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Based on observation the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 18. 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 18. 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On August 4, 2011, the surveyor, accompanied by Facility Staff and Maintenance Staff, observed that two Office corridor doors had door stops installed.

During the exit conference on August 4, 2011, the above findings were again acknowledged by the Facility Staff.

In time of a fire failing to protect patients from heat and smoke could cause harm to the patients.

Based on observation the facility failed to fill penetrations in the smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 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 at least ? hour." (1 Hour New) Chapter 8, Section 8.3.6. "Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:"
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
(a) It shall be made on either side of the smoke barrier.
(b) It shall be made by an approved device that is designed for the specific purpose.

Findings include:

On August 4, 2011, the surveyor, accompanied by Facility Staff and Maintenance Staff, observed an unsealed penetration in the smoke barrier , located at the front Nursing station. The smoke barrier doors were tested and one door would not tightly close.

During the exit conference on August 4, 2011, the above findings were again acknowledged by the Facility Staff.

Failing to fill holes in smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility, which will cause harm to patients.

Based on observation the facility failed to maintain the smoke resistance of the ceiling in the Communications room.

NFPA 101, Life Safety Code, 2000, Chapter 19,. Section 19.3.2.1 Requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls, doors, and ceilings must be able to resist the passage of smoke.

Findings include:

On August 4, 2011, the surveyor, accompanied by Facility Staff and Maintenance Staff , observed unsealed pipes and holes in the ceiling of the Communications room.

During the exit conference on August 4, 2011 the above findings were again acknowledged by the Facility Staff.

Failing to fill pipe chases or holes could allow heat and smoke to spread into walls, attics, or exit corridors which will cause harm to the patients.

Based on observation the facility failed to conduct the required fire drills.

NFPA 101, Life Safety Code, 2000, Chapter 18, Section 18.7.1.2, Chapter 19, Section 19.7.1.2 Fire exit drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions."

Findings include:

On August 4, 2011 the surveyor, accompanied by Facility Staff, reviewed the facility's fire drill records. The documentation on June 10, 2011 indicated an actual alarm due to the systems being set off by the Fire Protection Company. False and accidental alarms are not to be documented as a training Fire Drill.
During fire drills personnel shall be instructed in the use of and response to fire alarms.

During the exit conference on August 4, 2011, the above findings were again acknowledged by the Facility Staff.

Failure to train and drill the staff on fire procedures could result in harm to the patients.

Based on observation the facility failed to maintain automatic sprinkler heads.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.5.1 "Buildings containing health care facilities shall be protected throughout by and approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection,
Testing, and Maintenance of Water-Based Fire Protection systems. NFPA 25, Section 2-2.1.1 "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign material , paint, and physical damage and shall be installed in the proper orientation.

Findings Include:

On August 4, 2011 the surveyor, accompanied by Facility Staff observed the automatic sprinkler heads located in the Administration area. The sprinkler heads located in the offices were covered with an excessive amount of lint.

During the exit conference on August 4, 2011, the above findings were again acknowledged by the Facility Staff. .

Failing to maintain sprinkler heads and keep the fusible link clean could allow a fire to burn longer before the sprinkler head will activate. This could cause harm to the patients.

Based on observation the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 18. 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 18. 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On August 4, 2011, the surveyor, accompanied by Facility Staff and Maintenance Staff, observed that two Office corridor doors had door stops installed.

During the exit conference on August 4, 2011, the above findings were again acknowledged by the Facility Staff.

In time of a fire failing to protect patients from heat and smoke could cause harm to the patients.

Based on observation the facility failed to fill penetrations in the smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 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 at least ? hour." (1 Hour New) Chapter 8, Section 8.3.6. "Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:"
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
(a) It shall be made on either side of the smoke barrier.
(b) It shall be made by an approved device that is designed for the specific purpose.

Findings include:

On August 4, 2011, the surveyor, accompanied by Facility Staff and Maintenance Staff, observed an unsealed penetration in the smoke barrier , located at the front Nursing station. The smoke barrier doors were tested and one door would not tightly close.

During the exit conference on August 4, 2011, the above findings were again acknowledged by the Facility Staff.

Failing to fill holes in smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility, which will cause harm to patients.

Based on observation the facility failed to maintain the smoke resistance of the ceiling in the Communications room.

NFPA 101, Life Safety Code, 2000, Chapter 19,. Section 19.3.2.1 Requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls, doors, and ceilings must be able to resist the passage of smoke.

Findings include:

On August 4, 2011, the surveyor, accompanied by Facility Staff and Maintenance Staff , observed unsealed pipes and holes in the ceiling of the Communications room.

During the exit conference on August 4, 2011 the above findings were again acknowledged by the Facility Staff.

Failing to fill pipe chases or holes could allow heat and smoke to spread into walls, attics, or exit corridors which will cause harm to the patients.

Based on observation the facility failed to conduct the required fire drills.

NFPA 101, Life Safety Code, 2000, Chapter 18, Section 18.7.1.2, Chapter 19, Section 19.7.1.2 Fire exit drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions."

Findings include:

On August 4, 2011 the surveyor, accompanied by Facility Staff, reviewed the facility's fire drill records. The documentation on June 10, 2011 indicated an actual alarm due to the systems being set off by the Fire Protection Company. False and accidental alarms are not to be documented as a training Fire Drill.
During fire drills personnel shall be instructed in the use of and response to fire alarms.

During the exit conference on August 4, 2011, the above findings were again acknowledged by the Facility Staff.

Failure to train and drill the staff on fire procedures could result in harm to the patients.

Based on observation the facility failed to maintain automatic sprinkler heads.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.5.1 "Buildings containing health care facilities shall be protected throughout by and approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection,
Testing, and Maintenance of Water-Based Fire Protection systems. NFPA 25, Section 2-2.1.1 "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign material , paint, and physical damage and shall be installed in the proper orientation.

Findings Include:

On August 4, 2011 the surveyor, accompanied by Facility Staff observed the automatic sprinkler heads located in the Administration area. The sprinkler heads located in the offices were covered with an excessive amount of lint.

During the exit conference on August 4, 2011, the above findings were again acknowledged by the Facility Staff. .

Failing to maintain sprinkler heads and keep the fusible link clean could allow a fire to burn longer before the sprinkler head will activate. This could cause harm to the patients.