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

Findings include:

While inspecting corridor walls on March 13, 2012 at 11:00 a.m., the surveyor and maintenance person
observed a 2 inch by 2 inch penetrations in the corridor wall across from the nurses station.

These deficient practices have the potential of effecting one (1) of five (5) smoke compartments. The maintenance supervisor and the administrator were notified during an exit conference.

Based on observation and testing, the facility failed to provide the one hour fire rated construction (with 45 minute fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4.

Findings include:

On March 13, 2012 at 11:30 a.m., the maintenance person and the the surveyor found the one hour enclosure for the gas fired generator and water heaters had penetrations along the top of the wall.

These deficient practices have the potential of effecting one (1) of five (5) smoke compartments. The maintenance supervisor and the administrator were notified during an exit conference.

Based on documentation review the facility failed to provide written records of test in accordance with 19.3.4, 9.6.

Findings include:

On March 13, 2012 at 12:00 p.m., the maintenance person could not produce written records of the annual inspection for the fire alarm system.

These deficient practices have the potential of effecting five (5) of five (5) smoke compartments. The maintenance supervisor and the administrator were notified during an exit conference.

Based on observation and testing, the facility failed to provide a properly installed, tested and maintained fire alarm system in accordance with NFPA 70 National Electrical Code and NFPA 72..

Findings include:

On March 13, 2012 at 11:40 a.m., the maintenance person and surveyor found the location of the automatic dialer to be lacking a hard wired smoke detector.

These deficient practices have the potential of effecting five (5) of five (5) smoke compartments. The maintenance supervisor and the administrator were notified during an exit conference.

Based on documentation review the facility failed to provide the required smoke detectors, including those activating door hold open devices, are approved, maintained, inspected and tested in accordance with the manufacturer's specification in accordance with 9.6.1.3

Findings include:

On March 13, 2012 at 12:30 p.m., the maintenance person could not provide documentation that the smoke detectors had the required sensitivity testing done.

These deficient practices have the potential of effecting five (5) of five (5) smoke compartments. The maintenance supervisor and the administrator were notified during an exit conference.

Based on observations, the facility failed to provide a remote annunciator panel to monitor the Type 10, Class X, Level 2 generator serving the Type 2 Essential Electrical System. This deficiency had the potential to affect 100% of the residents and staff

Findings include:

During the survey on March 13, 2012 at 11:00 a.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's (NFPA) 99, Health CareFacilities, 1999 Edition.
3-6.1. Sources (Type 3 EES). The alternate source of power for the system shall be specifically designed for this purpose and shall be a generator, battery system, or self-contained battery intergral with the equipment.
3-6.1.1 Generators shall conform to 3-4.1.1.
3-4.1.1. On-Site Generator Set
3-4.1.1.4 General
3-4.1.1.4(b) Type III essential electrical system power sources (prime movers) shall be classified as Type 10, Class X, Level 2 generator set..
3-4.1.1.15 Alarm Annuciator
A remote annuciator, 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]

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

Findings include:

While inspecting corridor walls on March 13, 2012 at 11:00 a.m., the surveyor and maintenance person
observed a 2 inch by 2 inch penetrations in the corridor wall across from the nurses station.

These deficient practices have the potential of effecting one (1) of five (5) smoke compartments. The maintenance supervisor and the administrator were notified during an exit conference.

Based on observation and testing, the facility failed to provide the one hour fire rated construction (with 45 minute fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4.

Findings include:

On March 13, 2012 at 11:30 a.m., the maintenance person and the the surveyor found the one hour enclosure for the gas fired generator and water heaters had penetrations along the top of the wall.

These deficient practices have the potential of effecting one (1) of five (5) smoke compartments. The maintenance supervisor and the administrator were notified during an exit conference.

Based on documentation review the facility failed to provide written records of test in accordance with 19.3.4, 9.6.

Findings include:

On March 13, 2012 at 12:00 p.m., the maintenance person could not produce written records of the annual inspection for the fire alarm system.

These deficient practices have the potential of effecting five (5) of five (5) smoke compartments. The maintenance supervisor and the administrator were notified during an exit conference.

Based on observation and testing, the facility failed to provide a properly installed, tested and maintained fire alarm system in accordance with NFPA 70 National Electrical Code and NFPA 72..

Findings include:

On March 13, 2012 at 11:40 a.m., the maintenance person and surveyor found the location of the automatic dialer to be lacking a hard wired smoke detector.

These deficient practices have the potential of effecting five (5) of five (5) smoke compartments. The maintenance supervisor and the administrator were notified during an exit conference.

Based on documentation review the facility failed to provide the required smoke detectors, including those activating door hold open devices, are approved, maintained, inspected and tested in accordance with the manufacturer's specification in accordance with 9.6.1.3

Findings include:

On March 13, 2012 at 12:30 p.m., the maintenance person could not provide documentation that the smoke detectors had the required sensitivity testing done.

These deficient practices have the potential of effecting five (5) of five (5) smoke compartments. The maintenance supervisor and the administrator were notified during an exit conference.

Based on observations, the facility failed to provide a remote annunciator panel to monitor the Type 10, Class X, Level 2 generator serving the Type 2 Essential Electrical System. This deficiency had the potential to affect 100% of the residents and staff

Findings include:

During the survey on March 13, 2012 at 11:00 a.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's (NFPA) 99, Health CareFacilities, 1999 Edition.
3-6.1. Sources (Type 3 EES). The alternate source of power for the system shall be specifically designed for this purpose and shall be a generator, battery system, or self-contained battery intergral with the equipment.
3-6.1.1 Generators shall conform to 3-4.1.1.
3-4.1.1. On-Site Generator Set
3-4.1.1.4 General
3-4.1.1.4(b) Type III essential electrical system power sources (prime movers) shall be classified as Type 10, Class X, Level 2 generator set..
3-4.1.1.15 Alarm Annuciator
A remote annuciator, 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]