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Based on observation and staff interview, the facility failed to ensure all smoke barriers were maintained as a continuous membrane in 2 of 5 smoke compartments. The findings were:

Observations on 8/24/11 between 11 AM and 3 PM revealed the following concerns:
1. A 8" x12" hole was noted in the wall of room 507 (storage room).
2. A 6" diameter hole was noted in the wall of resident room 212.
3. Approximately 6 small (less than one-half inch diameter) holes were noted in the staff room.
4. A one-half inch gap was noted at the ceiling and at the floor level of a vertical pipe used for drain testing in the basement.
5. A one-inch diameter hole was noted in the ceiling of the administration office file room.
The maintenance manager verified these findings at the times of the observations.

Reference: NFPA 101, Life Safety Code, 2000 edition.
19.1.6.4 Each exterior wall of frame construction and all interior stud partitions shall be fire stopped to cut off all concealed draft openings, both horizontal and vertical, between any cellar or basement and the first floor. Such fire stopping shall consist of wood not less than 2 in. (5 cm) (nominal) thick or shall be of noncombustible material.
19.3.6.2.2 Corridor walls and ceilings shall form a barrier to limit the transfer of smoke.

Based on observation and staff interview, the facility failed to ensure 1 of 5 smoke barrier doors was resistant to the passage of smoke. The findings were:

Observation on 8/24/11 at 2:48 PM revealed the cross corridor smoke barrier door leading into the acute care unit did not close completely. The maintenance manager confirmed the observation and stated the door was kicked in by a resident recently and needed an astragal to create a good door seal.

Reference: NFPA 101, Life Safety Code, 2000 edition.
19.3.7.6 Doors in smoke barriers shall comply with 8.3.4 and shall be self closing or automatic closing in accordance with 19.2.2.2.6.
8.3.4.1 Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

Based on observation and staff interview, the facility failed to ensure five emergency exit signs were fully illuminated. The findings were:

Observation on 8/24/11 between 11 AM and 3 PM revealed one of two burned out light bulbs in the following emergency exit signs:
1. Two exit lights in the main entrance lobby.
2. The exit light near the fire wall in the acute care unit
3. The hallway exit light by room 301.
4. The exit light in the children/adolescent dining room.
Interview with the maintenance manager at the times of the observations confirmed the exit signs identified above had burned out light bulbs and needed to be replaced.

Reference: NFPA 101, Life Safety Code, 2000 edition.
19.2.10.1 Means of egress shall have signs in accordance with Section 7.10.
7.10.5.1 Continuous Illumination. Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.
7.8.1.4 Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less that 0.2 ft-candles.

Based on record review and staff interview, the facility failed to conduct a staged fire drill in the correct manner. The findings were:

Review of the facility fire drill records on 8/24/11 at 10:48 PM revealed the facility staff was recording resident initiated fire alarms as staged fire drills. As a result, eight fire drills were not conducted during all four previous quarters and during all shifts. Interview with the maintenance manager at the above time revealed he was unaware resident initiated fire alarms could not be counted as staged fire drills.

Reference: NFPA 101, Life Safety Code, 2000 edition.
18.7.1.2 Fire 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 with the signals and emergency action required under varied conditions.

Based on observation and staff interview, the facility failed to ensure four sprinkler heads in 2 of 5 smoke compartments were installed properly. The findings were:

Observation on 8/24/11 at 12:48 PM revealed the sprinkler head in the storage room in the basement was located above the ceiling light fixture interfering with the sprinkler head spray pattern. Observation on 8/24/11 at 1:11 PM also revealed 3 sprinkler head escutcheons were missing in the following locations: two escutcheons were missing in the gym and one was missing in the public restroom in the basement. The maintenance manager confirmed the above findings at the time of the observations.

Reference: NFPA 101, Life Safety Code, 2000 edition.
9.7.1.1 Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, 1994 Edition.
2-2.6.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.
5-6.5.3 Obstructions that Prevents Sprinkler Discharge from Reaching the Hazard. Continuous or noncontiguous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with this section.

Based on observation and staff interview, the facility failed to ensure the fire suppression (sprinkler) system was properly maintained. The findings were:

Observation on 8/24/11 at 12:48 PM revealed a gap greater than one-half inch existed between the sprinkler head escutcheons and the ceiling in the following locations:
Three escutcheon gaps were noted in the main lobby, 3 in the staffing room and 3 in the children/adolescent dining room. In addition, gaps were also noted in the utility closet in the acute care wing, in the hallway by the education staff room, by the exit sign at the end of the corner in the hallway in the basement, in room 512, in the resident phone room, in the
linen closet in the adult wing and one in the kitchen. Interview with the maintenance manager at the times of observation confirmed the escutcheons needed to be adjusted.

Reference: NFPA 13 Standard for the Installation of Sprinkler Systems, 1994 Edition:
2-2.6.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

Based on record review and staff interview, the facility failed to ensure the kitchen fire suppression equipment was maintained in proper working order. The findings were:

Review of facility records on 8/24/11 at 9:48 AM revealed the most recent inspection of the facility kitchen fire suppression system was conducted on 1/5/11. The biannual inspection for July 2011 was not conducted. Interview with the maintenance manager at the above time revealed the previous inspection revealed the fire suppression system needed to be replaced. The manager also stated the facility was in the process of obtaining bids to modernize the kitchen fire suppression system.

Reference: NFPA 101, Life Safety Code, 2000 edition.
9.2.3 Commercial Cooking Equipment shall be in accordance with NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.
NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1997 edition.
11.2.1 An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons.

Based on observation and staff interview, the facility failed to ensure electrical wiring was in compliance with the National Electrical Code in 3 of 5 smoke compartments. The findings were:

Observation on 8/24/11 at 12:48 PM revealed the following concerns:
1. Two wall mounted electrical outlets located in the adolescent exam room and in the adolescent class room were not ground fault circuit interrupter (GFCI) protected.
2. An electrical box cover plate was cracked in the adolescent class room and an electrical box in 317 utility room in adult wing was not firmly attached to the wall.
3. A surge protector was plugged into another surge protector in the following three locations: in resident room 513, in the classroom and in an intake assessment office.
4. A surge protector was also observed to be plugged into an electrical splicer in other intake office.
Interview with the maintenance manager at the time of the observations confirmed the above findings.

NFPA 70, National Electrical Code, 1993 edition:
370-28. Pull and Junction Boxes.
(3) (c) cover. All pull boxes, junction boxes and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use....
400-8. Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure;
(4) Where attached to building surfaces;
410-56. Rating and Type.
(e) Position of Receptacle Faces.
.... Face plates shall be installed so as to completely cover the opening and seat against the mounting surface.
517-20. Wet Locations.
(a) All receptacles and fixed equipment within the area of the wet location shall have ground-fault circuit-interrupter protection....

Based on observation and staff interview, the facility failed to ensure all smoke barriers were maintained as a continuous membrane in 2 of 5 smoke compartments. The findings were:

Observations on 8/24/11 between 11 AM and 3 PM revealed the following concerns:
1. A 8" x12" hole was noted in the wall of room 507 (storage room).
2. A 6" diameter hole was noted in the wall of resident room 212.
3. Approximately 6 small (less than one-half inch diameter) holes were noted in the staff room.
4. A one-half inch gap was noted at the ceiling and at the floor level of a vertical pipe used for drain testing in the basement.
5. A one-inch diameter hole was noted in the ceiling of the administration office file room.
The maintenance manager verified these findings at the times of the observations.

Reference: NFPA 101, Life Safety Code, 2000 edition.
19.1.6.4 Each exterior wall of frame construction and all interior stud partitions shall be fire stopped to cut off all concealed draft openings, both horizontal and vertical, between any cellar or basement and the first floor. Such fire stopping shall consist of wood not less than 2 in. (5 cm) (nominal) thick or shall be of noncombustible material.
19.3.6.2.2 Corridor walls and ceilings shall form a barrier to limit the transfer of smoke.

Based on observation and staff interview, the facility failed to ensure 1 of 5 smoke barrier doors was resistant to the passage of smoke. The findings were:

Observation on 8/24/11 at 2:48 PM revealed the cross corridor smoke barrier door leading into the acute care unit did not close completely. The maintenance manager confirmed the observation and stated the door was kicked in by a resident recently and needed an astragal to create a good door seal.

Reference: NFPA 101, Life Safety Code, 2000 edition.
19.3.7.6 Doors in smoke barriers shall comply with 8.3.4 and shall be self closing or automatic closing in accordance with 19.2.2.2.6.
8.3.4.1 Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

Based on observation and staff interview, the facility failed to ensure five emergency exit signs were fully illuminated. The findings were:

Observation on 8/24/11 between 11 AM and 3 PM revealed one of two burned out light bulbs in the following emergency exit signs:
1. Two exit lights in the main entrance lobby.
2. The exit light near the fire wall in the acute care unit
3. The hallway exit light by room 301.
4. The exit light in the children/adolescent dining room.
Interview with the maintenance manager at the times of the observations confirmed the exit signs identified above had burned out light bulbs and needed to be replaced.

Reference: NFPA 101, Life Safety Code, 2000 edition.
19.2.10.1 Means of egress shall have signs in accordance with Section 7.10.
7.10.5.1 Continuous Illumination. Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.
7.8.1.4 Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less that 0.2 ft-candles.

Based on record review and staff interview, the facility failed to conduct a staged fire drill in the correct manner. The findings were:

Review of the facility fire drill records on 8/24/11 at 10:48 PM revealed the facility staff was recording resident initiated fire alarms as staged fire drills. As a result, eight fire drills were not conducted during all four previous quarters and during all shifts. Interview with the maintenance manager at the above time revealed he was unaware resident initiated fire alarms could not be counted as staged fire drills.

Reference: NFPA 101, Life Safety Code, 2000 edition.
18.7.1.2 Fire 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 with the signals and emergency action required under varied conditions.

Based on observation and staff interview, the facility failed to ensure four sprinkler heads in 2 of 5 smoke compartments were installed properly. The findings were:

Observation on 8/24/11 at 12:48 PM revealed the sprinkler head in the storage room in the basement was located above the ceiling light fixture interfering with the sprinkler head spray pattern. Observation on 8/24/11 at 1:11 PM also revealed 3 sprinkler head escutcheons were missing in the following locations: two escutcheons were missing in the gym and one was missing in the public restroom in the basement. The maintenance manager confirmed the above findings at the time of the observations.

Reference: NFPA 101, Life Safety Code, 2000 edition.
9.7.1.1 Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, 1994 Edition.
2-2.6.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.
5-6.5.3 Obstructions that Prevents Sprinkler Discharge from Reaching the Hazard. Continuous or noncontiguous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with this section.

Based on observation and staff interview, the facility failed to ensure the fire suppression (sprinkler) system was properly maintained. The findings were:

Observation on 8/24/11 at 12:48 PM revealed a gap greater than one-half inch existed between the sprinkler head escutcheons and the ceiling in the following locations:
Three escutcheon gaps were noted in the main lobby, 3 in the staffing room and 3 in the children/adolescent dining room. In addition, gaps were also noted in the utility closet in the acute care wing, in the hallway by the education staff room, by the exit sign at the end of the corner in the hallway in the basement, in room 512, in the resident phone room, in the
linen closet in the adult wing and one in the kitchen. Interview with the maintenance manager at the times of observation confirmed the escutcheons needed to be adjusted.

Reference: NFPA 13 Standard for the Installation of Sprinkler Systems, 1994 Edition:
2-2.6.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

Based on record review and staff interview, the facility failed to ensure the kitchen fire suppression equipment was maintained in proper working order. The findings were:

Review of facility records on 8/24/11 at 9:48 AM revealed the most recent inspection of the facility kitchen fire suppression system was conducted on 1/5/11. The biannual inspection for July 2011 was not conducted. Interview with the maintenance manager at the above time revealed the previous inspection revealed the fire suppression system needed to be replaced. The manager also stated the facility was in the process of obtaining bids to modernize the kitchen fire suppression system.

Reference: NFPA 101, Life Safety Code, 2000 edition.
9.2.3 Commercial Cooking Equipment shall be in accordance with NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.
NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1997 edition.
11.2.1 An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons.

Based on observation and staff interview, the facility failed to ensure electrical wiring was in compliance with the National Electrical Code in 3 of 5 smoke compartments. The findings were:

Observation on 8/24/11 at 12:48 PM revealed the following concerns:
1. Two wall mounted electrical outlets located in the adolescent exam room and in the adolescent class room were not ground fault circuit interrupter (GFCI) protected.
2. An electrical box cover plate was cracked in the adolescent class room and an electrical box in 317 utility room in adult wing was not firmly attached to the wall.
3. A surge protector was plugged into another surge protector in the following three locations: in resident room 513, in the classroom and in an intake assessment office.
4. A surge protector was also observed to be plugged into an electrical splicer in other intake office.
Interview with the maintenance manager at the time of the observations confirmed the above findings.

NFPA 70, National Electrical Code, 1993 edition:
370-28. Pull and Junction Boxes.
(3) (c) cover. All pull boxes, junction boxes and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use....
400-8. Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure;
(4) Where attached to building surfaces;
410-56. Rating and Type.
(e) Position of Receptacle Faces.
.... Face plates shall be installed so as to completely cover the opening and seat against the mounting surface.
517-20. Wet Locations.
(a) All receptacles and fixed equipment within the area of the wet location shall have ground-fault circuit-interrupter protection....