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Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other spaces. The area of deficient practice would provide a path for smoke and fire to travel into the adjacent area, affecting patients and staff in 3 of 12 smoke zones. The facility has a capacity of 58 with a census of 39 at the time of survey.

Findings include:

During the survey on February 22, 2018 the following is observed:

1.At 9:32 am is observed that linens are being stored room E 206 this room. is not properly rated for the storage of combustible.

2.At 9:48 am is observed that combustibles such as boxes are being stored in mechanical room 6

3.At 10:10 am is observed that the doors to linen room 3, did not self close and latch.

The Administrator and Maintenance Director was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: Any hazardous areas shall be safeguarded by a fire barrier having a 1 hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. 2012 NFPA 101, 19.3.2.1

Review of the following NFPA Standard revealed: An automatic extinguishing system, where used in hazardous areas, shall be permitted to be in accordance with 19.3.5.9. 2012 NFPA 101, 19.3.2.1.1

Review of the following NFPA Standard revealed: Where the sprinkler option of19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4. 2012 NFPA 101,19.3.2.1.2

Review of the following NFPA Standard revealed: The doors shall be self-closing or automatic-closing. 2012
NFPA 101, 19.3.2.1.3

Based on observation and interviews, the facility fails to ensure that the facility's automatic sprinkler system is installed in accordance with NFPA 13 and maintained in accordance with NFPA 25. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting staff and patients in 1 of the 12 smoke zones. The facility has a capacity of 58 with a census of 39 at the time of survey.

During the tour on February 22, 2018 the following is observed:

At 9:40: AM, it is observed that storage has been placed within 10" of the sprinkler head in the Pharmacy storage room.

The Administrator and Maintenance Director was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall). 2011 NFPA 25, 5.2.1.1.1

Based on observation and staff interview the facility is not ensuring that room doors latch properly. This deficient practice of not ensuring that room doors latch properly prevents the ability of the facility to properly confine fire and smoke products and to properly defend occupants in place, affecting patients and staff in 1 of 12 smoke zones. The facility has a capacity of 58 with a census of 39 at the time of survey.

Findings include:

During the survey on February 22,2018 the following is observed:

1. At 9:50 am the door to room W 212 from corridor did not latch

The Administrator and Maintenance Director was present during the survey and acknowledged the findings.

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

Based on observation and staff interviews, the facility fails to maintain smoke barriers to at least one hour fire resistance. This deficient practice would cause containment of fire and smoke, affecting patients and staff in 10 of 12 smoke zones. The facility has a capacity of 58 with a census of 39 at the time of survey.
Findings include:

During the survey on February 22,2018 the following is observed:

1.At 10:45 am, it is observed that the smoke barriers corridor wall from admissions to receiving, above double doors in the attic space, has a penetration in the end of a 3/4" conduit pipe.

2. At 11:15 am, it is observed that the smoke barriers corridor 100 by room E 104, above double doors in the attic space, has a penetration around a 1/2" conduit pipe.

3. At 11:25 am, it is observed that the smoke barrier wall to intermediate care across from the telemetry nursing station in the attic space, has a penetration around a IT cable run.

4.At 11:45 am, it is observed that the smoke barriers corridor wall from ICU north to nursing station, above double doors in the attic space, has a penetration in the end of a 2" conduit pipe.

5.At 12:10 am, it is observed that the smoke barriers corridor wall by 103 and 104, by the double doors in the attic space, has a penetration in the end of a 4" conduit pipe.

The Administrator and Maintenance Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1 hour fire resistance rating, unless otherwise permitted by one of the following:
(1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply:
(a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1) (c).
(b) Not less than two separate smoke compartments shall be provided on each floor.

(2)*Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier.
19.3.7.4 Reserved.

Based on observation and record review, the facility fails to maintain fire dampers in heating, ventilation and air conditioning assemblies as required. This deficient practice of not identifying, testing and maintaining fire dampers as required, increases the risk fire affecting patients and staff in all 12 smoke zones. The facility has a capacity of 58 and census of 39 at the time of the survey.

Findings include:

A record review on February 21,2018 between 1:30 PM and 4:00 PM, revealed no documentation of fire and smoke damper testing and maintenance.

The Administrator and Maintenance Director was present during the survey and record review and acknowledged the findings.

Review of the following NFPA Standard revealed: Where required by the provisions of another section of this Code, smoke control systems shall be installed, inspected, tested, and maintained in accordance with NFPA 92, Standard for Smoke Control Systems; NFPA 204, Standard for Smoke and Heat Venting; or nationally recognized standards, engineering
guides, or recommended practices, as approved by the authority having jurisdiction.
2012 NFPA 101, 9.3.1

Review of the following NFPA Standard revealed: The building owner shall be responsible for all systems testing and shall maintain records and all periodic testing and maintenance in accordance with the operation and maintenance manual.
2012 NFPA 92, 7.3.4

Review of the following NFPA Standard revealed: Smoke dampers for dedicated and non-dedicated smoke controls systems shall be inspected and tested in accordance with NFPA 92A (standard for smoke -control systems unitizing barriers and pressure differences).
2010 NFPA 105, 6.5.1

Review of the following NFPA Standard revealed: Each damper shall be tested and inspected one year after insulation, the test and inspection frequency shall then be every 4 years except for hospitals, where the frequency shall be every 6 years.
2010 NFPA 105,6.5.2*

Based on record review and staff interview, the facility is not conducting fire drills as required and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency, affecting all patients and staff in all 12 smoke zones. The facility has a capacity of 58 with a census of 36 at the time of survey.

Findings include:

1.It is observed during record review of the facility's fire drill documentation on February 21,2018 between 1:30 pm and 4:00 pm, The facility's fire drill record for the previous 12 months revealed that no fire drill was conducted on the 1st shift of the 2nd quarter.

The Administrator and Maintenance Director was present during the survey and record review and acknowledged the findings.

Review of the following NFPA Standard revealed: 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

Review of the following NFPA Standard revealed: 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. 2012 NFPA 101, 19.7.1.6