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Based on observations the facility failed to provide smoke barriers that were constructed with at least a one-half hour fire resistance rating for 1 of 1 wall. This deficiency affects 2 of 2 smoke compartments and 8 residents in the facility.

Findings:

During facility tour on April 12, 2011 between 2:30 p.m. and 4:30 p.m., the integrity of the smoke barrier wall was observed to be compromised. There is a broken piece of drywall that is three feet by two feet above the smoke barrier doors. The piece is broken and falling off.

Based on observation the facility failed to provide proper protection for 1 of 3 hazardous areas as per NFPA 101 (Life Safety Code). This deficiency could affect all 8 patients in 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 April 12, 2011 between 2:30 p.m. and 4:30 p.m., it was observed that the following hazardous areas did not have walls or ceiling that resist the passage of smoke. The ceiling in the boiler room has places that are breaking or have holes in it.

1.
Based on visual observation the facility failed to provide smoking regulations that are in accordance with NFPA 101: 19.7.4., for 3 of 3 locations. This deficiency affects all patients that use the designated smoking area, 2 patients were observed using the smoking areas.

Actual Code:
NFPA 101:18.7.4 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.
(2) 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.
(3) Smoking by patients classified as not responsible shall be prohibited, unless under direct supervision.
(4) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(5) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.

Findings:

During facility tour on April 11, 2011 between 10:00 a.m. and 10:30 a.m., it was observed that the three designated smoking areas did not have safe ashtrays nor a metal container with a self-closing cover device into which ashtrays can be emptied.


2.
Base on visual observation the facility failed to provide egress from the building that is in accordance with National Fire Protection Association-NFPA 101 (Life Safety Code) for 2 of 4 exits. This deficiency could affect all patients in the facility.

Actual Code:
NFPA 101: 7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.

Findings:

During facility tour on April 11, 2011 between 10:00 a.m. and 10:30 a.m., it was observed that the two patio areas have pad locks on the gates that serve as part of the exit. These locks do not meet the requirements or the exceptions for 7.2.1.5.1. The gates were unlocked during the survey.

Based on observation, the facility failed to provide exit signage that is in accordance with the National Fire Protection Association-NFPA 101 (Life Safety Code) for 3 of 5 exit signs. Exit signs shall indicate the direction of travel and shall be illuminated as to be legible in both normal and emergency lighting conditions. This deficiency affects all patients in the facility.

Actual Code: NFPA 101, 2000 edition
NFPA 101:7.10.2 (Directional Signs)
7.10.2 A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.
Or
NFPA 101:7.10.5. (Illumination of signs)
7.10.5.1 Every sign required by 7.10.1.2 or 7.10.1.4, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.

Findings:

During facility tour on April 12, 2011 between 9:00 a.m. and 10:00 a.m., the facility failed to have all exit signs completely lit. Three exit sign had bulbs that were burnt out.

Based on visual observation the facility failed to provide smoking regulations that are in accordance with NFPA 101: 19.7.4., for 1 of 1 location. This deficiency affects all patients that use the designated smoking area, 2 patients were observed using the smoking area.

Actual Code:
NFPA 101:18.7.4 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.
(2) 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.
(3) Smoking by patients classified as not responsible shall be prohibited, unless under direct supervision.
(4) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(5) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.

Findings:

During facility tour on April 12, 2011 between 11:00 a.m. and 12:00 p.m., it was observed that the designated smoking area did not have a metal container with a self-closing cover device into which ashtrays can be emptied.

Based on observations the facility failed to provide smoke barriers that were constructed with at least a one-half hour fire resistance rating for 1 of 1 wall. This deficiency affects 2 of 2 smoke compartments and 8 residents in the facility.

Findings:

During facility tour on April 12, 2011 between 2:30 p.m. and 4:30 p.m., the integrity of the smoke barrier wall was observed to be compromised. There is a broken piece of drywall that is three feet by two feet above the smoke barrier doors. The piece is broken and falling off.

Based on observation the facility failed to provide proper protection for 1 of 3 hazardous areas as per NFPA 101 (Life Safety Code). This deficiency could affect all 8 patients in 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 April 12, 2011 between 2:30 p.m. and 4:30 p.m., it was observed that the following hazardous areas did not have walls or ceiling that resist the passage of smoke. The ceiling in the boiler room has places that are breaking or have holes in it.

1.
Based on visual observation the facility failed to provide smoking regulations that are in accordance with NFPA 101: 19.7.4., for 3 of 3 locations. This deficiency affects all patients that use the designated smoking area, 2 patients were observed using the smoking areas.

Actual Code:
NFPA 101:18.7.4 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.
(2) 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.
(3) Smoking by patients classified as not responsible shall be prohibited, unless under direct supervision.
(4) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(5) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.

Findings:

During facility tour on April 11, 2011 between 10:00 a.m. and 10:30 a.m., it was observed that the three designated smoking areas did not have safe ashtrays nor a metal container with a self-closing cover device into which ashtrays can be emptied.


2.
Base on visual observation the facility failed to provide egress from the building that is in accordance with National Fire Protection Association-NFPA 101 (Life Safety Code) for 2 of 4 exits. This deficiency could affect all patients in the facility.

Actual Code:
NFPA 101: 7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.

Findings:

During facility tour on April 11, 2011 between 10:00 a.m. and 10:30 a.m., it was observed that the two patio areas have pad locks on the gates that serve as part of the exit. These locks do not meet the requirements or the exceptions for 7.2.1.5.1. The gates were unlocked during the survey.

Based on observation, the facility failed to provide exit signage that is in accordance with the National Fire Protection Association-NFPA 101 (Life Safety Code) for 3 of 5 exit signs. Exit signs shall indicate the direction of travel and shall be illuminated as to be legible in both normal and emergency lighting conditions. This deficiency affects all patients in the facility.

Actual Code: NFPA 101, 2000 edition
NFPA 101:7.10.2 (Directional Signs)
7.10.2 A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.
Or
NFPA 101:7.10.5. (Illumination of signs)
7.10.5.1 Every sign required by 7.10.1.2 or 7.10.1.4, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.

Findings:

During facility tour on April 12, 2011 between 9:00 a.m. and 10:00 a.m., the facility failed to have all exit signs completely lit. Three exit sign had bulbs that were burnt out.

Based on visual observation the facility failed to provide smoking regulations that are in accordance with NFPA 101: 19.7.4., for 1 of 1 location. This deficiency affects all patients that use the designated smoking area, 2 patients were observed using the smoking area.

Actual Code:
NFPA 101:18.7.4 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.
(2) 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.
(3) Smoking by patients classified as not responsible shall be prohibited, unless under direct supervision.
(4) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(5) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.

Findings:

During facility tour on April 12, 2011 between 11:00 a.m. and 12:00 p.m., it was observed that the designated smoking area did not have a metal container with a self-closing cover device into which ashtrays can be emptied.