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Based on observation and interview, the Facility failed to maintain hazardous areas are protected by a fire barrier having 1-hour fire resistance rating.

Hazardous Areas - Enclosure
2012 EXISTING
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4-hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1

Area Automatic Sprinkler Seperation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K3220)

Findings include:

On facility tour between 10:00 AM and 2:00 PM on 01/10/2017, observation revealed penetrations around the conduit pipes in the wall of the Boiler Room. Holes in the plaster ceiling were also observed that entered into a void above the ceiling, these need to be sealed/patched if this space enters area that would extend outside of this Hazardous Area.

This deficient practice was verified by the Facility Maintenance Director.

Based on documentation review and interview, the Facility failed to provide a current and accurate Fire Alarm Out of Service Policy.

Fire Alarm - Out of Service
Where required fire alarm system is out of services for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.
9.6.1.6

FINDINGS INCLUDE:

On facility tour between 11:00 AM and 2:00 PM on 01/10/2017, documentation review revealed that the Out of Service Policy for the Fire Alarm System does not have current Staff/Fire Marshal contact information.

This deficient practice was verified by the Facility Maintenance Director.

Based on documentation review and interview, the Facility failed to provide a current and accurate Fire Sprinkler Out of Service Policy.

Sprinkler System - Out of Service
Where the sprinkler system is impaired, the extent and duration of the impairment has been determined, areas or buildings involved are inspected and risks are determined, recommendations are submitted to management or designated representative, and the fire department and other authorities having jurisdiction have been notified. Where the sprinkler system is out of service for more than 10 hours in a 24-hour period, the building or portion of the building affected are evacuated or an approved fire watch is provided until the sprinkler system has been returned to service.
18.3.5.1, 19.3.5.1, 9.7.5, 15.5.2 (NFPA 25)

Findings include:

On facility tour between 10:00 AM and 2:00 PM on 01/10/2017, documentation review revealed that the Out of Service Policy for the Fire Sprinkler System does not have current Staff/ Fire Marshal contact information and the 10 hour out of service time needs to be updated.

This deficient practice was verified by the Facility Maintenance Director.

Based on documentation review and interview, the Facility failed to conduct Fire Drills in accordnance with 18.7.1.4 through 18.7.1.7, 19.7.1.4 through 19.7.1.7.

Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
18.7.1.4 through 18.7.1.7, 19.7.1.4 through 19.7.1.7.

Findings include:

On facility tour between 10:00 AM and 2:00 PM on 01/10/2017, documentation reviewed revealed that fire drill documentation could not be located showing that Hospital Staff participated with fire drill emergency procedures within the Hospital when fire drills were conducted in the connected Skilled Nursing Facility. These fire drills were conducted on 02/29/16, 04/12/16, 06/29/16, 10/07/16 and 12/21/16.


This deficient practice was verified by the Facility Maintenance Director.