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Based on observation, operational testing and interview, the facility failed to ensure that hazardous areas were protected with self-closing doors. Failure to provide self-closing doors for hazardous areas would allow smoke and dangerous gases to pass freely into corridors and hinder egress during a fire event. This deficient practice affected staff and visitors on the date of the survey. The facility is licensed for 15 beds with a census of 7 on the day of the survey.

Findings include:

During the facility tour on September 11, 2015 at approximately 2:00 PM, observation and operational testing revealed two sets of doors leading from the corridor to the cafeteria/kitchen area were not equipped with self closing devices. When asked, the Director of Engineering stated the facility was unsure the doors needed to be on self closures.


Actual NFPA Standard:
18.3.2.1* Hazardous Areas.
Any hazardous area shall be protected in accordance with Section 8.4. The areas described in Table 18.3.2.1 shall be protected as indicated.

3.3.13.2 Area, Hazardous.
An area of a structure or building that poses a degree of hazard greater than that normal to the general occupancy of the building or structure, such as areas used for the storage or use of combustibles or flammables; toxic, noxious, or corrosive materials; or heat-producing appliances.

8.4.1.1*
Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42.

Based on record review and interview, the facility failed to ensure that fire suppression systems were tested and maintained in accordance with NFPA 25. Failure to properly test, inspect and maintain the sprinkler systems could result in the system not performing as designed during a fire event. This deficient practice affected all patients, staff and visitors on the date of the survey. The facility is licensed for 15 beds with a census of 7 on the day of the survey.

Findings Include:

During record review on September 11, 2015 at approximately 10:00 AM, the facility was unable to provide documented 5 year internal piping inspection reports of the automatic sprinkler system. When asked, the maintenance supervisor stated they were unaware of the 5 year internal piping inspection requirements.

Actual NFPA standards:

NFPA 25, 10-2.2 Obstruction Prevention.
Systems shall be examined internally for obstructions where conditions exist that could cause obstructed piping. If the condition has not been corrected or the condition is one that could result in obstruction of piping despite any previous flushing procedures that have been performed, the system shall be examined internally for obstructions every 5 years. This investigation shall be accomplished by examining the interior of a dry valve or preaction valve and by removing two cross main flushing connections.

Based on record review and interview, the facility failed to provide continuing safety education for the laboratory. Failure to provide continuing education could prohibit the facilities ability to effectively deal with the care, health and safety of staff and other individuals should a laboratory emergency occur. This deficient practice affected laboratory staff only of the date of survey. The facility has the capacity for 15 beds with a census of 7 the day of survey.

Findings include:

During laboratory record review on September 11, 2015 at approximately 11:00 PM, record review revealed the facility could not provide continuing safety education for the employees in the laboratory. When asked, the Laboratory Manager stated the facility does conduct continuing education for staff but the records were not available to view.

Actual NFPA Standard: NFPA 99, Chapter 10, Laboratories

10-2.1.4.2 Continuing safety education and supervision shall be provided, incidents shall be reviewed monthly, and procedures shall be reviewed annually.

Based on observation, operational testing and interview, the facility failed to ensure that hazardous areas were protected with self-closing doors. Failure to provide self-closing doors for hazardous areas would allow smoke and dangerous gases to pass freely into corridors and hinder egress during a fire event. This deficient practice affected staff and visitors on the date of the survey. The facility is licensed for 15 beds with a census of 7 on the day of the survey.

Findings include:

During the facility tour on September 11, 2015 at approximately 2:00 PM, observation and operational testing revealed two sets of doors leading from the corridor to the cafeteria/kitchen area were not equipped with self closing devices. When asked, the Director of Engineering stated the facility was unsure the doors needed to be on self closures.


Actual NFPA Standard:
18.3.2.1* Hazardous Areas.
Any hazardous area shall be protected in accordance with Section 8.4. The areas described in Table 18.3.2.1 shall be protected as indicated.

3.3.13.2 Area, Hazardous.
An area of a structure or building that poses a degree of hazard greater than that normal to the general occupancy of the building or structure, such as areas used for the storage or use of combustibles or flammables; toxic, noxious, or corrosive materials; or heat-producing appliances.

8.4.1.1*
Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42.

Based on record review and interview, the facility failed to ensure that fire suppression systems were tested and maintained in accordance with NFPA 25. Failure to properly test, inspect and maintain the sprinkler systems could result in the system not performing as designed during a fire event. This deficient practice affected all patients, staff and visitors on the date of the survey. The facility is licensed for 15 beds with a census of 7 on the day of the survey.

Findings Include:

During record review on September 11, 2015 at approximately 10:00 AM, the facility was unable to provide documented 5 year internal piping inspection reports of the automatic sprinkler system. When asked, the maintenance supervisor stated they were unaware of the 5 year internal piping inspection requirements.

Actual NFPA standards:

NFPA 25, 10-2.2 Obstruction Prevention.
Systems shall be examined internally for obstructions where conditions exist that could cause obstructed piping. If the condition has not been corrected or the condition is one that could result in obstruction of piping despite any previous flushing procedures that have been performed, the system shall be examined internally for obstructions every 5 years. This investigation shall be accomplished by examining the interior of a dry valve or preaction valve and by removing two cross main flushing connections.