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Based on observation during tour and staff interview it was determined this facility failed to ensure the smoke doors, when in the closed position would resist the passage of smoke as required by the National Fire Protection Association (NFPA) Chapter 8.3.4.1, specifically A.8.3.4.1 which states the clearance for proper operation of smoke doors is defined as 1/8 inch. This has the potential to affect all those who may utilize this facility. The current census is zero.

Findings include:

Tour of the facility took place on 04/12/10 at 3:30 PM with staff E. During tour of the facility the three smoke barrier doors were released from their magnetic holding devices in order to test for proper closure. The double smoke barrier doors located in the east and west wing were both observed to have a gap greater than 1/8 inch between the doors when in the closed position.
Interview with staff E took place during tour and staff E stated he/she thought the gap had to be 1/4 inch or less according to this facility's accrediting body.

Based on facility observation and staff interview and verification the facility failed to ensure that two exit discharges and an enclosed patio were arranged so that exits were accessible at all times and terminated at a public way. This had the potential to affect all those utilizing this facility. The facility census at the time of the survey was zero.

Findings included:

Tour of the facility took place on 04/12/10 at 3:30 PM with staff E. During tour of the east wing exit discharge observation was made of a six foot by nine foot cement stoop which was surrounded by a grassy area. There is approximately 41 feet of grass between the cement stoop and the common way. Additionally, within two to three feet from the cement stoop into the grassy area the elevation begins to decline to a total depth of approximately two to three feet within a 15 foot distance.
Interview with staff E during tour of the east wing verifies the need of a safe access to the common way.

Tour of the facility took place on 04/12/10 at 3:30 PM with staff E. During tour of the west wing exit discharge observation was made of a six foot by nine foot cement stoop which was surrounded by a grassy area. There is approximately 41 feet of grass between the cement stoop and the common way. Additionally, within two to three feet from the cement stoop into the grassy area the elevation begins to decline to a total depth of approximately two to three feet within a 15 foot distance.
Interview with staff E during tour of the west wing verifies the need of a safe access to the common way.

During tour of the main lounge, observation was made of a door which allowed residents to exit out into an enclosed patio area. This area is approximately 80 foot by 40 foot and is enclosed with a five foot high vinyl fence. There is no exit discharge from this enclosed patio area and the only way out is to re-enter the building from the same door which exits out into the enclosed patio area. There is no safe access from the exit discharge of the building to the common way.
Interview with staff E during the of the tour of the patio area verifies there is no gate which leads out of the fenced in area. Staff E stated he/she would use a bobcat to dig out the grass and put in a safe exit access in all three areas.

Based on documentation review and staff interview it was determined this agency failed to ensure fire drills were held at unexpected times under varying conditions at least quarterly on each shift. The facility census was zero at the time of the survey.

Findings include:

This facility operates in two shifts for the nursing staff which is from 7:00 AM - 7:00 PM and 7:00 PM - 7:00 AM. The remaining staff primarily worked the day shift.
Review of the facility's documentation for fire drills took place on 04/12/10. The first and second shift fire drills for the second quarter in 2009 had not been completed. The first shift fire drill for the fourth quarter in 2009 had not been completed.
This was verified by staff E at approximately 3:00 PM on 04/12/10.

Based on staff interviews and review of the fire alarm inspection, the facility lacked evidence the smoke detectors were inspected for sensitivity as required by the code at NFPA 101, 9.6.1.3 and NFPA 72, 7-3.2.1. This could potentially affect all the patients, staff, and visitors in the facility. The current census was zero.

Findings include:

On 04/12/10 at 2:37 PM an interview was conducted with Staff E regarding sensitivity testing of smoke detectors in the facility. Upon review of the outside service company's fire alarm and smoke detection inspections for the past year, the reports were silent to sensitivity testing of smoke detectors. During this interview, Staff E stated "if there isn't sensitivity testing on the documentation then they did not do it."

Based on staff interviews and review of the sprinkler system inspections, the facility lacked evidence the sprinkler system was inspected quarterly as required by the National Fire Protection Agency (NFPA) code at NFPA 25, 2-3. This could potentially affect all the patients, staff, and visitors in the facility. The current census was zero.

Findings include:

On 04/12/10 at 2:37 PM an interview was conducted with Staff E regarding the quarterly sprinkler system tests in the facility. Upon review of the outside service company's sprinkler system inspections for the past year it was revealed this facility had it's sprinkler system tested biannually and not quarterly as required by the code.
During this interview, Staff E stated "I did not know the sprinkler system had to be checked quarterly but if that's what we have to do then we'll have it arranged."

Based on the review of the documentation for generator record maintenance and load testing and staff interview it was determined this facility failed to ensure the generator was inspected weekly. This has the potential to affect all those utilizing this facility. Currently the facility census is zero.

Findings include:

Review of the documentation for generator record maintenance and load testing took place on 04/12/10. The weekly generator maintenance records failed to include all components required for the weekly inspection such as belt inspection, fluid levels and checking for leaks. The documentation presented to this surveyor only indicated the date, start and stop time of the generator and initials of the individual who performed this task.
Interview with staff E on 04/12/10 at 2:15 PM reveals the generator automatically turns on and off each week and staff E simply documents the date and run time of the generator.

Based on review of fire procedures and staff interview, the facility failed to maintain a written fire watch plan for when the automatic sprinkler system is out of service for more than 4 hours in a 24-hour period. This could potentially affect all the patients, staff, and visitors in the facility. The current census was zero.

Findings include:

A review of fire policies and procedures on 04/12/10 at 3:00 PM with Staff E revealed the lack of a written fire watch plan when the required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period. Staff E stated there is a fire watch policy in place for the fire alarm system but he/she did not realize there was a requirement for a separate policy regarding the automatic sprinkler system. This was verified during review of the fire watch plan.