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Based on observation the facility failed to provide doors that close, latch, or resist the passage of smoke for 8 of 78 doors in the facility as per National Fire Protection Association (NFPA) 101 (Life Safety Code). This deficiency affects all 20 residents on this side of the facility.

Note: NFPA 101, 2000 edition
NFPA 101 Chapter 19, " Existing Health Care Occupancy, " 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1 3/4-in. thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required.
And
Note: NFPA 101, 2000 edition
NFPA 101 Chapter 19, "Existing Health Care Occupancy, " 19.3.6.3.3 Hold-open devices that release when the door is pushed or pulled shall be permitted. Doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

Findings:

During facility tour on June 12, 2013 between 2:00 p.m. and 3:30 p.m. the door to the following rooms did not close, latch, or resist the passage of smoke.

1. The corridor door to rooms 15, 17, 22, 29, 30, 31, 32, and 34 has gaps between the frame and the door. The gaps would allow smoke to move between the room and corridor.

Based on observations the facility failed to assure that smoke barriers were constructed with at least a one-half hour fire resistance rating for 2 of 5 smoke barrier walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke from one compartment to the other in the facility. This deficient practice had the potential to affect 4 of 7 smoke compartments and the 45 patients in the facility.

Note: NFPA 101, 2000 edition:
NFPA 101: 19.3.7.3
Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

Findings:

During facility tour on June 12, 2013 between 8:00 a.m. and 1:30 p.m., the integrity of the smoke barrier wall was observed to be compromised in the following areas.

1. There was one hole with a gray cables in room 320 that was not sealed going through the smoke barrier wall above the headwall.

2. There is a gap between the smoke barrier wall and the roof on the 1st floor in the front lobby that is not sealed.

Based on observation the facility failed to provide door to smoke barriers that were self-closing or automatic-closing in accordance with National Fire Protection Association (NFPA) 101 (Life Safety Code). This deficiency affects 1 of 4 smoke barriers, 2 of 5 smoke compartments on the second floor of the facility.

Note: NFPA 101, 2000 edition:
NFPA 101:19.2.2.2.6 Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.
AND
NFPA 101:19.3.7 Subdivision of Building Spaces
19.3.7.6 Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6. Positive latching hardware shall not be required.


During a tour of the facility on June 12, 2013 between 8:00 a.m. and 1:30 p.m. it was observed that the smoke barrier door by room 237 is not closing all the way. The door is dragging on the top of the frame and would not close completely.

Based on observation the facility failed to provide complete protection for 1 of 8 hazardous areas as per National Fire Protection Association (NFPA) 101 (Life Safety Code). Hazardous areas are required to be separated from other parts of the building, including the egress corridor by a smoke resistive partition. This deficiency could have the potential to cause harm to the 21 patients on the first floor of the facility.

Note: NFPA 101, 2000 Edition:
NFPA 101, Chapter 3, "Protection" 19.3.5.4 if the hazardous areas is sprinkled then the walls and doors to the hazardous area shall be smoke resistive and the door shall be self-closing.

Findings:

During a tour of the facility on June 12, 2013 between 8:00 a.m. and 1:30 p.m., it was observed that the elevator equipment room on the first floor has missing ceiling tiles. The missing tiles would allow smoke to move to other parts of the building and prevent the sprinkler heads from working properly.

Based on observation and review of documentation, the facility failed to have the fire alarm system fully operational as per National Fire Protection Association (NFPA) 72 (National Fire Alarm Code) and NFPA 101 (Life Safety Code) for 1 of 2 system. This deficiency affects all 8 patients in the MRI area of the facility.

Note: NFPA 101, 2000 edition:
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, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

Findings:

An observation was made on June 12, 2013 at 1:00 p.m. of the fire alarm system in the MRI area. Review of the annual inspection report (dated 3-11-11) revealed that the facility failed to have a current annual inspection done for the fire alarm system, within the last twelve months. Interview with the Plant Operation director during the survey process and at the exit interview verified that no additional documentation of a current fire alarm system inspection was available.

Based on review of documentation the facility failed to provide routine inspection, testing and maintenance of the sprinkler system as per NFPA 25 (Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems) for 1 of 1 system. This deficiency could affect all 117 residents in the facility.

Note: NFPA 25, 1998 Edition:
NFPA 25, Chapter 2, " General " 2-1 This chapter provides the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems.

Findings:

During review of the sprinkler system documentation on June 13, 2013 between 7:30 a.m. and 8:00 a.m. it was revealed that facility failed to have all devices on the sprinkler system routinely inspected or tested at the proper intervals or failed to document such actions.

Interview with the Plant Operation director during the survey process and at the exit interview verified that no additional documentation of the sprinkler system inspection was available. The maintenance director stated that he was unaware of all the required routine inspection of the sprinkler system.

Based on observation the facility failed to provide doors that close, latch, or resist the passage of smoke for 8 of 78 doors in the facility as per National Fire Protection Association (NFPA) 101 (Life Safety Code). This deficiency affects all 20 residents on this side of the facility.

Note: NFPA 101, 2000 edition
NFPA 101 Chapter 19, " Existing Health Care Occupancy, " 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1 3/4-in. thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required.
And
Note: NFPA 101, 2000 edition
NFPA 101 Chapter 19, "Existing Health Care Occupancy, " 19.3.6.3.3 Hold-open devices that release when the door is pushed or pulled shall be permitted. Doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

Findings:

During facility tour on June 12, 2013 between 2:00 p.m. and 3:30 p.m. the door to the following rooms did not close, latch, or resist the passage of smoke.

1. The corridor door to rooms 15, 17, 22, 29, 30, 31, 32, and 34 has gaps between the frame and the door. The gaps would allow smoke to move between the room and corridor.

Based on observations the facility failed to assure that smoke barriers were constructed with at least a one-half hour fire resistance rating for 2 of 5 smoke barrier walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke from one compartment to the other in the facility. This deficient practice had the potential to affect 4 of 7 smoke compartments and the 45 patients in the facility.

Note: NFPA 101, 2000 edition:
NFPA 101: 19.3.7.3
Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

Findings:

During facility tour on June 12, 2013 between 8:00 a.m. and 1:30 p.m., the integrity of the smoke barrier wall was observed to be compromised in the following areas.

1. There was one hole with a gray cables in room 320 that was not sealed going through the smoke barrier wall above the headwall.

2. There is a gap between the smoke barrier wall and the roof on the 1st floor in the front lobby that is not sealed.

Based on observation the facility failed to provide door to smoke barriers that were self-closing or automatic-closing in accordance with National Fire Protection Association (NFPA) 101 (Life Safety Code). This deficiency affects 1 of 4 smoke barriers, 2 of 5 smoke compartments on the second floor of the facility.

Note: NFPA 101, 2000 edition:
NFPA 101:19.2.2.2.6 Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.
AND
NFPA 101:19.3.7 Subdivision of Building Spaces
19.3.7.6 Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6. Positive latching hardware shall not be required.


During a tour of the facility on June 12, 2013 between 8:00 a.m. and 1:30 p.m. it was observed that the smoke barrier door by room 237 is not closing all the way. The door is dragging on the top of the frame and would not close completely.

Based on observation the facility failed to provide complete protection for 1 of 8 hazardous areas as per National Fire Protection Association (NFPA) 101 (Life Safety Code). Hazardous areas are required to be separated from other parts of the building, including the egress corridor by a smoke resistive partition. This deficiency could have the potential to cause harm to the 21 patients on the first floor of the facility.

Note: NFPA 101, 2000 Edition:
NFPA 101, Chapter 3, "Protection" 19.3.5.4 if the hazardous areas is sprinkled then the walls and doors to the hazardous area shall be smoke resistive and the door shall be self-closing.

Findings:

During a tour of the facility on June 12, 2013 between 8:00 a.m. and 1:30 p.m., it was observed that the elevator equipment room on the first floor has missing ceiling tiles. The missing tiles would allow smoke to move to other parts of the building and prevent the sprinkler heads from working properly.

Based on observation and review of documentation, the facility failed to have the fire alarm system fully operational as per National Fire Protection Association (NFPA) 72 (National Fire Alarm Code) and NFPA 101 (Life Safety Code) for 1 of 2 system. This deficiency affects all 8 patients in the MRI area of the facility.

Note: NFPA 101, 2000 edition:
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, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

Findings:

An observation was made on June 12, 2013 at 1:00 p.m. of the fire alarm system in the MRI area. Review of the annual inspection report (dated 3-11-11) revealed that the facility failed to have a current annual inspection done for the fire alarm system, within the last twelve months. Interview with the Plant Operation director during the survey process and at the exit interview verified that no additional documentation of a current fire alarm system inspection was available.

Based on review of documentation the facility failed to provide routine inspection, testing and maintenance of the sprinkler system as per NFPA 25 (Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems) for 1 of 1 system. This deficiency could affect all 117 residents in the facility.

Note: NFPA 25, 1998 Edition:
NFPA 25, Chapter 2, " General " 2-1 This chapter provides the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems.

Findings:

During review of the sprinkler system documentation on June 13, 2013 between 7:30 a.m. and 8:00 a.m. it was revealed that facility failed to have all devices on the sprinkler system routinely inspected or tested at the proper intervals or failed to document such actions.

Interview with the Plant Operation director during the survey process and at the exit interview verified that no additional documentation of the sprinkler system inspection was available. The maintenance director stated that he was unaware of all the required routine inspection of the sprinkler system.