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Based on observations and interview, the facility failed to maintain a Type II-(III) construction type in 4 locations of the facility by allowing a penetrations to be present. This effects 4 of 11 smoke zones within the facility. The facility had a capacity of 78 residents and a census of 58.

Findings include:

Observations and interview on 11-20-13 revealed the following:

1. There was multiple pipe penetrations (ranging in size from 1/2 inch to 3/4 inch in size) in the 2 West Janitor Closet.
2. There was a hole (approximately 2 inches in size) located in the wall of Classroom #FC204AA.
3. There was a missing escutcheon ring around a sprinkler head (creating a penetration) located in the ceiling of Room #FN223AA.
4. There was a penetration around a sprinkler head located in the ceiling of Room #FN214AA.

Administrative Staff A and Safety Department Staff B verified these observations at the time of the inspection process.

Based on observations and interview, the facility failed to maintain 2 hazardous rooms properly separated. This affects 1 of 11 smoke zones in the facility. The facility had a license capacity of 78 residents and a census of 58 residents.

Findings include:

Observations and interview on 11-21-13 revealed storage rooms #BB007AA and BB005AA failed to be equipped with doors that are self-closing. Both of these storage rooms measured more than 50 square feet and contained combustible storage material.

Administrative Staff A and Safety Department Staff A verified these observations at the time of the survey process.

Based on record review and interview, the facility failed to comply with the fire drill requirements by failing to conduct and document fire drills on each nursing shift, during each quarter year. This would affect all smoke zones. The facility had a capacity of 78 residents and a census of 58 residents.

Findings include:

Record review and interview on 11-21-13 revealed the facility failed to conduct and document required fire drill at the following times:

1. On the 3rd nursing shift, during the 1st quarter year of 2013.
2. On the 1st nursing shift, during the 2nd quarter year of 2013.
3. On the 3rd nursing shift, during the 2nd quarter year of 2013.
4. On the 3rd nursing shift, during the 3rd quarter year of 2013.

Administrative Staff A and Safety Department Staff A verified these observations at the time of the survey process.

Based on observations and interview, the facility failed to provide the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code 1999 edition by improperly locating smoke detectors. This affects 1 of 11 smoke zones in the facility. The facility had a license of 78 residents and a census of 58 residents.

Findings include:

Observations and interview on 11-20-13 revealed a smoke detector was located closer than 3 feet from an air diffuser (HVAC) in the ceiling near the Pharmacy.

Administrative Staff A and Safety Department Staff A verified this observation during the survey process.

Based on record review and interview, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code 1999 edition by failing to have the fire alarm system inspected on a semi-annual basis. This affects all 11 smoke zones in the facility. The facility had a license of 78 residents and a census of 58 residents.

Findings include:

Record review and interview on 11-21-13 revealed the facility failed to have the fire alarm inspected 2 times per year. Within the previous 12 months, the facilities fire alarm system was only inspected 1 time (2-18-13).

Safety Department Staff A verified this observation during the survey process.

(A.)
Based on observations and interview, the facility failed to maintain 1 portable fire extinguishers in accordance with National Fire Protection Association (NFPA) Standard 10, Standard for Portable Fire Extinguishers, 1998 edition by failing to have the extinguisher visually inspected on a monthly basis. This affects 1 of 11 smoke zones within the facility. The facility had a capacity of 78 residents and a census of 58 residents.

Findings include:

Observations and interview on 11-20-13 revealed the fire extinguisher located in the Gymnasium failed to be visually inspected during the month of October, 2013.

Administrative Staff A and Safety Department Staff A verified this observation at the time of the survey process.

(B.)
Based on observations and interview, the facility failed to maintain 1 portable fire extinguishers in accordance with National Fire Protection Association (NFPA) Standard 10, Standard for Portable Fire Extinguishers, 1998 edition by failing to have the extinguisher visually inspected or serviced on an annual basis. This affects 1 of 11 smoke zones within the facility. The facility had a capacity of 78 residents and a census of 58 residents.

Findings include:

Observations and interview on 11-20-13 revealed the fire extinguisher located in the Basement Elevator Room failed to be serviced or inspected by a certified fire extinguisher company within the previous 12 months. The inspection tag on this fire extinguisher was dated 2012.

Administrative Staff A and Safety Department Staff A verified this observation at the time of the survey process.

Based on observations and interview, the facility failed to provide drapery, curtains, including cubicle curtains in accordance with provisions of 10.3.1 of the Life Safety Code and NFPA 13, Standard for Installation of Sprinkler Systems, 1999 edition by allowing non-conforming mini-blinds. This affects 1 of 11 smoke zones in the facility. The facility had a capacity of 78 residents and a census of 58 residents.

Findings include:

Observations and interview on 11-20-13 revealed 2 sets of vinyl mini-blind window coverings located in the Women's Day Room.

Administrative Staff A and Safety Department Staff A verified this observation at the time of the survey process.

(A.)
Based on observations and interview, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition by 1 allowing non-operational Ground Fault Circuit Interrupter to be in use. This affects 1 of 11 smoke zones in the facility. The facility had a capacity of 78 residents and a census of 58 residents.

Findings include:

Observations and interview on 11-20-13 revealed a faulty Ground Fault Circuit Interrupter located near the sink in the 20 Building Kitchen.

Administrative Staff A and Safety Department Staff A verified these observations at the time of the survey process.

(B.)
Based on observations and interview, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition by allowing open gaps in an electrical panel. This affects 1 of 11 smoke zones in the facility. The facility had a capacity of 78 residents and a census of 58 residents.

Findings include:

Observations and interview on 11-20-13 revealed open spaces in the electrical panel box in Room #BB209EA.

Administrative Staff A and Safety Department Staff A verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to have an adequate policy in writing that meets the requirements of the 2000 Life Safety Code 9.7.6.1 (plans for automatic sprinkler systems out of service for more than 4 hours in a 24 hour period). This affects all 11 smoke zones in the facility. The facility had a license of 78 residents and a census of 58 residents.

Findings include:

Record review and interview on 11-21-13 revealed the absense of a written policy that is intended to meet the requirements of the 2000 Life Safety Code 9.7.6.1 (plans for automatic sprinkler systems out of service for more than 4 hours in a 24 hour period).

Safety Department Staff A verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to have an adequate policy in writing that meets the requirements of the 2000 Life Safety Code 9.6.1.8 (plans for fire alarm systems out of service for more than 4 hours in a 24 hour period). This affects all 11 smoke zones in the facility. The facility had a license of 78 residents and a census of 58 residents.

Findings include:

Record review and interview on 11-21-13 revealed the absence of a written policy that is intended to meet the requirements of the 2000 Life Safety Code 9.6.1.8 (plans for fire alarm systems out of service for more than 4 hours in a 24 hour period).

Safety Department Staff A verified this observation at the time of the survey process.