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Based on observation and interview, the facility failed to ensure that the doors in the corridor were capable of resisting the passage of smoke and failed to ensure the doors had a suitable means of keeping the door closed. These deficient practices would allow smoke and fire to migrate into the corridor. This facility census was 2.

Findings are:
Observations on 9-14-11 at 12:54 pm revealed the physical therapy room # 6 failed to latch and be secure.

During an interview on 9-14-11 at 12:54 pm, Maintenance A acknowledged and confirmed the findings.

NFPA Standard:
Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Based on observation and interview the facility failed to provide doors in hazard areas which would close securely into door frames, failed to provide self-closing devices and allowed doors to hazard areas to be obstructed and held open. These deficient practices would allow smoke and fire to migrate from hazard areas into other portions of the building. The facility census was 2.

Findings are:
Observations on 9-14-11 from 2:00 pm to 3:15 pm revealed:

1. The storage room that includes the sprinkler riser failed to have a closure.
2. The storage room in the kitchen had a louver in the door.
3. The storage room next to the kitchen had two doors that were alter. The glass was removed and plywood and drywall was put into the opening and sealed.

During an interview on 9-14-11 from 2:00 pm to 3:15, Maintenance A confirmed the confirmed all the findings.

NFPA Standard:
Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.2000 NFPA 101, 19.3.2.1

Based on observation and interview the facility failed to maintain the exit signs that indicate the path of egress. This deficient practice could delay evacuation based on the confusion of which direction to exit. The facility census was 2.

Findings are:

Observations on 9-14-11 at 1:00 pm and 1:40 pm revealed:
1. The exit sign next to the nurses ' station had one of the two bulbs burned out.
2. The exit sign at the west exit had one of the two bulbs burned out.

During an interview on 9-14-11 at 1:00 pm and 1:40 pm, Maintenance A acknowledged and confirmed the bulbs that were burned out.

Based on observation and interview, the facility failed to assure that the fire alarm system is installed and maintained in accordance with NFPA 72. This deficient practice would delay the response time to evacuate the area. The facility census was 2.
Findings Include:
Observations on 9-14-11 at 1:08 pm revealed the staff sleeping room had no smoke detection and visible notification appliance.
During an interview 9-14-11 at 1:08 pm, Maintenance A confirmed and acknowledges all of the findings.
NFPA Standard:
Combination smoke detectors and visible notification appliances shall be installed in sleeping areas. 1999, NFPA 72, 4-4.4.3.1

Based on observation and staff interview the facility failed to provide documentation for an acceptance test and failed to install the automatic sprinkler system to provide complete coverage for all portions of the building in accordance with NFPA 13. This deficient practice would allow fire and smoke to spread throughout the faciltiy. The facility census was 2.

Findings are:

Observations on 9-14-11 between 1:07 pm and 2:00 pm revealed:

1. A sprinkler head is missing in the staff dining ' s closet
2. A sprinkler head is missing in the ER patient room ' s closet
3. The automatic sprinkler system was installed in August 2011 and no documentation was found for an acceptance test.


During an interview on 9-14-11 from 1:07 pm to 2:00, Maintenance A acknowledged and confirmed the confirmed all the findings.

NFPA Standard:
Where required by 19.1.61 health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. 2000 NFPA 101, 19.3.5

NFPA Standard:
The installing contractor shall do the following:
(1) Notify the authority having jurisdiction and owner ' s representative of the time and date testing will be performed
(2) Perform all required acceptance tests
(3) Complete and sign the appropriate contractor ' s material and test certificate(s)
NFPA 13: 10.1

Based on observation and interview, the facility is not providing appropriate metal containers with self-closing cover devices for the collection of ashes from the ashtrays. This deficient practice affected all residents in the facility as the spread of smoke and fire would delay evacuation. The facility census was 2 residents.
Findings are:
Observation on 9-14-2011 at 1:37 pm revealed the facility failed to provide metal self-closing can to dispose of used cigarette butts.
During an interview on 9-14-2011 at 1:37 pm. Maintenance A confirmed the missing metal can and all of the butts covering the floor of smoking area.
NFPA Standard:
Metal self-closing containers for disposing of cigarette butts and ashes from ashtrays, and ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted as required in NFPA 101, 18/19.7.4

Based on observation and interview, the facility failed to provide a complete generator documentation of the weekly tests or the monthly tests under a 30% load. This deficient practice affected the entire building emergency lighting system and all the building occupants. The facility census was 2 residents.

Findings are:
Observations on 9-14-11 at 3:15 pm and 3:27 pm revealed
1. The facility failed to provide any documentation of a weekly test for the generator
2. The facility failed to provide documentation that every month the generator was able to pick up the load within 10 seconds after loss of normal power.

During an interview on 9-14-11 at 3:15 pm and 3:27 pm, Administrator confirmed the lack of documentation, and stated that new staff had been hired and the documentation from previous staff could not be located.

NFPA Standard:
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods: 1999 NPPA 110, 6-4.2
a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
c) The date and time of day for required testing shall be decided by the owner, based on facility operations

NFPA Standard
The generator set(s) shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. NFPA 99:3-4.1.1.8

Based on interview and observation, the facility failed to ensure all electrical is installed in accordance with National Fire Protection Association 70 (electrical code). This deficient practice would increase the probability of an electrical fire or shock. The facility census was 2 residents.
Findings are:
Observations on 9-14-2011 between 12:52 pm and 1:45 pm revealed:
1. The use of two unapproved surge protector multi strip in the physical therapy room #6.
2. The use of two extension cords was found in the staff sleeping room.
3. A refrigerator was plugged into a surge protector in the ER patient room.
4. A surge protector was plugged into another surge protector along with an extension cord in the x ray room.
5. The x ray storage room had a light bulb that produced a large amount of heat was within inches of combustible files.
During an interview on between 12:52 pm and 1:45 pm, Maintenance A confirmed the findings.
NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8
NE State Fire Marshal Official Interpretation: Relocatable power taps are not permitted in areas of health care occupancies regularly occupied by patients. This includes general patient care areas and critical patient care areas. General care areas include patient bedrooms, examining rooms, treatment rooms, clinics and similar areas where it is intended that the patient will come in contact with ordinary appliances such as nurse call systems, electrical beds, examining lamps, telephones and entertainment devices such as radios, televisions and computers. This will also include common spaces such as corridors, lounges, dining rooms and similarly occupied spaces where electrical appliances noted above may be found. Critical patient care areas are: intensive care units, coronary care units, angiography labs, cardiac catheterization labs, delivery rooms, operating rooms, post anesthesia recovery rooms and emergency rooms. In areas not occupied by patients, properly listed portable power taps are permitted. This can include business offices and staff lounges and similar spaces.