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Based on observation and staff interview, the facility fails to assure that the 2-hours rated fire barrier is free of penetrations and openings. The deficient practice compromises the fire resistance rating of the 2 hour floor and ceiling, affecting all residents and staff in the skilled nursing facility and staff and visitors in 2 of 11 smoke zones. The facility has a capacity of 28 and a census of 2 at the time of the survey.

Findings Include:

During the portion of the survey conducted on 12/28/18, at 11:07 a.m., observation of the designated 2-hour wall above the classroom, revealed two areas where non-approved expanding foam has been used to seal penetrations.

Staff M-1, Staff M-2 and Staff A-1 were present and acknowledged the finding.

NFPA Standard: Multiple occupancies shall be in accordance with 6.1.14. Sections of health care facilities shall be permitted to be classified as other occupancies in accordance with the separated occupancies provisions of 6.1.14.4 and either 19.1.3.3 or 19.1.3.4. Sections of health care facilities shall be permitted to be classified as other occupancies, provided that they meet all of the following conditions: (1) They are not intended to provide services simultaneously for four or more inpatients for purposes of housing, treatment,
or customary access by inpatients incapable of self-preservation. (2) They are separated from areas of health care occupancies by construction having a minimum 2-hour fire resistance rating in accordance with Chapter 8. (3) For other than previously approved occupancy separation arrangements, the entire building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. NFPA (2012) 19.1.3.1, 19.1.3.2, 19.1.3.3, 19.1.3.

Based on observation, record review and interview, this facility is not providing a firewall with a two-hour fire rating between the nursing home hospital and an independent business portion of the facility in accordance with 8.2.1.3. The deficient practice does not provide separation of healthcare portion of the facility from non-healthcare occupancies, affecting all patients, visitors and staff in 2 of 11 smoke zones. The facility has a capacity of 28 and a census of 2 at the time of this survey.

Findings Include:

During the portion of the tour conducted on 12/28/18, at 10:40 a.m., it is observed:

-- 1. The former geriatric care unit (decommissioned) has recently been converted to a private business wellness spa. There is no 2-hour separation between the hospital and this new, independent business.

Staff M-1, Staff M-2 and Staff A-1 were present and acknowledged the finding.

NFPA Standard: Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition. (See 4.6.7 and 4.6.11.) Communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire door assemblies. (See also Section 8.3.) 2012 NFPA 101 19.1.1.4.1

Based on observation and staff interview the facility fails to ensure that all means of egress are free of all obstructions or impediments to a full instant use. This deficient practice could impede occupants from exiting in the event of a fire or other emergency situation, affecting all residents in 2 of 11 smoke zones. The facility has a capacity of 28 with a census of 2 at the time of survey.

Findings include:

During the portion of the survey conducted on 12/28/18, at the former geriatric care unit, now a non-separated wellness center, between 11:27 a.m. and 11:49 a.m., it is observed:

-- 1. The south exit door has been covered with a vinyl surface potentially disguising the door as an exit.

-- 2. Various combustible seasonal decorations are displayed on both sides of the corridor.

-- 3. Several of the former patient room doors have been removed. The doors have been either replaced with non-latching "barn door" style doors or have no door in place. Corridor doors remaining have been covered with decorative wood with no documented proof that the finish is flame retardant.

-- 4. Former patient room currently designated "Power Stride Fitness Training" is being used as a storage room for construction materials and equipment. There is no self-closing device on the door.

Staff M-1, Staff M-2 and Staff A-1 were present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: Any required aisle, corridor, or ramp shall be not less than 48 in. (1220 mm) in clear width where serving as means of egress from patient sleeping rooms, unless otherwise permitted by one of the following:
(1) Aisles, corridors, and ramps in adjunct areas not intended for the housing, treatment, or use of inpatients shall be not less than 44 in. (1120 mm) in clear and unobstructed width.
(2) Where corridor width is at least 6 ft (1830 mm), noncontinuous projections not more than 6 in. (150 mm) from the corridor wall, above the handrail height, shall be permitted.
(3) Exit access within a room or suite of rooms complying with the requirements of 19.2.5 shall be permitted.
(4) Projections into the required width shall be permitted for wheeled equipment, provided that all of the following conditions are met:
(a) The wheeled equipment does not reduce the clear unobstructed corridor width to less than 60 in. (152.5 mm).
(b) The health care occupancy fire safety plan and training program address the relocation of the wheeled equipment during a fire or similar emergency.
(c) The wheeled equipment is limited to the following:
i. Equipment in use and carts in use
ii. Medical emergency equipment not in use
iii. Patient lift and transport equipment
(5) Where the corridor width is at least 8 ft (2440 mm), projections into the required width shall be permitted for fixed furniture, provided that all of the following conditions are met:
(a) The fixed furniture is securely attached to the floor or to the wall.
(b) The fixed furniture does not reduce the clear unobstructed corridor width to less than 6 ft (1830 mm), except as permitted by 19.2.3.4(2).
(c) The fixed furniture is located only on one side of the corridor.
(d) The fixed furniture is grouped such that each grouping does not exceed an area of 50 sq. ft. (4.6 m2).
(e) The fixed furniture groupings addressed in 19.2.3.4(5) (d) are separated from each other by a distance of at least 10 ft (3050 mm).
(f) The fixed furniture is located so as to not obstruct access to building service and fire protection equipment.
(g) Corridors throughout the smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the fixed furniture spaces are arranged and located to allow direct supervision by the facility staff from a nurses' station or similar space.
(h) The smoke compartment is protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.8. 2012 NFPA 101, 19.2.3.4

Based upon observation and staff interview, the facility fails to assure that hazardous areas are separated from other spaces by smoke resisting partitions and doors. The deficient practice fails to provide solid, smoke resisting walls or ceiling in hazardous areas which would not stop the spread of smoke, affecting all residents or patients and any visitors or staff in 2 of 11 smoke zones. The facility has a capacity of 28 with a census of 2 at the time of this survey.

Findings include:

During the portion of the tour conducted on 12/28/18, at 10:40 a.m. in the room designated as I.T. Storage, ceiling tiles are missing. Missing ceiling tiles would not prevent the passage of fire or smoke to other areas of the building.

Staff M-1, Staff M-2 and Staff A-1 affirmed the observations and findings at the time of discovery.

NFPA Standard: 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 non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. 2012 NFPA 101 19.3.2.1

Based on record review, observation and staff interview, this facility is not maintaining the sprinkler system in accordance with the 2012 edition of NFPA 25, and the 2010 edition of NFPA 13 by not maintaining the system with an acceptable clearance around sprinkler heads to prevent obstructions to spray patterns. This deficient practice could affect the operation of the heads by obstructing spray patterns, delaying the response time or preventing the operation of the heads that can compromise the effectiveness of the fire suppression system, affecting all residents, patients, visitors and staff in 1 of 11 smoke zones. The facility has a capacity of 28 with a census of 2 at the time of this survey.

Findings include:

During the portion of the tour conducted on 12/28/18, at 11:31 a.m. it is observed:

-- 1. In the former geriatric care unit and now a non-separated wellness center, in the massage room, ceiling is completely covered with draped fabric, all within 18" of the sprinkler head deflectors.

Staff M-1, Staff M-2 and Staff A-1 were present and acknowledged the findings.

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: Obstructions shall not prevent sprinkler discharge from reaching the protected area. Continuous or non-continuous obstructions that interrupt the water discharge in a horizontal plane more than 18 inches below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with this section. The requirements of this section shall also apply to obstructions 18 in. or less below the sprinkler for light and ordinary hazard occupancies per NFPA 13, 5-6.5.3.

Based on observation and staff interview, the facility did not ensure that electrical wiring and equipment is installed and maintained in accordance with NFPA 70, National Electrical Code. This deficient practice does not ensure prevention of an electrical fire or electric shock hazard, affecting no patients and any visitors or staff in 2 of 11 smoke zones. The facility has a capacity of 28 with a census of 2 at the time of this survey.

Findings include:

During the portion of the tour conducted on 12/28/18, in the former geriatric care unit and now a non-separated wellness center, it is observed:

-- 1. Between 11:23 a.m. and 11:28 a.m. observation above the dropped ceiling revealed multiple cords and cables not protected by junction boxes or conduit.

-- 2. At 11:33 a.m.,, in the employee locker room, that an outlet is within 6' of the hand sink and is not protected with a Ground Fault Circuit Interrupter (GFCI)

Staff M-1, Staff M-2 and Staff A-1 were present and acknowledged the findings.

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 interview, the facility fails to prohibit the use of portable space heating devices within the facility without assurance that heating elements do not exceed 212 degrees Fahrenheit. The deficient practice would affect no patients and any visitors or staff in 1 of 11 smoke zones. The facility has a capacity of 28 and a census of 2 residents at the time of the survey.

Findings include:

During the portion of the tour conducted on 12/28/18, at 11:42 a.m., in the former geriatric care unit now a non-separated wellness center, in the room designated as "Gathering Place", is a wall-mounted faux-fireplace space heater. Specification sheets on the space heater showing the heating element would not exceed 212 degrees Fahrenheit (100 degrees Celsius) were not available at the time of inspection.

Staff M-1, Staff M-2 and Staff A-1 were present and acknowledged the findings.

NFPA Standard: Prohibits the use of portable space heating devices in healthcare occupancies except for nonresident and staff sleeping areas with heating elements that exceed 212 degrees. 2012 NFPA 101, 18/19.7.8

Based on observation and staff interview, the facility failed to properly protect and store compressed gasses as required by NFPA 99. The deficient practice could affect approximately 2 patients and any visitors or staff in 1 of 11 smoke zones. The facility has a capacity of 28 with a census of 2 at the time of the survey.

Findings include:

During the portion of the survey conducted on 12/28/18, at 12:31 p.m., in the respiratory therapy room, it is observed that oxygen cylinders are store in crates not composed of non or limited combustible material.

Staff M-1, Staff M-2 and Staff A-1 were 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.