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Based on observation, interview and record review, facility staff failed to inspect, test and maintain the fire egress doors in accordance with the 2010 Editions of NFPA 80 (Standard for Fire Doors and Other Opening Protectives) and NFPA 105 (Standard for Fire Doors and Other Opening Protectives). Facility staff failed to conduct an annual inspection of the fire egress doors. The facility census was eight.

1. Review of the facility's inspection, testing and maintenance records for the 2018 year showed the records did not contain documentation of an annual inspection of the fire egress doors during the 12-month period.

During an interview on 1/15/19 at 1:40 P.M., the Maintenance Director said he/she did not know of the requirement to conduct annual inspections of the egress doors.


Review of NFPA 101, 2012 Edition showed the following:
-7.1.10.2.1 showed no furnishings, decorations, or other objects shall obstruct exits or their access thereto, egress therefrom, or visibility thereof.
-19.2.2.2.1 Doors complying with 7.2.1 shall be permitted.
-7.2.1.15.1* Where required by Chapters 11 through 43, the following door assemblies shall be inspected and tested not less than annually in accordance with 7.2.1.15.2 through 7.2.1.15.8:
(1) Door leaves equipped with panic hardware or fire exit hardware in accordance with 7.2.1.7;
(2) Door assemblies in exit enclosures;
(3) Electrically controlled egress doors;
(4) Door assemblies with special locking arrangements subject to 7.2.1.6.
-7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives.
-7.2.1.15.3 The inspection and testing interval for fire-rated and nonrated door assemblies shall be permitted to exceed 12 months under a written performance-based program in accordance with 5.2.2 of NFPA 80, Standard for Fire Doors and Other Opening Protectives.
-7.2.1.15.4 A written record of the inspections and testing shall be signed and kept for inspection by the authority having jurisdiction.

Based on observation, staff interview, and record review, the facility staff failed to provide continuously maintained exit ways free of all obstructions or impediments continuous to a public way such as a parking lot. This deficient practice has the potential to affect all patients, staff and visitors in the facility. The facility census was 8.


1. Observation on 1/15/19, during the facility tour, showed the following;

-designated exit from the commons requires patients, staff and visitors to walk 50 feet to a hard surface. Observation showed the path to the hard surface consisted of dirt.

- designated exit on the med surge wing, near room 112 blocked by a flower bed. Observation showed the exit did not lead to a public way.

Record review of the facility layout showed the exit discharge areas designated for resident use.

During an interview on 1/15/19 the Director of Facility Services confirmed the observations.


The National Fire Protection Association 101, Life Safety Code 2012 Edition, section 7.7 states:
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7.7 Discharge from Exits.

7.7.1* Exit Termination. Exits shall terminate directly, at a
public way or at an exterior exit discharge, unless otherwise
provided in 7.7.1.2 through 7.7.1.4.

Based on observation and facility staff interview, facility staff failed to provide emergency lighting inside one medication room. This deficient practice has the potential to affect all patients within the nursing unit served by the medication room. Failure to provide emergency lighting could prevent proper illumination of required areas in the event of power loss. The facility census was 8.

1. Observations on 1/15/19, during the Life Safety Code (LCS) tour, showed the medication room in the med surge unit did not have emergency lighting.

During an interview on 1/15/19 at 11:37 A.M., the Maintenance Supervisor confirmed the observation.

NFPA 99, 2012 edition, section 6.4.2.2.4.2 states:

"6.4.2.2.4.2 The critical branch shall supply power for task illumination,
fixed equipment, select receptacles, and select power
circuits serving the following areas and functions related to patient
care:
(1) Critical care areas that utilize anesthetizing gases, task illumination,
select receptacles, and fixed equipment
(2) Isolated power systems in special environments
(3) Task illumination and select receptacles in the following:
(a) Patient care rooms, including infant nurseries, selected
acute nursing areas, psychiatric bed areas (omit receptacles),
and ward treatment rooms
(b) Medication preparation areas
(c) Pharmacy dispensing areas
(d) Nurses ' stations (unless adequately lighted by corridor
luminaires)
(4) Additional specialized patient care task illumination and
receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7)*Telephone equipment rooms and closets
(8) Task illumination, select receptacles, and select power circuits
for the following areas:
(a) General care beds with at least one duplex receptacle
per patient bedroom, and task illumination as required
by the governing body of the health care facility
(b) Angiographic labs
(c) Cardiac catheterization labs
(d) Coronary care units
(e) Hemodialysis rooms or areas
(f) Emergency room treatment areas (select)
(g) Human physiology labs
(h) Intensive care units
(i) Postoperative recovery rooms (select)
(9) Additional task illumination, receptacles, and select power
circuits needed for effective facility operation, including
single-phase fractional horsepower motors, which are permitted
to be connected to the critical branch"

Based on observation, staff interview and record review facility staff failed to equip commercial cooking equipment with grease filters. Facility staff failed to have the range hood inspected every six months. The facility census was 8.

1. Observation on 1/15/19, during the facility tour, showed the range hood did not contain grease filters.

During an interview on 1/15/19 at 2:03 P.M., the Maintenance Supervisor confirmed the observation.

The National Fire Protection Association (NFPA) 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition section 6.1.1 states " Listed grease filters, listed baffles, or other listed grease removal devices for use with commercial cooking equipment shall be provided".

2. Record review on 1/15/19 showed the last range hood inspection conducted on 6/28/18.

During an interview on 1/15/19 at 1:35 P.M., the Maintenance Supervisor confirmed that only one range hood inspection was conducted in 2018.

The National Fire Protection Association (NFPA) 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition section 11.2.1 states "Maintenance of the fire extinguishing systems and listed exhaust hoods containing a constant or fire activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified person (s) acceptable to the authority having jurisdiction at least every six months".

Based on observation and facility staff interview, the facility staff failed to ensure interior ceiling and wall finishes met Class A or Class B flame spread requirements. The facility census was 8.

1. Observation on 1/15/19, during the facility tour, showed the business office walls contained carpet from floor to ceiling. Observation showed the business office on an exit corridor.

During an interview on 1/15/18 at 10:55 A.M., The Director of Facility Services said that the he did not know if the carpet had a fire rating.


National Fire Protection Association 101, 2012 edition, section 19.3.3.2 states:


"19.3.3.2* Interior Wall and Ceiling Finishes. Existing interior wall and ceiling finish materials complying with Section 10.2 shall be permitted to be Class A or Class B."

Based on observation and facility staff interview, the facility failed to ensure that one of one fire alarm systems was installed per NFPA 72, The National Fire Alarm and Signaling Code. This deficient practice has the potential to effect all facility patients, staff and visitors. This deficient practice could delay fire and emergency personnel response in the event of a fire. The facility census was 8.

1. Observations on 1/15/19, during the facility tour, showed the following areas missing required smoke detector coverage:

- Administrative/cardiac rehab corridor contained one smoke detector. Observation showed the corridor measured 115 feet long.

During an interview on 1/15/19 at 12:55 P.M. the Maintenance Supervisor confirmed the observation.

NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, 19.3.4.1 states:

19.3.4.1 General. Health care occupancies shall be provided
with a fire alarm system in accordance with Section 9.6.

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, sections 17.6.3 Location and Spacing and 17.6.3.3.1 Spacing for additional information.

Based on observation and facility staff interview, facility staff failed to ensure the building sprinkler system met NFPA 13, Standard For The Installation Of Sprinkler Systems, 2010 edition installation requirements. This deficient practice could delay prompt fire extinguishment and evacuation in the event of a fire.
The facility census was 8.

Observations on 1/15/19, during the facility tour, did not show a sprinkler installed in one of one elevator pits containing combustible hydraulic fluid.

During an interview on 1/15/19 at 12:45 P.M the Maintenance Supervisor confirmed the observation.

NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS, 2010 Edition section 8.15.5 states:


"8.15.5 Elevator Hoistways and Machine Rooms.

8.15.5.1* Sidewall spray sprinklers shall be installed at the bottom
of each elevator hoistway not more than 2 ft (0.61 m)
above the floor of the pit.

8.15.5.2 The sprinkler required at the bottom of the elevator
hoistway by 8.15.5.1 shall not be required for enclosed, noncombustible
elevator shafts that do not contain combustible
hydraulic fluids."

Based on staff interview and record review, facility staff failed to inspect the two wet & one dry sprinkler systems per NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition. The facility census was 8

Record review on 1/15/19 did not show the 5 year internal pipe inspections for the two wet sprinkler systems.

Record review on 1/15/19 did not show monthly sprinkler inspections for the two wet and one dry sprinkler system.


Refer to NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition, Chapters 5, 13 and 14 for additional information.

Based on observation and interview the facility failed to provide window blinds that were flame resistant in accordance with provisions of NFPA 101, 10.3. The facility census was 8.

1. Observations on 1/15/19, during the Life Safety Code tour, showed window blinds throughout the facility did not have identification that showed them as being flame retardant.


NFPA Standard: Draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as /demonstrated by testing in accordance with NFPA 701. 2012 NFPA 101.

Based on observation and facility staff interview, the facility failed to maintain their emergency power generator in accordance with the National Fire Protection Association (NFPA) 110, 2010 edition. The generator did not have an emergency stop switch remotely located away from the generator location. The facility census was 8.

Observation on 1/15/19, during the facility tour, of the facility emergency generator showed the uncovered manual stop switch located on the generator.

During an interview on 1/15/19, at 12:53 P.M., the Maintenance Supervisor confirmed the observation.
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NFPA 110 "Emergency and Standby Power Systems", 2010 edition, section 5.6.5.6 states: "5.6.5.6* All installations shall have a remote manual stop station
of a type to prevent inadvertent or unintentional operation located
outside the room housing the prime mover, where so installed,
or elsewhere on the premises where the prime mover is
located outside the building.

5.6.5.6.1 The remote manual stop station shall be labeled."