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Based on observation, this facility is not assuring that four smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone. This deficient practice affects all occupants of the building, including staff, visitors and residents in eight of twelve smoke zones. This facility has a capacity of 25 with a census of 11 residents.

Findings include:

Observation on 4/21/10 from 9:30 a.m. to 10:52 a.m., revealed the following penetration in smoke barriers:
1. The smoke barrier for the Maintenance hallway to the Administrative hall had large penetration (approximately 4 inches).
2. The smoke barrier by room #106 had three open ended conduit.
3. The smoke barrier in the Ambulance hallway had two open conduit.
4. The smoke barrier by the Laboratory (North double doors) had a 1/2 inch penetration around conduit/wires.
According to the facility layout, these are required barriers. Maintenance Staff A confirmed these observations.

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

Based on observation, the facility is not ensuring that hazardous areas are separated from other areas by partitions and self-closing doors to ensure a one-hour fire-resistance rating. This deficient practice affects all occupants in one smoke zone, in the event of a fire. This facility has a capacity of 25 and a census of 11 residents.

Findings include:

Observation on 4/21/10, revealed the deficiencies in hazardous rooms:
1. The Housekeeping storage room did not have a rated door.
2. The Housekeeping deep sink room was not rated and had louvers in the door.
3. The Pump room(soiled linen room) was not rated, had louvers in the door and did not have a closure for the door.
4. The Nurse's station Housekeeping room had a one inch penetration around a copper pipe.
Maintenance Staff A confirmed these observations.


Hazardous area without Sprinkler
NFPA standard: Hazardous areas without sprinkler protection require one-hour fire resistance rating construction and doors shall be 3/4 hour fire rated with self closers and positive latches. 2000 NFPA 101, 19.3.2.1

Based on observation, this facility is not providing an all-weather surface from each exit to a public way (an area of safety). This affects all occupants of the building. This facility has a capacity of 25 with a census of 11 residents.

Findings include:

Observation on 4/21/10 at 9:47 a.m., revealed the path of egress from Exit #12 only had a concrete pad outside of the door and the remaining path was composed of grass instead of an all-weather surface. Maintenance Staff A verified the observation. According to the facility layout, these were required exits.

NFPA standard: 2000 NFPA 101, 19.

Based on observation, the facility failed to maintain the exit discharge lighting so that the failure of one bulb would not leave the path from the facility to the public way in darkness. This deficient practice affects all occupants of the building. This facility has a capacity of 25 and a census of 11 residents.

Findings include:

Observation on 4/21/10, revealed that light fixture outside of Exit #12 was only equipped with a single source of light (bulb) and did not have emergency lighting to the public way.

Administrative Staff A verified the observations.

Based on record review, the facility failed to document the emergency egress lighting monthly and annually. This deficient practice affects all smoke compartments and all occupants of the facility. This facility has a capacity of 25 and a census of 11 residents.

Findings include:

Observation of the facility's maintenance records on 4/21/10, revealed the absence of documentation regarding the testing of the emergency battery lighting system. According to Maintenance Staff A, the lights were tested monthly, but there was no documentation to show that the monthly tests were conducted for 30 seconds or that an annual test was completed for 90 minutes under load. This deficiency was also in the Clinic building also.

NFPA standard: Requires a documented monthly test of battery-powered emergency lighting for at least 30 seconds, and an annual test for a duration of 1-1/2 hours. 2000 NFPA 101, 7.9.3

Based on observation, the facility did not provide a directional exit sign in the Operating Room (OR) break room corridor. This deficient practice effects occupants the OR area. The facility has a census of 11 residents with the capacity of 25.

Findings include:

Observation on 4/21/10 at 10:17 a.m., revealed the corridor by the OR breakroom did not have an exit sign. According to the facility layout, which is used in conjunction with the emergency procedures, this designated exit is a required exit.

Maintenance Staff A verified this finding.

Based upon record review, the facility failed to hold fire drills under varied conditions at different times of the day for four of four quarters reviewed. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This facility has a capacity of 25 with a census of 11.

Findings include:

On 4/21/10, the facility fire drill documentation showed the second shift drills were conducted at 10:30 p.m. for the last three quarters of 2009 and the first quarter of 2010. The third shift drills were conducted between 11:00 p.m. for the last three quarters of 2009 and the first quarter of 2010. At least two of the quarters had the drills conducted on the same day only 45 minutes apart from each other.

Maintenance Staff A verified the documentation.

NFPA standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. 2000 NFPA 101, 19.7.1.2

A)
Based on observation, the facility did not assure that the fire alarm system is in accordance with NFPA 72, and chapter 9.6.4 of NFPA 101 by ensuring that the fire alarm breaker is mechanically protected. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 25 with a census of 11.

Findings include:

Observation on 4/21/10, the facility failed to provide a properly maintained fire alarm system. The fire alarm breaker located in the electrical panel E2, breaker #27, was not secured with a mechanical lock to assure that the breaker is not inadvertently shut off. All occupants would be directly affected by the deficient practice. Maintenance Staff A verified this observation.



B)
Based on observation and interview, the facility failed to provide a properly tested and maintained fire alarm system. The deficient practice of failing to have an alarm sound during phone line trouble would affect all of the building occupants. This facility has a capacity of 25 and a census of 11 residents.

Findings include:

Observation 4/21/10 during the inspection and of the fire alarm system, revealed the automatic dialer panel could not be placed into trouble to test the dialer. Maintenance Staff A was unable to find the location of the automatic dialer for the fire alarm system.

Based on record review, the facility failed to provide a properly tested and maintained fire alarm system. All of the facility was directly affected by the deficient practice this would include all occupants in the facility. The facility has 25 certified beds and at the time of the survey the census was 11.

Findings include:

Review of the inspection records for the fire alarm system on 04/21/10 at 8:45 a.m., revealed the fire alarm was only being inspected annually.

Maintenance Staff A confirmed observations during the survey process.

NFPA standard: A permanent record of all inspections, testing, and maintenance shall be maintained that includes periodic tests and applicable information, per the 1999 edition of NFPA 72, table 7-3.2. and listed as required by NFPA 72, 7-5.2.2

Based on observation, the facility failed to install the sprinkler system in accordance with the 1999 edition of National Fire Protection Association (NFPA) 13. This deficient practice affects all occupants in this facility with a capacity of 25 and a census of 11.

Findings include:

Observations on 4/21/10, revealed the following areas did not have sprinkler coverage:
1. The Kitchen storage room did not have sprinkler coverage, this is a very large room.
2. The Laundry room did not have sprinkler/fire alarm coverage.
3. The Housekeeping store room did not have sprinkler coverage.
4. The Housekeeping Deep sink room did not have sprinkler coverage.
5. The Pump room (soiled linen room) did not have sprinkler coverage.

Maintenance Staff A verified these findings.


NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. NFPA 13, 12.1

A)
Based on record review, the facility failed to maintain the sprinkler system in accordance with the National Fire Protection Association (NFPA), Standard 25, by ensuring the 5 year Flow test had been performed. This deficient practice affects all occupants in the building. The facility has a capacity of 25 with the census of 11 residents.

Findings include:

Record review on 4/21/10 at 8:40 a.m., revealed the facility could not find documentation the 5 year Flow test had been performed.

NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. NFPA 13, 12.1


B)

Based on record review, the facility failed to maintain and test a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998 edition. All residents and staff could be affected by the deficient practice. The facility has 25 certified beds and at the time of the survey the census was 11.

Findings include:

During the record review of the facilities fire safety components on 04/21/10 at 8:45 a.m., revealed the facility did not have documentation of the quarterly testing.

NFPA standard: Requires every required sprinkler system to be continuously maintained in proper operating condition. NFPA 25, 2-2 & table 2-1 requires an inspection every quarter of a calendar year. 2000 NFPA 101, 4.6.12.1.

C)

Based on observation, this facility is not maintaining the sprinkler system in accordance with the 1998 edition of National Fire Protection Association (NFPA) 25, and the 1999 edition of National Fire Protection Association (NFPA) 13 by ensuring sprinkler heads are free from obstructions. This can affect the operation of the heads by obstructing spray patterns, delaying the response time or preventing the operation of the heads that can compromise the effectiveness of the fire suppression system. This deficient practice can place all occupants at risk in the event of a fire. The census was 11 with a capacity of 25.

Findings include:


Observation on 4/21/10 at 9:22 a.m., revealed storage within 18 inches of the sprinkler head in the Vending room closet.

These items were verified with Maintenance Staff A.

NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. NFPA 13, 12.1


NFPA Standard: Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. NFPA 25, 2-2.1.1

A)
Based on observation, the facility failed to maintain and test fire extinguishers as required. One fire extinguisher was affected by the deficient practice. The deficient practice could affect one smoke zone. The facility has 25 certified beds and at the time of the survey the census was 11.

Findings include:

Observation of the fire extinguishers on 4/21/10, found one extinguishers missing monthly inspections. There was no date or initials marked on the extinguisher tags as required in the TI room.

Actual NFPA standard: Fire extinguishers shall be inspected when placed in service and thereafter at approximately 30-day intervals per 1998 NFPA 10, 4-3.1


B)

Based on observation the facility failed to maintain the fire extinguishers in accordance with the National Fire Protection Association 10. This deficient practice affects all occupants in the building. The facility has a capacity of 25 beds with the current census of 11 residents.

Findings include:

Observation on 4/21/10, revealed the majority of fire extinguishers in the building were mounted over 5 feet off of the floor, and the fire extinguisher in the Maintenance office was not secured to the wall. Maintenance Staff A verified these findings.

Based on observation and record review, this facility is not providing a range hood suppression system that is in compliance with National Fire Protection Association (NFPA) 96, 3-1 and 2-1.2 and with the standard UL-300. The grease extractors were composed of a mesh screen, instead of a baffled design. This deficient practice affects the occupants of one smoke zone. This facility has a capacity of 25 with a census of 11.

Findings include:

According to the last semi-annual inspection paperwork, dated 10/20/09, the range hood was UL-300 compliant. Observation on 4/21/10, at approximately 9:20 a.m., the range hood in the kitchen was observed. Grease extractors were composed of a mesh screen instead of a smooth baffle design.

Maintenance Staff A verified this finding.

Based on observation, the facility is not storing oxygen tanks in accordance with National Fire Protection Association (NFPA) Standard 99, ensuring that tanks were adequately secured to prevent them from accidental damage or dislocation. This deficient practice occurred in one oxygen storage areas and affects all occupants of the Dialysis area. This facility has a capacity of 25 and a census of 11 residents.

Findings include:

Observation on 4/21/10, revealed one oxygen tank in the Dialysis area was not properly secured.

Maintenance Staff A verified this finding.

Based on observation, the facility failed to maintain the electrical components in accordance with the National Fire Protection Association 70. The location of deficient practice was located in tow of twelve smoke compartments affecting all of the residents in that compartment. The facility census was 11 with a capacity of 25.

Findings include:

Observation on 04/21/10, revealed a open junction box above the ceiling tile by room #403 and a plastic surge protector in the ER/Nursing store room.

Maintenance Staff A confirmed observations.

NFPA standard: 1999 NFPA 70, article 240-4

Based on staff interview and record review, the facility is not assuring that a policy is in place regarding the procedures to be taken in the event that the fire alarm is out of service for more than four hours in any twenty-four hour period. The lack of procedures could effect the actions taken by staff in the event of an emergency. This deficient practice affects all occupants of the building in this facility with a capacity of 25 and a census of 11.

Findings include:

According to Maintenance Staff A, interviewed on 4/21/10, they did not have a written policy regarding the procedures to be taken in the event that the fire alarm was out of service for more than four hours in a twenty-four hour period.

NFPA standard: Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. A fire watch should consist of trained personnel who continuously patrol the effected area. Ready access to fire extinguishers and the ability to promptly notify the fire department are important items to consider. During the patrol of the area, the person should not only be looking for fire, but making sure that the other fire protection features of the building such as egress routes and alarm systems are available and functioning properly. 2000 NFPA 101, 9.6.1.8

Based on observation, this facility is not assuring that four smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone. This deficient practice affects all occupants of the building, including staff, visitors and residents in eight of twelve smoke zones. This facility has a capacity of 25 with a census of 11 residents.

Findings include:

Observation on 4/21/10 from 9:30 a.m. to 10:52 a.m., revealed the following penetration in smoke barriers:
1. The smoke barrier for the Maintenance hallway to the Administrative hall had large penetration (approximately 4 inches).
2. The smoke barrier by room #106 had three open ended conduit.
3. The smoke barrier in the Ambulance hallway had two open conduit.
4. The smoke barrier by the Laboratory (North double doors) had a 1/2 inch penetration around conduit/wires.
According to the facility layout, these are required barriers. Maintenance Staff A confirmed these observations.

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

Based on observation, the facility is not ensuring that hazardous areas are separated from other areas by partitions and self-closing doors to ensure a one-hour fire-resistance rating. This deficient practice affects all occupants in one smoke zone, in the event of a fire. This facility has a capacity of 25 and a census of 11 residents.

Findings include:

Observation on 4/21/10, revealed the deficiencies in hazardous rooms:
1. The Housekeeping storage room did not have a rated door.
2. The Housekeeping deep sink room was not rated and had louvers in the door.
3. The Pump room(soiled linen room) was not rated, had louvers in the door and did not have a closure for the door.
4. The Nurse's station Housekeeping room had a one inch penetration around a copper pipe.
Maintenance Staff A confirmed these observations.


Hazardous area without Sprinkler
NFPA standard: Hazardous areas without sprinkler protection require one-hour fire resistance rating construction and doors shall be 3/4 hour fire rated with self closers and positive latches. 2000 NFPA 101, 19.3.2.1

Based on observation, this facility is not providing an all-weather surface from each exit to a public way (an area of safety). This affects all occupants of the building. This facility has a capacity of 25 with a census of 11 residents.

Findings include:

Observation on 4/21/10 at 9:47 a.m., revealed the path of egress from Exit #12 only had a concrete pad outside of the door and the remaining path was composed of grass instead of an all-weather surface. Maintenance Staff A verified the observation. According to the facility layout, these were required exits.

NFPA standard: 2000 NFPA 101, 19.

Based on observation, the facility failed to maintain the exit discharge lighting so that the failure of one bulb would not leave the path from the facility to the public way in darkness. This deficient practice affects all occupants of the building. This facility has a capacity of 25 and a census of 11 residents.

Findings include:

Observation on 4/21/10, revealed that light fixture outside of Exit #12 was only equipped with a single source of light (bulb) and did not have emergency lighting to the public way.

Administrative Staff A verified the observations.

Based on record review, the facility failed to document the emergency egress lighting monthly and annually. This deficient practice affects all smoke compartments and all occupants of the facility. This facility has a capacity of 25 and a census of 11 residents.

Findings include:

Observation of the facility's maintenance records on 4/21/10, revealed the absence of documentation regarding the testing of the emergency battery lighting system. According to Maintenance Staff A, the lights were tested monthly, but there was no documentation to show that the monthly tests were conducted for 30 seconds or that an annual test was completed for 90 minutes under load. This deficiency was also in the Clinic building also.

NFPA standard: Requires a documented monthly test of battery-powered emergency lighting for at least 30 seconds, and an annual test for a duration of 1-1/2 hours. 2000 NFPA 101, 7.9.3

Based on observation, the facility did not provide a directional exit sign in the Operating Room (OR) break room corridor. This deficient practice effects occupants the OR area. The facility has a census of 11 residents with the capacity of 25.

Findings include:

Observation on 4/21/10 at 10:17 a.m., revealed the corridor by the OR breakroom did not have an exit sign. According to the facility layout, which is used in conjunction with the emergency procedures, this designated exit is a required exit.

Maintenance Staff A verified this finding.

Based upon record review, the facility failed to hold fire drills under varied conditions at different times of the day for four of four quarters reviewed. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This facility has a capacity of 25 with a census of 11.

Findings include:

On 4/21/10, the facility fire drill documentation showed the second shift drills were conducted at 10:30 p.m. for the last three quarters of 2009 and the first quarter of 2010. The third shift drills were conducted between 11:00 p.m. for the last three quarters of 2009 and the first quarter of 2010. At least two of the quarters had the drills conducted on the same day only 45 minutes apart from each other.

Maintenance Staff A verified the documentation.

NFPA standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. 2000 NFPA 101, 19.7.1.2

A)
Based on observation, the facility did not assure that the fire alarm system is in accordance with NFPA 72, and chapter 9.6.4 of NFPA 101 by ensuring that the fire alarm breaker is mechanically protected. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 25 with a census of 11.

Findings include:

Observation on 4/21/10, the facility failed to provide a properly maintained fire alarm system. The fire alarm breaker located in the electrical panel E2, breaker #27, was not secured with a mechanical lock to assure that the breaker is not inadvertently shut off. All occupants would be directly affected by the deficient practice. Maintenance Staff A verified this observation.



B)
Based on observation and interview, the facility failed to provide a properly tested and maintained fire alarm system. The deficient practice of failing to have an alarm sound during phone line trouble would affect all of the building occupants. This facility has a capacity of 25 and a census of 11 residents.

Findings include:

Observation 4/21/10 during the inspection and of the fire alarm system, revealed the automatic dialer panel could not be placed into trouble to test the dialer. Maintenance Staff A was unable to find the location of the automatic dialer for the fire alarm system.

Based on record review, the facility failed to provide a properly tested and maintained fire alarm system. All of the facility was directly affected by the deficient practice this would include all occupants in the facility. The facility has 25 certified beds and at the time of the survey the census was 11.

Findings include:

Review of the inspection records for the fire alarm system on 04/21/10 at 8:45 a.m., revealed the fire alarm was only being inspected annually.

Maintenance Staff A confirmed observations during the survey process.

NFPA standard: A permanent record of all inspections, testing, and maintenance shall be maintained that includes periodic tests and applicable information, per the 1999 edition of NFPA 72, table 7-3.2. and listed as required by NFPA 72, 7-5.2.2

Based on observation, the facility failed to install the sprinkler system in accordance with the 1999 edition of National Fire Protection Association (NFPA) 13. This deficient practice affects all occupants in this facility with a capacity of 25 and a census of 11.

Findings include:

Observations on 4/21/10, revealed the following areas did not have sprinkler coverage:
1. The Kitchen storage room did not have sprinkler coverage, this is a very large room.
2. The Laundry room did not have sprinkler/fire alarm coverage.
3. The Housekeeping store room did not have sprinkler coverage.
4. The Housekeeping Deep sink room did not have sprinkler coverage.
5. The Pump room (soiled linen room) did not have sprinkler coverage.

Maintenance Staff A verified these findings.


NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. NFPA 13, 12.1

A)
Based on record review, the facility failed to maintain the sprinkler system in accordance with the National Fire Protection Association (NFPA), Standard 25, by ensuring the 5 year Flow test had been performed. This deficient practice affects all occupants in the building. The facility has a capacity of 25 with the census of 11 residents.

Findings include:

Record review on 4/21/10 at 8:40 a.m., revealed the facility could not find documentation the 5 year Flow test had been performed.

NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. NFPA 13, 12.1


B)

Based on record review, the facility failed to maintain and test a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998 edition. All residents and staff could be affected by the deficient practice. The facility has 25 certified beds and at the time of the survey the census was 11.

Findings include:

During the record review of the facilities fire safety components on 04/21/10 at 8:45 a.m., revealed the facility did not have documentation of the quarterly testing.

NFPA standard: Requires every required sprinkler system to be continuously maintained in proper operating condition. NFPA 25, 2-2 & table 2-1 requires an inspection every quarter of a calendar year. 2000 NFPA 101, 4.6.12.1.

C)

Based on observation, this facility is not maintaining the sprinkler system in accordance with the 1998 edition of National Fire Protection Association (NFPA) 25, and the 1999 edition of National Fire Protection Association (NFPA) 13 by ensuring sprinkler heads are free from obstructions. This can affect the operation of the heads by obstructing spray patterns, delaying the response time or preventing the operation of the heads that can compromise the effectiveness of the fire suppression system. This deficient practice can place all occupants at risk in the event of a fire. The census was 11 with a capacity of 25.

Findings include:


Observation on 4/21/10 at 9:22 a.m., revealed storage within 18 inches of the sprinkler head in the Vending room closet.

These items were verified with Maintenance Staff A.

NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. NFPA 13, 12.1


NFPA Standard: Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. NFPA 25, 2-2.1.1

A)
Based on observation, the facility failed to maintain and test fire extinguishers as required. One fire extinguisher was affected by the deficient practice. The deficient practice could affect one smoke zone. The facility has 25 certified beds and at the time of the survey the census was 11.

Findings include:

Observation of the fire extinguishers on 4/21/10, found one extinguishers missing monthly inspections. There was no date or initials marked on the extinguisher tags as required in the TI room.

Actual NFPA standard: Fire extinguishers shall be inspected when placed in service and thereafter at approximately 30-day intervals per 1998 NFPA 10, 4-3.1


B)

Based on observation the facility failed to maintain the fire extinguishers in accordance with the National Fire Protection Association 10. This deficient practice affects all occupants in the building. The facility has a capacity of 25 beds with the current census of 11 residents.

Findings include:

Observation on 4/21/10, revealed the majority of fire extinguishers in the building were mounted over 5 feet off of the floor, and the fire extinguisher in the Maintenance office was not secured to the wall. Maintenance Staff A verified these findings.

Based on observation and record review, this facility is not providing a range hood suppression system that is in compliance with National Fire Protection Association (NFPA) 96, 3-1 and 2-1.2 and with the standard UL-300. The grease extractors were composed of a mesh screen, instead of a baffled design. This deficient practice affects the occupants of one smoke zone. This facility has a capacity of 25 with a census of 11.

Findings include:

According to the last semi-annual inspection paperwork, dated 10/20/09, the range hood was UL-300 compliant. Observation on 4/21/10, at approximately 9:20 a.m., the range hood in the kitchen was observed. Grease extractors were composed of a mesh screen instead of a smooth baffle design.

Maintenance Staff A verified this finding.

Based on observation, the facility is not storing oxygen tanks in accordance with National Fire Protection Association (NFPA) Standard 99, ensuring that tanks were adequately secured to prevent them from accidental damage or dislocation. This deficient practice occurred in one oxygen storage areas and affects all occupants of the Dialysis area. This facility has a capacity of 25 and a census of 11 residents.

Findings include:

Observation on 4/21/10, revealed one oxygen tank in the Dialysis area was not properly secured.

Maintenance Staff A verified this finding.

Based on observation, the facility failed to maintain the electrical components in accordance with the National Fire Protection Association 70. The location of deficient practice was located in tow of twelve smoke compartments affecting all of the residents in that compartment. The facility census was 11 with a capacity of 25.

Findings include:

Observation on 04/21/10, revealed a open junction box above the ceiling tile by room #403 and a plastic surge protector in the ER/Nursing store room.

Maintenance Staff A confirmed observations.

NFPA standard: 1999 NFPA 70, article 240-4

Based on staff interview and record review, the facility is not assuring that a policy is in place regarding the procedures to be taken in the event that the fire alarm is out of service for more than four hours in any twenty-four hour period. The lack of procedures could effect the actions taken by staff in the event of an emergency. This deficient practice affects all occupants of the building in this facility with a capacity of 25 and a census of 11.

Findings include:

According to Maintenance Staff A, interviewed on 4/21/10, they did not have a written policy regarding the procedures to be taken in the event that the fire alarm was out of service for more than four hours in a twenty-four hour period.

NFPA standard: Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. A fire watch should consist of trained personnel who continuously patrol the effected area. Ready access to fire extinguishers and the ability to promptly notify the fire department are important items to consider. During the patrol of the area, the person should not only be looking for fire, but making sure that the other fire protection features of the building such as egress routes and alarm systems are available and functioning properly. 2000 NFPA 101, 9.6.1.8