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Based on observation and staff interview the facility fails to properly protect and maintain their hazardous areas in accordance with NFPA 101. The deficient practice would affect all patients, visitors, and all staff in 1 of 2 smoke zones. The facility has a capacity of 21 with a census of 6 at the time of the survey.

Findings include:

During the survey conducted on 3/23/17 the following deficiencies are noted:

1. During the survey at 2:00 PM it is observed that there is an approximate 1" by 3" unsealed penetration around pipe and conduit near the front door of the boiler room wall.
2. During the survey at 2:11 PM it is observed that the door to the soiled linen, room across the hallway from the boiler room, is not equipped with a self-closing device.
3. During the survey at 3:35 PM it is observed that there are unsealed penetrations around conduit and pipes over the entry door in the dietary manager / material manager storage room wall.

Maintenance staff was present and acknowledged the unsealed penetrations and the needed closing device to the soiled linen closet door.

NFPA Standard: NFPA 101 19.3.2.1.3 The doors shall be self-closing or automatic-closing. 19.3.2.1.5 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) Rooms with soiled linen in volume exceeding 64 gal (242 L) (6) Rooms with collected trash in volume exceeding 64 gal (242 L) (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 19.3.2.1.2* Where the sprinkler option of 19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4.

Based on staff interview and observation, the facility fails to maintain their smoke partition walls in the kitchen in accordance with NFPA 101. The deficient practice would affect all patients, visitors, and staff in 1 of 2 smoke zones. The facility has a capacity of 21 with a census of 6 at the time of the survey.

Findings include:

During the survey conducted on 3/23/17 the following deficiency is noted:

1. During the survey at 4:10 PM it is observed that there is an abandoned section of HVAC through the smoke partition wall of the kitchen and hallway corridor that is not sealed on the kitchen side and has only a metal cover on the side in the hallway.

Maintenance staff was present and acknowledged the unsealed abandoned HVAC through the smoke wall.


NFPA Standard: Life Safety Code 101 2012 8.7.1.1* Protection from any area having a degree of hazard
greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means: (1) Enclosing the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.3 (2) Protecting the area with automatic extinguishing systems in accordance with Section 9.7 (3) Applying both 8.7.1.1(1) and (2) where the hazard is severe
or where otherwise specified by Chapters 11 through 43 8.7.1.3 Doors in barriers required to have a fire resistance rating shall have a minimum 3?4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8. 19.3.2.5.3* Within a smoke compartment, where residential or commercial cooking equipment is used to prepare meals for 30 or fewer persons, one cooking facility shall be permitted to be open to the corridor, provided that all of the following
conditions are met: (1) The portion of the health care facility served by the cooking facility is limited to 30 beds and is separated from other portions of the health care facility by a smoke barrier constructed
in accordance with 19.3.7.3, 19.3.7.6, and 19.3.7.8.

Based on staff interview and observation, the facility fails to install and maintain their Alcohol Based Hand Rub dispensers in accordance with NFPA 101. The deficient practice would approximately 4 patients and all visitors and staff in 1 of 2 smoke zones. The facility has a capacity of 21 with a census of 6 at the time of the survey.

Findings include:

During the survey conducted on 3/24/17 the following deficiencies are noted:

1. During the survey at 9:35 AM it is observed that the alcohol based hand rub dispenser in room 18 is installed within a 1" distance from the light switch near the door.
2. During the survey at 9:40 AM it is observed that the alcohol based hand rub dispenser in room 102 is installed within a 1" distance from the light switch near the door.

Maintenance staff was present and acknowledged the alcohol based hand rub dispensers were too closely mounted to the light switch.

NFPA Standars: Life Safety Code 101 2012 19.3.2.6* Alcohol-Based Hand-Rub Dispensers. Alcohol-based hand-rub dispensers shall be protected in accordance with 8.7.3.1, unless all of the following conditions are met: (8) Dispensers shall not be installed in the following locations: (a) Above an ignition source within a 1 in. (25 mm) horizontal distance from each side of the ignition source (b) To the side of an ignition source within a 1 in. (25mm) horizontal distance from the ignition source (c) Beneath an ignition source within a 1 in. (25 mm) vertical distance from the ignition source.

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 or visitors and all staff in 1 of 2 smoke zones. The facility has a capacity of 21 with a census of 6 at the time of the survey.

Findings include:

During the survey conducted on 3/23/17 the following deficiency is noted:

1. During the survey at 3:31 PM it is observed that there is a power strip hanging that is powering several devices in the IT server room.

Maintenance staff was present and acknowledged the power strip hanging.

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 or visitors and all staff in 1 of 2 smoke zones. The facility has a capacity of 21 with a census of 6 at the time of the survey.

Findings include:

During the survey conducted on 3/23/17 the following deficiency is noted:

1. During the survey at 4:03 PM it is observed that there is no signage on the door to the clean utility room where oxygen cylinders and equipment are being stored.

Maintenance staff was present and acknowledged the needed signage on the oxygen storage room door.

NFPA Standard: NFPA 99 2012 11.3.4.1 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. 11.3.4.2 The sign shall include the following wording as a minimum: CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING