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Based on observation, document review, and staff interview the facility failed to maintain the building fire wall separations. This deficient practice affected all smoke compartments, staff, visitors and all residents. The facility has the capacity for 44 beds and at the time of survey the census was 36.

Findings include:

On April 15, 2014 between 8:45 a.m. and 5 p.m., accompanied by maintenance director, surveyor observed there are improper and/or unsealed fire-stop penetrations; examples include but are not limited to the following:

(1) In at least five areas where piping through the fire wall fire-stop material occurred in the main mechanical room.
(2) In a least five areas where piping through the fire wall fire-stop material occurred in the boiler room.

Improper fire stopping voids a fire barrier rating and is considered a zero hour rating. Based on an interview with the maintenance director at the time of observation he could not produce any type of documentation showing the fire stopping was installed per the manufactures specifications for the fire walls. No documentation of meeting manufacture specifications, UL or nationally recognized products to seal the hole penetrations to the required fire barrier ratings were provided. No additional documentation to support the fire rated protection by fire-stopping of the fire-stop penetrations was provided at the time of exit.

The census was verified by Administrator. The findings were acknowledged by the Administrator and verified by the maintenance director at the times of observation and at the exit conference on April 15, 2014.

Actual NFPA Standards:

NFPA LSC 101 (2000) 19.1.6. 8.2.3.2.4.2, 8.2.4.4 and 8.3.6 Penetration opening protection. NFPA 101 LSC (2000) 8.2.3.2.4.2 requires pipes, conduits, bus ducts, cables wires, air ducts, pneumatic tubes and ducts, and similar building service that pass through fire barriers shall be protected ...need documentation of meeting NFPA 251 standard methods of tests of fire endurance of building construction and materials, as part of a rated assembly. Protection is to be by an approved through penetration system that has been tested in accordance with ASTM E 814. Methods for fire tests of through-penetration fire stops. The facility failed to maintain the required minimum construction requirements including required hour rating and/or sprinkler protection for the facility.

Based on observation, document review, and staff interview the facility failed to maintain the building automatic fire sprinkler system to code requirements. This deficient practice affected all smoke compartments, staff, visitors and all residents. The facility has the capacity for 44 beds and at the time of survey the census was 36.

Findings include:

On April 15, 2014 between 8:45 a.m. and 5 p.m., accompanied by the maintenance director, during the observation tour the surveyor observed there is no fire sprinkler head coverage in rooms 145 and 147 closets. Room 149 the decorative head cover is painted and in the East wing nursing station a cabinet blocks the spray pattern being at 6 inches and is required to be at least 18 inches from obstructions. An interview was conducted at this time with the maintenance director who acknowledged that the fire sprinkler heads have not been installed as per manufacture and code requirements.

The census was verified by Administrator. The findings were acknowledged by the Administrator and verified by the maintenance director at the times of observation and at the exit conference on April 15, 2014.

Actual NFPA Standards:

NFPA LSC 101 (2000) 19.1. NFPA 1 (2000) 7-1 and NFPA 13 (1999) 8.5 installation of fire sprinkler systems.

NFPA 1 (2000) 7.3.3.9 Sprinklers shall not be altered in any respect or have any type of ornamentation, paint, or coatings, applied after shipment from the place of manufacture 25: 2-4.1.8.

Based on observation, and staff interview the facility failed to maintain facility smoking policy to code requirements. This deficient practice affected all smoke compartments, staff, visitors and all residents. The facility has the capacity for 44 beds and at the time of survey the census was 36.

Findings include:

On April 15, 2014 between 8:45 a.m. and 5 p.m. accompanied by the maintenance director during the observation tour the surveyor observed there are people smoking in various areas outside. These areas are not designated as smoking areas and the required ashtrays and metal containers with self-closing metal lids are not available as required by code. An interview was conducted at this time with the maintenance director who acknowledged that the smoking policy is not being observed to meet code requirements.

The census was verified by Administrator. The findings were acknowledged by the Administrator and verified by the maintenance director at the times of observation and at the exit conference on April 15, 2014.

Actual NFPA Standards:

NFPA 1 (2000) - 5-7.1, NFPA 101 LSC (2000) 19.7.4 Smoking requirements. Ashtrays of noncombustible material and safe design were not provided in all areas where smoking is permitted, and metal containers with self-closing cover devices into which ashtrays can be emptied were not readily available to all areas where smoking is permitted.

Based on observation and staff interview the facility failed to maintain the building exit egress. This deficient practice affected all smoke compartments, staff, visitors and all residents. The facility has the capacity for 44 beds and at the time of survey the census was 36.

Findings include:

On April 15, 2014 between 8:45 a.m. and 5 p.m., during the facility tour, the following doors which have the appearance of exit doors where not signed as required by code to state NO EXIT so as to not cause confusion in an emergency. These doors located at the East unit patio and are likely to be mistaken for an exit. Based on interview at this same time, the maintenance director acknowledged the required signage is not posted as required by code.

The census was verified by Administrator. The findings were acknowledged by the Administrator and verified by the maintenance director at the times of observation and at the exit conference on April 15, 2014.

Actual NFPA Standards:

NFPA LSC 101 (2000) 7.10.8.1 NO EXIT. Any door, passage, or stairway that is neither an exit nor an exit way of exit access and that is located or arranged so that is likely to be mistaken for an exit shall be identified by a sign that reads as follows: NO EXIT. Such sign shall have the word NO in letters 2 in. high with a stroke width of 3/8 inch. And the word EXIT below the word NO.

Based on observation, and staff interview the facility failed to properly maintain the emergency generator. This deficient practice affected all smoke compartments, staff, visitors and all patients. The facility has the capacity for 44 beds and at the time of survey the census was 36.

Findings include:

On April 15, 2014 between 8:45 a.m. and 5 p.m., accompanied by the maintenance director, during the observation tour when looking to test the remote generator alarm located in an area readily observed by staff, no remote panel was located. An interview was conducted at this time with the maintenance director who acknowledged the remote alarm panel could not be located.

The census was verified by Administrator. The findings were acknowledged by the Administrator and verified by the maintenance director at the times of observation and at the exit conference on April 15, 2014.

Actual NFPA Standards:

NFPA LSC 101 (2000) 4.5.6. System design and installation. NFPA 99 (1999) 3-4.1.1 and NFPA 110 (1999) 3-5.5.2 require and NFPA 99 (2000) 3-4.1.15 Alarm Annunciation. Code requires 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 ...

Based on observation, document review, and staff interview the facility failed to maintain the building electrical system to code requirements. This deficient practice affected all smoke compartments, staff, visitors and all residents. The facility has the capacity for 44 beds and at the time of survey the census was 36.

Findings include:

(1) On April 15, 2014 between 8:45 a.m. and 5 p.m., accompanied by the maintenance director, during the observation tour the surveyor found an electrical cord through the ceiling smoke barrier in the medical records room. An interview was conducted at this time with the maintenance director who acknowledged the electrical wiring is installed through the smoke barrier.

(2) On April 15, 2014 between 8:45 a.m. and 5 p.m., accompanied by the maintenance director, during the observation tour the surveyor found in the medical records room, and room 192, a number of zip cords that were plugged together in a daisy chain. An interview was conducted at this time with the maintenance director who stated, the electrical extension cords were installed without his knowledge.

The census was verified by Administrator. The findings were acknowledged by the Administrator and verified by the maintenance director at the times of observation and at the exit conference on April 15, 2014.

Actual NFPA Standards:

NFPA LSC 101 (2000) 19.5.1, 9.1.2, 4.2.1 and NFPA 1, NFPA 70.
NFPA 1 (2000) 6-1.2 Permanent wiring shall be installed and maintained in accordance with NFPA 70, National Electrical Code.