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42 CFR 482.41(a)

Based on observations, on 8/11/2015 at approximately 9:30 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Exit access door to room W452.01 is not equipped with positive latching hardware.

2. Door opening to nourishment room, W459, is not equipped with a door assembly and positive latching hardware - space is located behind clerical station.

NFPA 101, 19.3.6.3


This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 8/11/2015 at approximately 9:30 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:


1. Door opening to equipment storage room, W452.03, is not equipped with a door assembly and positive latching hardware - space is located behind main nurse's station.

NFPA 101, 19.3.2.1


This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 8/11/2015 at approximately 9:30 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Exit access doors to rooms U491, and W1012 are equipped with excessive latching hardware assemblies - hardware requires greater than a single hand motion to operate.


NFPA 101, 19.2.1, 7.1


This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 8/11/2015 at approximately 9:30 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

There are no documented fire drills for the LTAC unit for each quarter and shift - available documentation revealed one second shift, second quarter 2015, fire drill observation for fourth floor unit.

NFPA 101, 19.7.1.2


This deficiency affected all smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 8/11/2015 at approximately 9:30 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

The fire alarm system audible signaling devices did not function in the first floor lobby with activation of smoke detector in main fire alarm control room W137.09.

NFPA 101, 19.3.4, 9.6


This deficiency affected first floor smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 8/11/2015 at approximately 9:30 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

The main sprinkler control valve audible signal can be permanently silenced with the valve closed - located in north stairway at fourth floor landing.

NFPA 101, 9.7.2.1, NFPA 72


This deficiency affected all fourth floor smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 8/11/2015 at approximately 9:30 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. There is debris on sprinkler heat sensitive element in resident room W433.

2. There are green and red bulb pendent sprinklers in stairway #12 - ambient temperature at lower and mid levels do not approach 100 degrees Fahrenheit or above.

NFPA 101, 19.7.6, 9.7.5, 4.6.12, NFPA 13, NFPA 25


This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 8/11/2015 at approximately 9:30 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

Generator lead acid batteries are not inspected weekly and findings documented monthly - available documentation from CAT reveals one monthly inspection report. The specific gravity and electrolyte levels are not documented for all months since batteries were installed.

NFPA 101, 19.1, NFPA 99, NFPA 110, 3-5.5.6


This deficiency affected all smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.