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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 approximately 15 patients in 1 of 4 smoke zones. The facility has a capacity of 15 with a census of 2 at the time of survey.

Findings include:

During the survey on August 8, 2018 the following is observed:

1) At 10:28 a.m. It was observed that the south marked exit in the dining facility is blocked by tables and chairs.

2) At 10:29 a.m. It was observed that the south marked exit door across the corridor from materials management is chained shut.

Staff M1 was 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 ft2 (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 on observation, record review and interview the facility fails to ensure that the facility' automatic sprinkler system is installed, maintained and tested in accordance with NFPA 25. This deficient practice fails to ensure that the sprinkler system will be properly prepared in the event of a fire, affecting all patients in 1 of 4 smoke zones. The facility has a capacity of 15 and census of 2 at the time of the survey.

Findings include:

During the survey on August 8, 2018 the following observations were made:

At 1023 a.m. It was observed in the dry good storage room by the kitchen there are boxes stacked within 18 inches of the sprinkler head.

Staff M1 was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2012 NFPA 101, 9.7.5 Table 5.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.

Review of the following NFPA Standard revealed: Sprinklers shall be inspected from the floor level annually. 2011 NFPA 25, 5.2.1.1

Based on observation and staff interview the facility fails to assure fire extinguishers have been selected, installed and maintained in accordance with NFPA 10. This deficiency practice fails to ensure that fire extinguishers will be maintained and in proper working condition when needed in the event of a fire emergency, affecting (9) patients in 1 of 4 smoke zones. The facility has a capacity of 15 with a census of 2 at the time of survey.

Findings include:

During the survey August 8, 2018 the following observations were made:

At 11:22 a.m. It was observed there is no pressure on extinguisher number five, located next to room 109.

Staff M1 was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 2012 NFPA 101, 9.7.4.1

Based on record review and interview, the facility failed to provide documentation of the completion of the required annual inspection program of fire door assemblies. The deficient practice affects all patients, visitors and staff in 4 of 4 smoke zones. The facility has the capacity of 15 with a census of 2 at the time of this survey.

Findings include:

1) It was observed on August 7th, 2018, that the facility was unable to provide documentation of an annual inspection program of fire door assemblies as required.

Staff Member M1 revealed the facility was unaware of the requirement for an annual inspection program of the facility's fire door assemblies.

NFPA Standard: Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code. 2012 NFPA 101, 8.3.3.1

NFPA Standard: Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ; functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing; before testing, a visual inspection shall be performed to identify any damaged or missing parts that can create a hazard during testing or affect operation or resetting; fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly. 2010 NFPA 80, 5.2.

NFPA Standard: As a minimum, the following items shall be verified: (1) No open holes or breaks exist in surfaces of either the door or frame; (2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped; (3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage; (4) No parts are missing or broken; (5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7; (6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position; (7) If a coordinator is installed, the inactive leaf closes before the active leaf; (8) Latching hardware operates and secures the door when it is in the closed position; (9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame; (10) No field modifications to the door assembly have been performed that void the label. (11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity. 2010 NFPA 80, 5.2.4.2 Reference: CMS S&C 17-38

Based upon observation and staff interview, the facility fails to provide testing of the generator fuel for contaminants. This deficient practice could result in the generator not being able to run. The deficient practice could affect all patients and any staff or visitors in 4 of 4 smoke zones. The facility has a capacity of 15 with a census of 2 at the time of this survey.

Findings include:

During the survey conducted on August 7th, 2018 the following observations were made:

1) It was observed there is no documentation of a fuel test for the stored fuel in the generator to determine if there are contaminates.

Staff Member M1 was present and acknowledged the observation.

NFPA Standard: NFPA 110 2010 ed. 8.3.8 A fuel quality test shall be performed at least annually
using tests approved by ASTM standards.