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Based on observation and interview, the facility is not assuring that vertical openings between floors are enclosed with a fire resistance rating of at least one hour. This deficient practice affects all occupants using the Home Health stairewell, including staff, visitors and residents, who may need to use this designated exit in the event of an emergency. This facility has a capacity of 18 with a census of 3 residents.

Findings include:

Observation and interview on 12/19/11, revealed numerous penetrations in the smoke barrier separating the stairwell from the Home Health Clinic. Maintenance Staff A confirmed these observations during the survey process.

Based on observation and interview, this facility is not assuring that seven 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 ten of eighteen smoke zones. This facility has a capacity of 18 with a census of 3 residents.

Findings include:
Observation and interview on 12/19/11, revealed the following deficiencies in smoke barriers:
1. The smoke barrier by room #2215 had a 1/2 inch penetration around a wire.
2. The smoke barrier by room #2700 (Radiology) had a 1/2 inch penetration around red and blue wires.
3. The smoke barrier by room #2614 had a 1/2 inch penetration around a wire.
4. The smoke barrier by the Main Lobby Vending machines had a 2 inch open conduit.
5. The smoke barrier by room #2109 had a 2 inch open conduit.
6. The smoke barrier by Vending had numerous penetrations and open conduits.
7. The smoke barrier by room #2911 had open conduit.
According to the facility layout, this was a required barrier. Maintenance Staff A confirmed these observations.

NAPA 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 NAPA 101, 19.3.7.3

A)
Based on observation and staff interview, this facility is not providing an all-weather surface from each exit to a public way (an area of safety). This deficient practice affects all occupants in the West exit of the CS corridor. This facility has a capacity of 18 with a census of 3 residents.

Findings include:

Observation and interview on 12/19/11, revealed the West exit from the CS corridor was a concrete pad to grass instead of an all-weather surface to a public way. Maintenance Staff A verified the observation. According to the facility layout, these were required exits.



B)
Based on observation and interview, the facility failed to provide all exiting components are free and clear from obstructions. This deficient practice affects all occupants the Therapy Rehabilitation area and the Kitchen. The facility has a certified capacity of 18 with the current census of 3 residents.

Findings include:

Observation and interview on 12/19/11, revealed doors throughout the Therapy Rehabilitation Clinic and 3 doors in the Kitchen had dead bolts on the doors along with a latching door knob. This was verified by Maintenance Staff A.

Based on observation and interview the facility failed to maintain all emergency lighting and one exit sign in one clinic. This deficient practice affects all occupants in the Home Health Clinic. The facility has a certified capacity of 18 with the current census of 3 residents.

Findings include:

Observation and interview on 12/19/11, revealed all emergency lights and the Main exit sign in the Home Health Clinic would not illuminate when tested. Maintenance Staff A verified these findings.

Based on observation and interview, 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. This can affect the operation of the heads 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 in two out of eighteen smoke zones at risk in the event of a fire. The census was 3 with a capacity of 18.

Findings include:



1. Observation and interview on 12/19/11, revealed a fusible link sprinkler head in the same smoke area (by the Business office) as quick response sprinkler heads. This was verified with Maintenance Staff A.

2. Observation and interview on 12/19/11, revealed the a missing sprinkler escutcheon plate for a sprinkler head by the Employee entrance dock. This was 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: The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor. NFPA 25, 1-4.4

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

NFPA Standard: Corrective maintenance includes, but is not limited to, replacing loaded, corroded, or painted sprinklers; replacing missing or loose pipe hangers; cleaning clogged fire pump impellers; replacing valve seats and gaskets; restoring heat in areas subject to freezing temperatures where water-filled piping is installed; and replacing worn or missing fire hose or nozzles. NFPA 25, 1-11.3

Based on observation and interview, the facility failed to secure compressed tanks in one area. This deficient practice affects all occupants in the basement. The facility has a certified capacity of 18 with the current census of 3 residents.

Finding include:

Observation and interview on 12/19/11 at 12:29 p.m., revealed two small carbon dioxide tanks not secure in the Bulb Storage room. This was verified by Maintenance Staff A.

Based on staff interview and record review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice would affect all smoke compartments and all of the residents and staff. The facility has 18 certified beds and at the time of the survey the facility census was 3.

Findings include:

Documentation review and staff interview on 12/19/11 with Maintenance Staff A, revealed proper documentation of the generator weekly inspections. Documentation of monthly testing was provided. Interview with Maintenance Staff B revealed the generator was only tested between 8-12% of load.

NFPA standard: Level 1 and level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes. NFPA 110, 6.4.1 and 6.4.2.

Based on observation and interview, the facility failed to maintain all electrical components in accordance with the National Fire Protection Association 70. The location of deficient practice was located in one exiting stairwell affecting all occupants using the exit. The facility census was 3 with a capacity of 18.

Findings include:

Observation and interview on 12/19/11, revealed an open electrical junction box at the top of the stairwell in the Speciality Clinic stairwell. Maintenance Staff A confirmed observations.

Based on observation and interview, the facility is not assuring that vertical openings between floors are enclosed with a fire resistance rating of at least one hour. This deficient practice affects all occupants using the Home Health stairewell, including staff, visitors and residents, who may need to use this designated exit in the event of an emergency. This facility has a capacity of 18 with a census of 3 residents.

Findings include:

Observation and interview on 12/19/11, revealed numerous penetrations in the smoke barrier separating the stairwell from the Home Health Clinic. Maintenance Staff A confirmed these observations during the survey process.

Based on observation and interview, this facility is not assuring that seven 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 ten of eighteen smoke zones. This facility has a capacity of 18 with a census of 3 residents.

Findings include:
Observation and interview on 12/19/11, revealed the following deficiencies in smoke barriers:
1. The smoke barrier by room #2215 had a 1/2 inch penetration around a wire.
2. The smoke barrier by room #2700 (Radiology) had a 1/2 inch penetration around red and blue wires.
3. The smoke barrier by room #2614 had a 1/2 inch penetration around a wire.
4. The smoke barrier by the Main Lobby Vending machines had a 2 inch open conduit.
5. The smoke barrier by room #2109 had a 2 inch open conduit.
6. The smoke barrier by Vending had numerous penetrations and open conduits.
7. The smoke barrier by room #2911 had open conduit.
According to the facility layout, this was a required barrier. Maintenance Staff A confirmed these observations.

NAPA 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 NAPA 101, 19.3.7.3

A)
Based on observation and staff interview, this facility is not providing an all-weather surface from each exit to a public way (an area of safety). This deficient practice affects all occupants in the West exit of the CS corridor. This facility has a capacity of 18 with a census of 3 residents.

Findings include:

Observation and interview on 12/19/11, revealed the West exit from the CS corridor was a concrete pad to grass instead of an all-weather surface to a public way. Maintenance Staff A verified the observation. According to the facility layout, these were required exits.



B)
Based on observation and interview, the facility failed to provide all exiting components are free and clear from obstructions. This deficient practice affects all occupants the Therapy Rehabilitation area and the Kitchen. The facility has a certified capacity of 18 with the current census of 3 residents.

Findings include:

Observation and interview on 12/19/11, revealed doors throughout the Therapy Rehabilitation Clinic and 3 doors in the Kitchen had dead bolts on the doors along with a latching door knob. This was verified by Maintenance Staff A.

Based on observation and interview the facility failed to maintain all emergency lighting and one exit sign in one clinic. This deficient practice affects all occupants in the Home Health Clinic. The facility has a certified capacity of 18 with the current census of 3 residents.

Findings include:

Observation and interview on 12/19/11, revealed all emergency lights and the Main exit sign in the Home Health Clinic would not illuminate when tested. Maintenance Staff A verified these findings.

Based on observation and interview, 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. This can affect the operation of the heads 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 in two out of eighteen smoke zones at risk in the event of a fire. The census was 3 with a capacity of 18.

Findings include:



1. Observation and interview on 12/19/11, revealed a fusible link sprinkler head in the same smoke area (by the Business office) as quick response sprinkler heads. This was verified with Maintenance Staff A.

2. Observation and interview on 12/19/11, revealed the a missing sprinkler escutcheon plate for a sprinkler head by the Employee entrance dock. This was 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: The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor. NFPA 25, 1-4.4

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

NFPA Standard: Corrective maintenance includes, but is not limited to, replacing loaded, corroded, or painted sprinklers; replacing missing or loose pipe hangers; cleaning clogged fire pump impellers; replacing valve seats and gaskets; restoring heat in areas subject to freezing temperatures where water-filled piping is installed; and replacing worn or missing fire hose or nozzles. NFPA 25, 1-11.3

Based on observation and interview, the facility failed to secure compressed tanks in one area. This deficient practice affects all occupants in the basement. The facility has a certified capacity of 18 with the current census of 3 residents.

Finding include:

Observation and interview on 12/19/11 at 12:29 p.m., revealed two small carbon dioxide tanks not secure in the Bulb Storage room. This was verified by Maintenance Staff A.

Based on staff interview and record review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice would affect all smoke compartments and all of the residents and staff. The facility has 18 certified beds and at the time of the survey the facility census was 3.

Findings include:

Documentation review and staff interview on 12/19/11 with Maintenance Staff A, revealed proper documentation of the generator weekly inspections. Documentation of monthly testing was provided. Interview with Maintenance Staff B revealed the generator was only tested between 8-12% of load.

NFPA standard: Level 1 and level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes. NFPA 110, 6.4.1 and 6.4.2.

Based on observation and interview, the facility failed to maintain all electrical components in accordance with the National Fire Protection Association 70. The location of deficient practice was located in one exiting stairwell affecting all occupants using the exit. The facility census was 3 with a capacity of 18.

Findings include:

Observation and interview on 12/19/11, revealed an open electrical junction box at the top of the stairwell in the Speciality Clinic stairwell. Maintenance Staff A confirmed observations.