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Based on observation and interview, the facility failed to provide separation of hazardous areas from other areas in the facility in accordance with National Fire Protection Association (NFPA) standards. The deficient practice affected one (1) of three (3) smoke compartments, staff, and 16 residents. The facility had the capacity for 25 beds with a census of one (1) on the day of the survey.

Findings include:

Observation, during the building inspection tour on 06/08/2023 at 12:20 PM, revealed the Clean Utility Room (room 229) was over 50 square feet, used to store combustible materials such as boxes of medical supplies and the Pyxis Machine and the door would not self-close.

Interview, on 06/08/2023 at 12:21 PM with the Director of Facilities, stated the facility was not aware the door would not self-close.

The finding was verified by the Director of Facilities at the time of observation and the Administrator at the exit conference on 06/08/2023.

Actual NFPA Standard: NFPA 101 Life Safety Code (2012), 19.3.2.1 Hazardous Areas. 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
19.3.2.1.3 The doors shall be self-closing or automatic closing.

Based on observation and interview, it was determined the facility failed to install Alcohol Based Hand Rub (ABHR) dispensers in accordance with National Fire Protection Association (NFPA) standards. The deficient practice had the potential to affect one (1) of three (3) smoke compartments, staff, 16 residents. The facility had the capacity for 25 beds with a census of one (1) on the day of the survey.

The findings include:

Observation, during the building inspection tour on 06/08/2023 at 12:30 PM, revealed an ABHR dispenser installed directly above the light switch in rooms 205 and 212.

Interview, with the Director of Facilities on 06/08/2023 at 12:31 PM, stated the facility was not aware the ABHR dispenser was installed above an ignition source.

The finding was verified by the Director of Facilities at the time of observation and the Administrator at the exit conference on 06/08/2023.


Actual NFPA Standard: NFPA 101 Life Safety Code (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

Based on observation and interview, the facility failed to provide complete coverage by an automatic fire sprinkler system for the building in accordance with National Fire Protection Association (NFPA) Standards. The deficient practice affected two (2) of three (3) smoke compartments, staff, and 16 residents. The facility had the capacity for 25 beds with a census of one (1) on the day of the survey.

The findings include:

1. Observation, during the building inspection tour on 06/08/2023 at 11:31 AM, revealed stairwells A and E were not protected by an automatic sprinkler protection system under the lowest landing at the bottom of the stairwells. Interview, on 06/08/2023 at 11:32 AM, with the Director of Facilities, stated the facility was unaware the stairwells did not have sprinkler protection as required.
2. Observation, during the building inspection tour on 06/08/2023 at 12:01 PM, revealed a shipping block had not been removed from the sprinkler head after it was installed in the Janitor Closet/Room 255. Interview, on 06/08/2023 at 12:02 PM with the Director of Facilities, stated the facility was not aware the shipping block was not removed after the sprinkler head had been installed.

The finding was verified by the Director of Facilities at the time of observation and the Administrator at the exit conference on 06/08/2023.

Actual NFPA Standard: NFPA 101 (2012 Edition), Life Safety Code, Chapter 19 Existing Healthcare Occupancies,
19.3.5 Extinguishment Requirements.
19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.

Actual NFPA Standard: NFPA 13 (2010 Edition), Standard for the Installation of Sprinkler Syste

Based on observation and interview, the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) standards. The deficient practice had the potential to affect three (3) of three (3) smoke compartments, staff, and all residents. The facility had the capacity for 25 beds with a census of one (1) on the day of survey.

The findings include:

Observation, during the building inspection tour on 06/08/2023 at 11:54 AM, revealed the facility failed to calibrate or replace the sprinkler gauges every five (5) years. The gauges on the sprinkler standpipe in Stairwell E was marked as being installed in 1993.

Interview, on 06/08/2023 at 11:55 AM, with the Director of Facilities, stated the facility was not aware the sprinkler system was not properly inspected.

The finding was verified by the Director of Facilities at the time of observation and the Administrator at the exit conference on 06/08/2023.

Actual NFPA Standard: NFPA 101, 9.7.5 Maintenance and Testing. 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.
Actual NFPA Standard: NFPA 25, 5.1.1.1 This chapter shall provide the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems.
5.1.1.2 Table 5.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.
Table 5.1.1.2 Summary of Sprinkler System Inspection, Testing, and Maintenance
Inspection
Gauges (dry, preaction, and deluge systems)
Weekly/monthly 5.2.4.2, 5.2.4.3, 5.2.4.4
Control valves Table 13.1
Waterflow alarm devices Quarterly

Based on observation and interview, it was determined the facility failed to maintain doors protecting corridors in accordance with National Fire Protection Association (NFPA) standards. The deficient practice affected one (1) of three (3) smoke compartments, staff, and one (1) resident. The facility had the capacity for 25 beds with a census of one (1) on the day of survey.

The findings include:

Observation, during the building inspection tour on 06/08/2023 at 12:38 PM, revealed the corridor door to room 221 failed to latch in the door frame and provide the door with a means of keeping the door closed.

Interview, on 06/08/2023 at 12:39 PM with the Director of Facilities, stated the facility was not aware the door would not latch.

The finding was verified by the Director of Facilities at the time of observation and the Administrator at the exit conference on 06/08/2023.

Actual NFPA Standard: NFPA 101 Life Safety Code (2012)
19.3.6.3% Corridor Doors.
19.3.6.3.1 * Doors, including doors or panels to nurse servers and pass-through openings, protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following:
1. 13? 4 in. thick, solid-bonded wood core
2. Material that resists fire for a minimum of 20 minutes.

19.3.6.3.5 * Doors shall be provided with a means for keeping the door closed, 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 aut

Based on observation and interview, it was determined the facility failed to ensure smoke barriers could restrict the transfer of smoke in accordance with National Fire Protection Association (NFPA) Standards. The deficient practice affected three (3) of three (3) smoke compartments, staff, and all residents. The facility had the capacity for 25 beds with a census of one (1) on the day of survey.

The findings include:

1. Observation, during the building inspection tour, on 06/08/2023 at 11:10 AM, revealed the smoke barrier wall located above cross-corridor doors by room 235 had a 12 by 12 inch penetration around duct work and a one (1) inch conduit not sealed to resist the passage of smoke. Interview, on 06/08/2023 at 11:11 AM with the Director of Facilities, stated the facility was not aware of the penetrations in the smoke barrier.
2. Observation, during the building inspection tour, on 06/08/2023 at 11:20 AM, revealed the smoke barrier wall located above the cross-corridor doors by room 229 had three (3) unsealed pipe sleeve penetrations not sealed inside the sleeve to resist the passage of smoke. Interview, on 06/08/2023 at 11:21 AM with the Director of Facilities, stated the facility was not aware of the penetrations in the pipe sleeves.
3. Observation, during the building inspection tour, on 06/08/2023 at 11:24 AM, revealed the smoke barrier wall located above the cross-corridor doors by room 230 had a six (6) inch and a three (3) inch unsealed penetration that wound not resist the passage of smoke. Interview, on 06/08/2023 at 11:25 AM with the Director of Facilities, stated the facility was not aware of the penetrations in the smoke barrier.
4. Observation, during the building inspection tour, on 06/08/2023 at 11:27 AM, revealed the smoke barrier wall located above the cross-corrid

Based on observation and interview, the facility failed to ensure portable space heaters used in the facility were in accordance with National Fire Protection Association (NFPA) standards. The deficient practice affected one (1) of three (3) smoke compartments, staff, and six (6) residents. The facility has the capacity for 25 beds with a census of one (1) on the day of survey.

Findings include:

Observation, during the building inspection tour on 06/08/2023 at 11:58 AM, revealed the facility failed to provide documentation that a heat producing portable heater located in the Medical Records Office had a heating element that did not exceed 212 degrees Fahrenheit.

Interview, on 06/08/2023 at 11:59 AM with the Director of Facilities, stated the facility was aware of the requirements for portable heaters but was not aware the heater had been brought into the facility.


The finding was verified by the Director of Facilities at the time of observation and the Administrator at the exit conference on 06/08/2023.


Actual NFPA Standard: NFPA 101 Life Safety Code (2012)
19.7.8 Portable Space-Heating Devices. Portable space heating devices shall be prohibited in all health care occupancies, unless both of the following criteria are met:
(1) Such devices are used only in nonsleeping staff and employee areas.
(2) The heating elements of such devices do not exceed 212°F (100°C).

Based on record review and interview the facility failed to perform testing for the emergency generators. The deficient practice affected three (3) of three (3) smoke compartments, staff, and all residents. The facility had the capacity for 25 beds with a census of one (1) on the day of survey.

Findings include:

Record review, of the monthly generator documentation on 06/08/2023 at 1:00 PM with the Director of Facilities revealed the facility did not document the transfer times during the monthly generator testing.

Interview on 06/08/2023 at 1:01 PM with the Director of Facilities, stated the facility was not aware the transfer times were not being documented.

The finding was verified by the Director of Facilities at the time of observation and the Administrator at the exit conference on 06/08/2023.

Actual NFPA Standard: NFPA 99 (2012) Health Care Facilities Code
6.4.3.1 Source. The life safety and critical branches shall be installed and connected to the alternate power source specified in 6.4.1.1.4 and 6.4.1.1.5 so that all functions specified herein for the life safety and critical branches are automatically restored to operation within 10 seconds after interruption of the normal source.