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Based on observation and staff interview the facility fails to maintain two of two smoke barriers to at least one half hour fire resistance and ensure that all penetrations are properly sealed. This deficient practice would prevent containment of fire and smoke, affecting approximately 12 residents in two of two smoke zones. This facility has a capacity of 12 and census of 6 residents.

Findings Include:

During the tour starting 2/14/2013 between 8:30 A.M. and 1:00 P.M. the following is observed:

1)The north hall smoke barrier has unsealed penetrations where wiring and conduit pass through the smoke barrier. These unsealed penetrations were found in the attic on both sides of the smoke barrier.

Staff A was present and acknowledged this finding.

NFPA Standard: Requires smoke walls to have a fire resistance rating of at least a half hour and to be continuous from floor to roof deck and from outside wall to outside wall. 2000 NFPA 101, 19.3.7.3.

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1.

Based on observation, interview and record review, the facility failed to provide and maintain documentation of annual inspection and testing of the fire alarm system as required by NFPA 72. The absence of complete, verifiable documented maintenance and repair history on the fire alarm system fails to ensure reliability of the alarm system in the event of an emergency, affecting approximately 12 residents in two of two smoke zones. The facility has a capacity of 12 with a census of 6.

Findings Include:

During the tour starting 2/14/2013 between 8:30 A.M. and 1:00 P.M. the following is observed:

1)Record review of the facility's annual fire alarm system inspection and testing revealed that testing and information required by NFPA 72 was not properly documented. The Information provided was from 11/13/2011. The fire alarm annual test for 2012 was not conducted.

Staff A was present during record review and acknowledged the finding. Staff A immediately contacted the fire alarm vendor and scheduled an inspection for 2/18/2013.

NFPA Standard: Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7 2.2. 1999 NFPA 72, 7 2.2.

NFPA Standard: A permanent record of all inspections, testing, and maintenance shall be maintained that includes periodic tests and applicable information, per 1999 NFPA 72, 7 5.2.2 and figure 7 5.2.2; A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70. 2000 NFPA 101, 9.6.1.4.

Based on observation, interview and record review, the facility failed to ensure that all smoke detectors are maintained, inspected and tested as required by NFPA 72. The absence of complete, verifiable documented maintenance and repair history of all smoke detectors fails to ensure reliability of these alerting devices in the event of an emergency, affecting 12 resident sleeping rooms in one of two smoke zones.This facility has a capacity of 12 and a census of 6 at the time of the survey.

Findings Include:

During the tour starting 2/14/2013 between 8:30 A.M. and 1:00 P.M. the following is observed:

1. Record review and staff interview revealed no documentation of sensitivity testing completed on the corridor hard wired smoke detectors.

Staff A was present during record review and facility tour and acknowledged this finding.

NFPA Standard: Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7 2.2. 1999 NFPA 72, 7 2.2.

NFPA Standard: A permanent record of all inspections, testing, and maintenance shall be maintained that includes periodic tests and applicable information, per 1999 NFPA 72, 7 5.2.2 and figure 7 5.2.2; A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70. 2000 NFPA 101, 9.6.1.4.

NFPA Standard: Smoke detector sensitivity shall be checked within one year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed. 1999 NFPA 72, 7 3.2.1.

Based on observation and staff interview the facility fails to ensure that all means of egress are free of all obstructions or impediments to a full instant use. This deficient practice could impede all occupants from exiting in the event of a fire or other emergency situation, affecting 0 residents in one of two smoke zones. This facility has a capacity of 12 and a census of 6 at the time of the survey.

Findings Include:

During the tour starting 2/14/2013 between 8:30 A.M. and 1:00 P.M. the following is observed:

1) The group meeting room has a chair obstructing the inward swing of the corridor door from the west exit.

Staff A was present and acknowledged the finding.

NFPA Standard: No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress from, or visibility thereof. 2000 NFPA 101, 7.1.10.2.1.

NFPA Standard: Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1.

Based on observation, staff interview and record review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice may prevent the emergency power supply from being available at the time of a power loss, affecting approximately 12 residents in 2 of 2 smoke zones. The facility has a capacity of 12 and a census of 6 at the time of the survey.

Findings Include:

During the tour starting 2/14/2013 between 8:30 A.M. and 1:00 P.M. the following is observed:

1) A review of records and interview with Staff A revealed that monthly testing records do not include the percentage of capacity that the generator is running during the monthly testing. Also, no annual testing documentation was provided for review. Annual testing would include, but not be limited to, exercising annually with supplemental loads at 25% of nameplate rating for 30 minutes, followed by 50% of nameplate rating for 30 minutes, followed by 75% of nameplate rating for 60 minutes, for a total of 2 continuous hours.


Staff A was present and acknowledged the finding.

NFPA Standard: Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10 second interval specified in 3 4.1.1.8 and 3 4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
(b) Inspection and Testing.
1.* Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
2. Test Conditions. The scheduled test under load conditions shall include a complete simulated cold start and automatic and manual transfer of all essential electrical system loads.
3. Test Personnel. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures. 1999 NFPA 99 3.4.4.1.

NFPA Standard: Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
1999 NFPA 110 Standard for Emergency and Standby Power Systems, Section 6 4.2.