Medical Directors Office, Staffing Coordinators Office, two (2) in the Marketing Office, and the Director of Medical Records Office.

Interview, on 07/24/12 between 12:50 PM and 4:00 PM, with the Director of Plant Services revealed he was not aware the heaters could not exceed 212?F in non-sleeping, staff, and employee areas.


Reference: NFPA 101 (2000 edition)
19.7.8 Portable Space-Heating Devices. Portable space-heating
devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used
in non-sleeping staff and employee areas where the heating elements of
such devices do not exceed 212?F (100?C).

Based on observation and interview, it was determined the facility failed to maintain doors within a required means of egress in accordance with NFPA standards. The deficiency had the potential to affect one (1) of three (3) smoke compartments, residents, staff and visitors. The facility has one hundred forty (140) certified beds with a census of one hundred one (101) on the day of the survey.

The findings include:

Observation, on 07/24/12 between 12:50 PM and 4:00 PM, with the Director of Plant Services revealed unapproved door hold open devices (flip down type) were installed on doors to the following rooms; Unit 1 West: Nurses Lounge, Med Room, and Therapist Office, also, Unit 2 West Pharmacy, and Therapist Office. Further observation revealed more unapproved door stops located on the Medical Directors Office, Mail Room, Kitchen Door, Unit 3 Central Supply, and Clean Linen

Interview, on 07/24/12 between 12:50 PM and 4:00 PM, with the Director of Plant Services revealed he was not aware the door hold open devices could not be used.


Reference: NFPA 101 (2000 Edition)

19.2.2.2.4
Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.

Based on observation and interview, it was determined the facility failed to ensure emergency generators were maintained in accordance with NFPA standards. The deficiency had the potential to affect seven (7) of seven (7) smoke compartments, residents, staff, and visitors. The facility has one hundred forty (140) certified beds with a census of one hundred one (101) on the day of the survey.

The findings include:

Observation, on 7/24/12 at 11:28 AM, with the Director of Plant Services revealed the facility was equipped with an emergency generator. However, the generator was not equipped with an annunciation panel that could be readily observed by staff at a regular work station to inform staff of alarm conditions with the generators.

Interview, on 7/24/12 at 11:28 AM, with the Director of Plant Services revealed he was not aware the generator needed an annunciation panel to inform staff of alarm conditions with the generators.


Observation, on 07/24/12 at 11:26 AM, with the Director of Plant Operations revealed the facility did not have any battery-powered lighting installed in the room where the transfer switch for the emergency generator was located. The room where the transfer switch for the emergency generator is located must have battery-powered lighting in case there was a failure of the emergency generator and staff must operate the transfer switch manually.

Interview, on 07/24/12 at 11:26 AM, with the Director of Plant Operations revealed he was not aware of the requirement for the battery backup lighting. Observations were confirmed with the Administrator during the exit conference.


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]


Reference: NFPA 110 (1999 Edition).

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.

Based on observation and interview, it was determined the facility failed to ensure electrical wiring was maintained in accordance with NFPA standards. The deficiency had the potential to affect six (6) of seven (7) smoke compartments, residents, staff, and visitors. The facility has one hundred forty (140) certified beds with a census of one hundred one (101) on the day of the survey.

The findings include:

Observations, on 07/24/12 between 10:00 AM and 4:00 PM, with the Director of Plant Operations revealed:

1) An open electrical junction box located above the ceiling at cross corridor door #4, #11, and #12.
2) A power strip was plugged into another power strip located in the Pharmacy.
3) An extension cord was in use to a Christmas Tree, and a coffee pot was plugged into a power strip located in the Fiscal Accounting Office.
4) A refrigerator and a microwave were plugged into a power strip located in the Risk Management Office, also in the Director of Nursing Office.
5) A portable de-humidifier was plugged into a power strip located in the Main Lobby.
6) A power strip was plugged into another power strip located in the Receptionist Office.
7) A refrigerator and a toaster were plugged into a power strip located in the Medical Records Storage Room.
8) A refrigerator was plugged into a power strip located in the Unit 5 Clinical Director Office.


Interview, on 07/24/12 between 10:00 AM and 4:00 PM, with the Maintenance Director revealed he was not aware of the misuse of power strips, and extension cords. Further interview revealed they had recently done some work over the ceilings changing some exit signs, and the covers for the junction boxes must have just been overlooked.

Reference: NFPA 99 ( 1999 edition)
3-3.2.1.2 D

Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.


Reference: NFPA 70 (1999 edition)

370.28(c) Covers.

All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 370-22, Exception.

Based on interview and facility policy and procedure review, the facility failed to develop a fire watch policy in accordance with NFPA standards. The deficiency had the potential to affect seven (7) of seven (7) smoke compartments, residents, staff, and visitors. The facility has one hundred forty (140) beds with a census of one hundred one (101) on the day of the survey.


The findings include:

Policy and Procedure review, on 7/24/12 at 11:08 AM, with the Director of Plant Operations revealed the facility failed to provide a written policy outlining an approved fire watch system in the event the sprinkler system is shut down for four (4) or more hours in a twenty four (24) hour period.

Interview, on 7/24/12 at 11:08 AM, with the Director of Plant Operations revealed he was unaware the facility was required to have a written policy for the facilities fire watch system.

Reference; NFPA 101 (2000 edition)
9.7.6* Sprinkler System Shutdown.
9.7.6.1
Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.

Based on interview and facility policy and procedure review, the facility failed to develop a fire watch policy in accordance with NFPA standards. The deficiency had the potential to affect seven (7) of seven (7) smoke compartments, residents, staff, and visitors. The facility has one hundred forty (140) beds with a census of one hundred one (101) on the day of the survey.


The findings include:

Policy and Procedure review, on 7/24/12 at 11:08 AM, with the Director of Plant Operations revealed the facility failed to provide a written policy outlining an approved fire watch system in the event the fire alarm system is shut down for four (4) or more hours in a twenty four (24) hour period.

Interview, on 7/24/12 at 11:08 AM, with the Director of Plant Operations revealed he was unaware the facility was required to have a written policy for the facilities fire watch system.


Reference; NFPA 101 (2000 edition)
9.6.1.8*
Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.