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Based on observation and interview, it was determined the facility failed to ensure that any door with a required fire protection rating, if held open, is arranged to close automatically by the actuation of the fire alarm system. The facility is licensed for 125 beds, the census was 76 on the day of the survey.

Findings include:

1. During the facility tour on June 22, 2010 between 1:30 p.m. and 2:00 p.m.; observation of the approximately 20' by 5 ' steel, 90 minute fire rated kitchen roll up separation door between kitchen and dining area was operated either by push button or manually, by a chain drive. Interview with the facility Kitchen Manager, Associate Vice President, and Director of Housekeeping on June 22, 2010, indicated the facility was aware the door did not self close or automatically close upon activation of the fire alarm. This deficient practice was observed by the surveyor, Associate Vice President, and the Director of Housekeeping.

2. During the facility tour on June 22, 2010 between 1:30 p.m. and 2:00 p.m., observation of the approximately 4' by 5 ' roll down door between the dishwasher area and the dining area was not arranged to close automatically by the actuation of the manual fire alarm system. The dishwasher area door had a fusible link with no apparent temperature rating, nor a visible door rating label. Interview with the Kitchen Manager, Associate Vice President and the Director of Housekeeping on June 22, 2010, indicated the facility was aware the roll down door was not integrated with the fire alarm system, and that the door most likely required some maintenance and lubrication. This deficient practice was observed by the surveyor, Associate Vice President, and the Director of Housekeeping.

3. During the facility tour on June 22, 2010, between 1:00 p.m. and 1:30 p.m., the rated separation roll down doors between the ICU and ICU west nurses station was blocked by storage of a phone book, and miscellaneous files preventing it from closing in the event of a fire. This deficient practice was observed by the surveyor, Associate Vice President, and the Director of Housekeeping. The deficient practice was immediately corrected.

4. During a facility test of the fire alarm system between 2:30 p.m. and 3:00 p.m. the rated roll down doors between ICU and ICU west did not close as required upon activation of the alarm system. The rated roll down door between the ICU nurse station suite and the ICU corridor did not close as required upon activation of the fire alarm system. This deficient practice was observed by the surveyor, Associate Vice President, and the Director of Housekeeping.

Actual NFPA 101 standard:

19.2.2.2.6
Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

Based upon observation and interview the facility failed to ensure smoke barrier doors sealed tightly to prevent the passage of smoke between smoke compartments. This deficient practice affected all patients and staff in the New Start Unit on the day of the survey. Census on the date of the survey was 76.

Findings include:

During the facility tour on June 22, 2010 between 2:30 p.m. and 3:00 p.m. the smoke barrier doors on the New Start unit were observed to have an approximate 1/4 inch gap between the meeting edges of the doors while in a closed position. In new construction (wing opened in 2009) an astragal is required. Interview with the Associate Vice President, and Director of Housekeeping staff during the tour indicated they were unaware of this requirement as it had been approved during the final inspection.


Actual NFPA 101, standard:
?18.3.7.8
Rabbets, bevels, or astragals shall be required at the meeting edges, and stops shall be required at the head and sides of door frames in smoke barriers. Positive latching hardware shall not be required. Center mullions shall be prohibited.

Based on record review conducted on June 22, 2010, the facility failed to document fire drills were being performed once per shift per quarter. The deficient practice would affect all staff and all residents within the facility. The facility has the capacity for 125 licensed beds with a census of 76 on the day of the survey.

Findings include:

During record review on June 22, 2010 between 9:45 a.m. and 11:00 a.m., of the last 12 months fire drill records, the facility was unable to provide documentation of conducting a fire drill for first (day) shift during the fourth (4th) quarter of 2009.


Actual NFPA standard: NFPA 101 ?19.7.1.2
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 (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Based upon observation and interview the facility failed to train personnel in the operation and maintenance of the facility's fire alarm system control panel. This deficient practice could affect all patients, staff and visitors, census on the day of the survey was 76.

Findings include:

During a test of the fire alarm system to determine automatic door closing and magnetic release operation, facility personnel were unfamiliar with the operation and control of the main fire alarm panel. Maintenance staff #1 stated "he did not know how to work the panel". once activated, the notification devices could not be silenced without a key or code, at either the main panel or the remote annunciator panel. A key was provided by the Director of Housekeeping, which allowed silencing of the alarm. However, the Director of Housekeeping, Maintenance staff #1, Associate Vice President, nor other facility staff knew how to reset and re-arm the fire alarm system. The system was silenced and reset with the assistance of non facility personnel. When questioned, the facility personnel knew there was a code, but did not know what it was, where it was kept, or how to provide that information to responders if the need arose.

Actual NFPA 101 standard:
19.7.2.3
All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system
Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

Based on observation and interview, it was determined the facility failed to ensure that any door with a required fire protection rating, if held open, is arranged to close automatically by the actuation of the fire alarm system. The facility is licensed for 125 beds, the census was 76 on the day of the survey.

Findings include:

1. During the facility tour on June 22, 2010 between 1:30 p.m. and 2:00 p.m.; observation of the approximately 20' by 5 ' steel, 90 minute fire rated kitchen roll up separation door between kitchen and dining area was operated either by push button or manually, by a chain drive. Interview with the facility Kitchen Manager, Associate Vice President, and Director of Housekeeping on June 22, 2010, indicated the facility was aware the door did not self close or automatically close upon activation of the fire alarm. This deficient practice was observed by the surveyor, Associate Vice President, and the Director of Housekeeping.

2. During the facility tour on June 22, 2010 between 1:30 p.m. and 2:00 p.m., observation of the approximately 4' by 5 ' roll down door between the dishwasher area and the dining area was not arranged to close automatically by the actuation of the manual fire alarm system. The dishwasher area door had a fusible link with no apparent temperature rating, nor a visible door rating label. Interview with the Kitchen Manager, Associate Vice President and the Director of Housekeeping on June 22, 2010, indicated the facility was aware the roll down door was not integrated with the fire alarm system, and that the door most likely required some maintenance and lubrication. This deficient practice was observed by the surveyor, Associate Vice President, and the Director of Housekeeping.

3. During the facility tour on June 22, 2010, between 1:00 p.m. and 1:30 p.m., the rated separation roll down doors between the ICU and ICU west nurses station was blocked by storage of a phone book, and miscellaneous files preventing it from closing in the event of a fire. This deficient practice was observed by the surveyor, Associate Vice President, and the Director of Housekeeping. The deficient practice was immediately corrected.

4. During a facility test of the fire alarm system between 2:30 p.m. and 3:00 p.m. the rated roll down doors between ICU and ICU west did not close as required upon activation of the alarm system. The rated roll down door between the ICU nurse station suite and the ICU corridor did not close as required upon activation of the fire alarm system. This deficient practice was observed by the surveyor, Associate Vice President, and the Director of Housekeeping.

Actual NFPA 101 standard:

19.2.2.2.6
Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

Based upon observation and interview the facility failed to ensure smoke barrier doors sealed tightly to prevent the passage of smoke between smoke compartments. This deficient practice affected all patients and staff in the New Start Unit on the day of the survey. Census on the date of the survey was 76.

Findings include:

During the facility tour on June 22, 2010 between 2:30 p.m. and 3:00 p.m. the smoke barrier doors on the New Start unit were observed to have an approximate 1/4 inch gap between the meeting edges of the doors while in a closed position. In new construction (wing opened in 2009) an astragal is required. Interview with the Associate Vice President, and Director of Housekeeping staff during the tour indicated they were unaware of this requirement as it had been approved during the final inspection.


Actual NFPA 101, standard:
?18.3.7.8
Rabbets, bevels, or astragals shall be required at the meeting edges, and stops shall be required at the head and sides of door frames in smoke barriers. Positive latching hardware shall not be required. Center mullions shall be prohibited.

Based on record review conducted on June 22, 2010, the facility failed to document fire drills were being performed once per shift per quarter. The deficient practice would affect all staff and all residents within the facility. The facility has the capacity for 125 licensed beds with a census of 76 on the day of the survey.

Findings include:

During record review on June 22, 2010 between 9:45 a.m. and 11:00 a.m., of the last 12 months fire drill records, the facility was unable to provide documentation of conducting a fire drill for first (day) shift during the fourth (4th) quarter of 2009.


Actual NFPA standard: NFPA 101 ?19.7.1.2
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 (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Based upon observation and interview the facility failed to train personnel in the operation and maintenance of the facility's fire alarm system control panel. This deficient practice could affect all patients, staff and visitors, census on the day of the survey was 76.

Findings include:

During a test of the fire alarm system to determine automatic door closing and magnetic release operation, facility personnel were unfamiliar with the operation and control of the main fire alarm panel. Maintenance staff #1 stated "he did not know how to work the panel". once activated, the notification devices could not be silenced without a key or code, at either the main panel or the remote annunciator panel. A key was provided by the Director of Housekeeping, which allowed silencing of the alarm. However, the Director of Housekeeping, Maintenance staff #1, Associate Vice President, nor other facility staff knew how to reset and re-arm the fire alarm system. The system was silenced and reset with the assistance of non facility personnel. When questioned, the facility personnel knew there was a code, but did not know what it was, where it was kept, or how to provide that information to responders if the need arose.

Actual NFPA 101 standard:
19.7.2.3
All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system
Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.