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Based on observation and testing, the facility failed to provide walls constructed with at least 1/2 hour fire resistance rating.

Findings include:

While inspecting corridor walls on July 7, 2011 at approximately 11:30 a.m., the surveyor observed penetrations in the following corridor walls:
1. On second (2nd) floor next to nurses station there were unsealed spaces around water line penetrations.
2. On second (2nd) floor above Rooms #206 and #205 there were unsealed spaces around water line penetrations.
3. Unsealed penetrations around water lines down resident hallways on second (2nd) and third (3rd) floor.

These deficient practices have the potential of affecting the entire floors.

The Maintenance Supervisor and the Administrator were notified during the exit conference.

Based on observation and testing, the facility failed to provide walls constructed with at least 1/2 hour fire resistance rating.

Findings include:

While inspecting corridor walls on July 7, 2011 at approximately 11:30 a.m., the surveyor observed penetrations in the following corridor walls:
1. On second (2nd) floor next to nurses station there were unsealed spaces around water line penetrations.
2. On second (2nd) floor above Rooms #206 and #205 there were unsealed spaces around water line penetrations.
3. Unsealed penetrations around water lines down resident hallways on second (2nd) and third (3rd) floor.

These deficient practices have the potential of affecting the entire floors.

The Maintenance Supervisor and the Administrator were notified during the exit conference.

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Based on observation and testing, the facility failed to provide a properly installed, tested and maintained fire alarm system in accordance with NFPA 70 and NFPA 72. This condition affected 50% of the residents and staff.

Findings include:

On July 7, 2011 at 12:40 p.m. the maintenance person and surveyor found that the following fire alarm horns/strobes did not function properly:
1. The strobe located on the third (3rd) floor did not initiate when fire alarm was activated; and
2. The horn located on the first (1st ) floor in the administration hallway did not initiate when the fire alarm was activated.

The Maintenance Director said the fire alarm company had sent him the wrong parts.

This deficient practices have the potential of effecting the occupants of the first (1st) and third (3rd) floor of the facility.

The Maintenance Supervisor and the Administrator were notified during the exit conference.

Based on observations, the facility failed to provide a remote annunciator panel to generator serving the Type 1 Essential Electrical System. This deficiency had the potential to affect 100% of the residents and staff.

Findings include:

During the survey on July 7, 2011 at 12:10 p.m., the surveyor and the Maintenance Supervisor found no provision for monitoring the operational status of the emergency generator at a staffed remote location within the facility.

Specific Code: National Fire Protection Associations' (NFPA) 99, Health Care Facilities, 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 Maintenance Director said the facility had requested a waiver to review their options in regard to buying new generators as opposed to repairing the old generators.

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]

This deficient practices have the potential of effecting the entire facility.

The Maintenance Supervisor and the Administrator were notified during the exit conference.