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Based on record review and staff interview, this facility is not maintaining the sprinkler system in accordance with the 2011 edition of NFPA 25 by not providing complete documentation of monthly visual inspections of the automatic, wet-pipe sprinkler system. This deficient practice would affect no patients, and all visitors and staff in 2 of 5 smoke zones. The facility has 24 certified beds and at the time of the survey the census was 4.


Findings include:

During the survey conducted on 12/31/18 the following deficiencies are noted:

1. During the survey at 2:33 PM, it is observed that there is storage on a top shelf within 18" of the sprinkler head in the storage closet near the clinic lab.
2. During the survey at 3:26 PM, it is observed that there is a ceiling fan within 36" of a sprinkler head in the Support Services Directors office.

Staff A was present and acknowledged the finding.

NFPA Standard: Automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25 per 2012 NFPA 101, 9.7.5. NFPA Standard: Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. 2012 NFPA 101 4.6.12.1 NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 2012 NFPA 101, 4.6.12.1 NFPA Standard: NFPA 13 2010 26.1* General. A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained by the property owner or their authorized representative in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. NFPA 13 8.2.5.2.1 Pendent sprinklers shall be located at least 3ft (914 mm) away from obstructions such as ceiling fans and light fixtures unless the requirements of 8.2.5.4

Based on observation and staff interview the facility is not inspecting and maintaining their corridor doors properly. This deficient practice prevents the ability of the facility to properly confine fire and smoke. This deficient practice would affect no patients, and all visitors and staff in 1 of 5 smoke zones. The facility has 24 certified beds and at the time of the survey the census was 4.


Findings include:

During the survey conducted on 12/31/18 the following deficiency is noted:

1. During the survey at 1:45 PM, it is observed that the corridor door to the medical records office is held open with a kick down device.

Staff A was present and acknowledged the finding.

Review of the following NFPA Standard revealed: Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following:
(1) 13?4 in. (44 mm) thick, solid-bonded core wood
(2) Material that resists fire for a minimum of 20 minutes
2012 NFPA 101, 19.3.6.3.1
Review of the following NFPA Standard revealed: Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply:
(1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.
(2) Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7.
2012 NFPA 101, 19.3.6.3.5

Review of the following NFPA Standard revealed: Doors shall not be held open by devices other
than those that release when the door is pushed or pulled. 2012 NFPA 101, 19.3.6.3.10

Based on observation and staff interview the facility fails to properly maintain their electrical systems in accordance with NFPA 70. This deficient practice would affect no patients, and all visitors and staff in 1 of 5 smoke zones. The facility has a capacity of 24 with a census of 4 at the time of the survey.

Findings include:

During the survey conducted on 12/31/18 the following deficiency is noted:

1. During the survey at 2:25 PM, it is observed that there is an open junction box above the ceiling tiles in the IT Room.

Staff A was present and acknowledged the finding.

NFPA Standard: Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2

Based on document review and staff interview, the facility fails to conduct fire drills as required by Life Safety Code NFPA 101. This deficient practice would affect all patients, visitors, and staff in 5 of 5 smoke zones. The facility has a capacity of 24 with a census of 4 at the time of the survey.

Findings Include:

During the survey on 12/31/18 the following deficiencies are noted:

1. During document review at 1:05 PM, it is observed that the four of the last fire drills held on 1st shift all occurred between 8:45 and 9:35 AM.
2. During document review at 1:05 PM, it is observed that the last fire drill held on 2nd shift at 7:00 PM in the 3rd quarter of 2018 was held as a coded silent drill.

Staff A was present and acknowledged the findings.

NFPA Standard: NFPA 101 2012 19.7.1.4* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 19.7.1.5 Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 19.7.1.6 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. 19.7.1.7 When drills are conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

Based upon observation, document review, and staff interview the facility is not inspecting and maintaining their rated door assemblies in compliance with NFPA 80. This deficient practice could prevent the ability of the facility to properly confine smoke and prevent fire from spreading to other zones. This deficient practice would affect all patients, visitors, and staff in 5 of 5 smoke zones. The facility has a capacity of 24 with a census of 4 at the time of this survey.

Findings include:

During the survey conducted on 12/31/18 the following deficiency is noted:

1. During document review at 1:20 PM, it is observed that the annual inspection report for rated door assemblies show several deficiencies on doors that have no documentation for being corrected.


Staff A was present and acknowledged the finding.

NFPA Standard: NFPA 80 2010 5.2.1 Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ. 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing. 5.2.4.2 As a minimum, the following items shall be verified: (1) No open holes or breaks exist in the surfaces of either the door or frame. (2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped. (3) The door, frame, hinges, hardware, and non combustible threshold are secured, aligned, and in working order with no visible signs of damage. (4) No parts are missing or broken. (5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7 (6) The self-closing device is operational; that is, the active door completely closes when operated from the open position. (7) If a coordinator is installed, the inactive leaf closes before the active leaf. (8) Latching hardware operates and secures the door when it is in the closed position. (9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame. (10) No field modifications to the door assembly have been performed that void the label. (11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity. 3.3.95 Qualified Person. A person who, by possession of a recognized degree, certificate, professional standing, or skill, and who by knowledge, training, and experience, has demonstrated the ability to deal with the subject matter, the work, or the project.

Based on staff interview and observation, the facility fails to maintain their electrical systems in accordance with NFPA 70. The deficient practice would affect no patients, and all visitors and staff in 1 of 5 smoke zones. The facility has a capacity of 24 with a census of 4 at the time of the survey.

Findings include:

During the survey conducted on 12/31/18 the following deficiency is noted:

1. During the survey at 1:40 PM, it is observed that there is an extension cord powering Christmas lights in the front lobby.

Staff A was present and acknowledged the finding.

NFPA Standard: Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction. 2012 NFPA 101, 9.1.2

Based on observation and staff interview, the facility failed to properly protect and store compressed gasses as required by NFPA 99. The deficient practice would affect no patients, and all visitors and staff in 1 of 5 smoke zones. The facility has a capacity of 24 with a census of 4 at the time of the survey.

Findings include:

During the survey conducted on 12/31/18 the following deficiency is noted:

1. During the survey at 1:59 PM, it is observed that there is an unsecured medical gas cylinder in the oxygen storage room.

Staff A was present and acknowledged the finding.

NFPA Standard: NFPA 99 5.1.3.3.2* Design and Construction. Locations for central supply systems and the storage of positive-pressure gases shall meet the following requirements: (1) They shall be constructed with access to move cylinders,
equipment, and so forth, in and out of the location on hand trucks complying with 11.4.3.1.1. (2) They shall be secured with lockable doors or gates or otherwise secured. (3) If outdoors, they shall be provided with an enclosure (wall or fencing) constructed of noncombustible materials with a minimum of two entry/exits. (4) If indoors, they shall be constructed and use interior finishes
of noncombustible or limited-combustible materials such that all walls, floors, ceilings, and doors are of a minimum 1-hour fire resistance rating. (5)*They shall be compliant with NFPA 70, National Electrical Code, for ordinary locations. (6) They shall be heated by indirect means (e.g., steam, hot water) if heat is required. (7) They shall be provided with racks, chains, or other fastenings
to secure all cylinders from falling, whether connected, unconnected, full, or empty. (8)*They shall be supplied with electrical power compliant with the requirements for essential electrical systems as described in Chapter 6. (9) They shall have racks, shelves, and supports, where provided, constructed of noncombustible materials or limited-combustible materials. (10) They shall protect electrical devices from physical damage.
NFPA standard revealed: A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum: CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING. (NFPA 99), 11.4