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Based on observation and staff interview, the facility failed to ensure that doors to ancillary areas are capable of resisting the passage of smoke. This deficient practice would not prevent the spread of fire and smoke products from entering the corridor, affecting three of five smoke zones. This facility has a capacity of 25 and census of 12 residents.

Findings Include:

During the tour from 8/29/16 to 8/30/16 it is noted that:

1. On 8/29/16 at 11:50 AM the latching hardware was removed from the day surgery clean utility room.
2. On 8/29/16 at 10:08 AM kitchen corridor door failed to latch when tested.
3. On 8/29/16 at 3:05 PM consultation rooms #1 and #2 were observed wedged open.

The maintenance director was present during the findings.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3.

Based on observation and staff interview the facility fails to maintain one of four smoke barriers to at least one half hour fire resistance and ensure that all penetrations are properly sealed. This deficient practice would prevent containment of fire and smoke, affecting four of five smoke zones. This facility has a capacity of 25 and census of 12 residents.

Findings Include:

During the tour from 8/29/16 to 8/30/16 it is noted that:

1. At 1:35 PM on 8/29/16 an unsealed 3 " opening around flex conduit above the double doors in the hot water heater room.
2. At 3:03 PM on 8/29/16 a 1 " unsealed gap around conduit in the south side of the smoke barrier wall near the infection control office.
3. At 3:04 PM on 8/29/16 two 3 " open pass through conduits in the south side of the smoke barrier wall near the infection control office.
4. At 3:05 PM on 8/29/16 a 2 " unsealed gap between drywall pieces near the roof deck in the south side of the smoke barrier wall near the infection control office.
5. At 3:11 PM on 8/29/16 a 1 " unsealed gap around flex conduit in the west side of the smoke barrier wall above the womens locker room.
6. At 3:15 PM on 8/29/16 two 3 " open pass through pipes in the north side of the smoke barrier wall above the surgery entrance.
7. At 3:18 PM on 8/29/16 two 1 " unsealed gaps around conduits in the east side of the smoke barrier wall near the consultation rooms.

The maintenance director was present during the findings.

NFPA Standard: Requires smoke walls to have a fire resistance rating of at least a half hour and to be continuous from floor to roof deck and from outside wall to outside wall. 2000 NFPA 101, 19.3.7.3.

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1.

Based on observation and staff interview, the facility failed to provide means of egress that are maintained free of all obstructions or impediments to a full instant use in case of fire or other emergency. The deficient practice would prevent these exits from being arranged so that they are readily available and accessible, affecting exit from two of five smoke zones. The facility has a capacity of 25 with a census of 12 at the time of survey.

Findings Include:

During the tour from 8/29/16 to 8/30/16 it is noted that:

1. At 12:23 PM on 8/29/16 thumb turn locks installed on the west (x3) horizontal sliding breakaway doors near the ER entrance. When locked the doors did not open allowing egress.

The maintenance director was present during the findings.

NFPA Standard: Exits and exit access shall be located and arranged so that exits are readily accessible at all times. 2000 NFPA 101, 7.5.1.1
NFPA Standard: Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1

Based on observation and staff interview the facility failed to provide adequate emergency lighting as required. The deficient practice could leave the ER rooms without illumination during a disruption of normal power or in the event of an emergency, affecting one of five smoke zones. The facility has a capacity of 25 with a census of 12.

Findings Include:

During the tour from 8/29/16 to 8/30/16 it is noted that:

1. At 2:00 PM on 8/29/16 emergency lights in OR #2 (x2) and OR #1 (X1) failed to illuminate when tested.

The maintenance director was present during the findings.

NFPA Standard: Emergency lighting for means of egress shall be provided in accordance with Section 7.9 for the following: buildings or structures where required by the occupancy chapters, underground and windowless structures as required by Section 11.7, high rise buildings as required by other sections of this Code, doors equipped with delayed egress locks, and stair shaft and vestibules of smoke proof enclosures. For the purposes of this requirement, exit access shall include designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit and exit discharge shall include designated stairs, ramps, aisles, walkways, and escalators leading to a public way. 2000 NFPA 101, 7.9.1.1.

NFPA Standard: Emergency illumination shall be provided for not less than 1 1/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 foot candle. 2000 NFPA 101, 7.9.2.1.

Based on record review and staff interview, the facility is not conducting fire drills as required quarterly on each shift 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 five of five smoke zones. The facility has a capacity of 25 with a census of 12.

Findings Include:

During the tour from 8/29/16 to 8/30/16 it is noted that:

1. At 10:07 AM on 8/29/16 no participant signature sheet provided for the drill held on 8/6/16.
2. At 10:10 AM on 8/29/16 fire drills held for first shift on 9/29/15, 10/27/15, 3/17/16 and 4/13/16 were all conducted within an hour and a half of each other.

The maintenance director was present during the findings.

NFPA Standard: Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 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. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 2000 NFPA 101, 19.7.1.2.

Based on observation, staff interview and record review, the facility failed to ensure that the kitchen portable deep fryer is protected as required in NFPA 96. The deficient practice would allow the grease laden vapors created by the deep fryer to accumulate uncontrolled, affecting one of five smoke zones. The facility has a capacity of 25 with a census of 12 at the time of survey.

Findings Include:

During the tour from 8/29/16 to 8/30/16 it is noted that:

1. At 12:23 PM on 8/29/16 a portable deep fryer was observed sitting on the kitchen prep table. Staff indicated that it was used on the table top without hood suppression coverage.

The maintenance director was present during the findings.

NFPA Standard: Cooking equipment that produces grease-laden vapors (such as, but not limited to, deep fat fryers, ranges, griddles, broilers, woks, tilting skillets, and braising pans) shall be protected by fire-extinguishing equipment. 1998 NFPA 96, 7-1.2

Based on record review and staff interview the facility failed to assure that portable space heaters being used within the facility are code compliant. This deficient practice could cause a fire due to excessive heat, affecting one of five smoke zones. This facility has a capacity of 25 and a census of 12.

FINDINGS INCLUDE:

During the tour from 8/29/16 to 8/30/16 it is noted that:
1. At 11:55 AM on 8/29/16 a portable space heater observed plugged in under the nurse desk in the post op patient care area.
2. At 11:59 AM on 8/29/16 a written portable space heater policy is not available for review.

The maintenance director was present during the findings.

NFPA Standard: Prohibits the use of portable space heating devices in non-resident and staff sleeping areas with heating elements that exceed 212 degrees. 2000 NFPA 101, 18/19.7.8

Based on observation, staff interview and record review, the facility failed to install and maintain the emergency generator power supply as required. The deficient practice may prevent the remote shut down of the generator in the event of an emergency, affecting five of five smoke zones. The facility has a capacity of 25 with a census of 12 at the time of survey.

Findings Include:

During the tour from 8/29/16 to 8/30/16 it is noted that:


1. At 9:45 AM on 8/29/16 generator load transfer time are not documented.
2. At 11:07 AM on 8/29/16 no remote generator shutoff provided.

The maintenance director was present during the findings.



NFPA Standard: All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building. 1999 NFPA 110 3-5.5.6*
NFPA Standard: For Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified. 1999 NFPA 110 A-3-5.5.6
NFPA Standard: The generator shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. 1999 NFPA 99, 3-4.1.1.8, 3-5.1 and 3-6.1

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 one of five smoke zones. This facility has a capacity of 25 and a census of 12.

Findings Include:

During the tour from 8/29/16 to 8/30/16 it is noted that:

1. Combustible materials stored within 36 " of the electrical panel in the emergency electrical room.

The maintenance director was present during the findings.

NFPA Standard: The width of the working space in front of the electrical equipment shall be the width of the equipment or 30 in. (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of the equipment doors or hinged panels. Minimum clear distance required for the working space of an electrical panel is 3 to 4 feet. 1999 NFPA 70, 110-26 (a)(1)(2).

Based on observation and staff interview, the facility failed to ensure that doors to ancillary areas are capable of resisting the passage of smoke. This deficient practice would not prevent the spread of fire and smoke products from entering the corridor, affecting three of five smoke zones. This facility has a capacity of 25 and census of 12 residents.

Findings Include:

During the tour from 8/29/16 to 8/30/16 it is noted that:

1. On 8/29/16 at 11:50 AM the latching hardware was removed from the day surgery clean utility room.
2. On 8/29/16 at 10:08 AM kitchen corridor door failed to latch when tested.
3. On 8/29/16 at 3:05 PM consultation rooms #1 and #2 were observed wedged open.

The maintenance director was present during the findings.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3.

Based on observation and staff interview the facility fails to maintain one of four smoke barriers to at least one half hour fire resistance and ensure that all penetrations are properly sealed. This deficient practice would prevent containment of fire and smoke, affecting four of five smoke zones. This facility has a capacity of 25 and census of 12 residents.

Findings Include:

During the tour from 8/29/16 to 8/30/16 it is noted that:

1. At 1:35 PM on 8/29/16 an unsealed 3 " opening around flex conduit above the double doors in the hot water heater room.
2. At 3:03 PM on 8/29/16 a 1 " unsealed gap around conduit in the south side of the smoke barrier wall near the infection control office.
3. At 3:04 PM on 8/29/16 two 3 " open pass through conduits in the south side of the smoke barrier wall near the infection control office.
4. At 3:05 PM on 8/29/16 a 2 " unsealed gap between drywall pieces near the roof deck in the south side of the smoke barrier wall near the infection control office.
5. At 3:11 PM on 8/29/16 a 1 " unsealed gap around flex conduit in the west side of the smoke barrier wall above the womens locker room.
6. At 3:15 PM on 8/29/16 two 3 " open pass through pipes in the north side of the smoke barrier wall above the surgery entrance.
7. At 3:18 PM on 8/29/16 two 1 " unsealed gaps around conduits in the east side of the smoke barrier wall near the consultation rooms.

The maintenance director was present during the findings.

NFPA Standard: Requires smoke walls to have a fire resistance rating of at least a half hour and to be continuous from floor to roof deck and from outside wall to outside wall. 2000 NFPA 101, 19.3.7.3.

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1.

Based on observation and staff interview, the facility failed to provide means of egress that are maintained free of all obstructions or impediments to a full instant use in case of fire or other emergency. The deficient practice would prevent these exits from being arranged so that they are readily available and accessible, affecting exit from two of five smoke zones. The facility has a capacity of 25 with a census of 12 at the time of survey.

Findings Include:

During the tour from 8/29/16 to 8/30/16 it is noted that:

1. At 12:23 PM on 8/29/16 thumb turn locks installed on the west (x3) horizontal sliding breakaway doors near the ER entrance. When locked the doors did not open allowing egress.

The maintenance director was present during the findings.

NFPA Standard: Exits and exit access shall be located and arranged so that exits are readily accessible at all times. 2000 NFPA 101, 7.5.1.1
NFPA Standard: Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1

Based on observation and staff interview the facility failed to provide adequate emergency lighting as required. The deficient practice could leave the ER rooms without illumination during a disruption of normal power or in the event of an emergency, affecting one of five smoke zones. The facility has a capacity of 25 with a census of 12.

Findings Include:

During the tour from 8/29/16 to 8/30/16 it is noted that:

1. At 2:00 PM on 8/29/16 emergency lights in OR #2 (x2) and OR #1 (X1) failed to illuminate when tested.

The maintenance director was present during the findings.

NFPA Standard: Emergency lighting for means of egress shall be provided in accordance with Section 7.9 for the following: buildings or structures where required by the occupancy chapters, underground and windowless structures as required by Section 11.7, high rise buildings as required by other sections of this Code, doors equipped with delayed egress locks, and stair shaft and vestibules of smoke proof enclosures. For the purposes of this requirement, exit access shall include designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit and exit discharge shall include designated stairs, ramps, aisles, walkways, and escalators leading to a public way. 2000 NFPA 101, 7.9.1.1.

NFPA Standard: Emergency illumination shall be provided for not less than 1 1/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 foot candle. 2000 NFPA 101, 7.9.2.1.

Based on record review and staff interview, the facility is not conducting fire drills as required quarterly on each shift 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 five of five smoke zones. The facility has a capacity of 25 with a census of 12.

Findings Include:

During the tour from 8/29/16 to 8/30/16 it is noted that:

1. At 10:07 AM on 8/29/16 no participant signature sheet provided for the drill held on 8/6/16.
2. At 10:10 AM on 8/29/16 fire drills held for first shift on 9/29/15, 10/27/15, 3/17/16 and 4/13/16 were all conducted within an hour and a half of each other.

The maintenance director was present during the findings.

NFPA Standard: Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 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. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 2000 NFPA 101, 19.7.1.2.

Based on observation, staff interview and record review, the facility failed to ensure that the kitchen portable deep fryer is protected as required in NFPA 96. The deficient practice would allow the grease laden vapors created by the deep fryer to accumulate uncontrolled, affecting one of five smoke zones. The facility has a capacity of 25 with a census of 12 at the time of survey.

Findings Include:

During the tour from 8/29/16 to 8/30/16 it is noted that:

1. At 12:23 PM on 8/29/16 a portable deep fryer was observed sitting on the kitchen prep table. Staff indicated that it was used on the table top without hood suppression coverage.

The maintenance director was present during the findings.

NFPA Standard: Cooking equipment that produces grease-laden vapors (such as, but not limited to, deep fat fryers, ranges, griddles, broilers, woks, tilting skillets, and braising pans) shall be protected by fire-extinguishing equipment. 1998 NFPA 96, 7-1.2

Based on record review and staff interview the facility failed to assure that portable space heaters being used within the facility are code compliant. This deficient practice could cause a fire due to excessive heat, affecting one of five smoke zones. This facility has a capacity of 25 and a census of 12.

FINDINGS INCLUDE:

During the tour from 8/29/16 to 8/30/16 it is noted that:
1. At 11:55 AM on 8/29/16 a portable space heater observed plugged in under the nurse desk in the post op patient care area.
2. At 11:59 AM on 8/29/16 a written portable space heater policy is not available for review.

The maintenance director was present during the findings.

NFPA Standard: Prohibits the use of portable space heating devices in non-resident and staff sleeping areas with heating elements that exceed 212 degrees. 2000 NFPA 101, 18/19.7.8

Based on observation, staff interview and record review, the facility failed to install and maintain the emergency generator power supply as required. The deficient practice may prevent the remote shut down of the generator in the event of an emergency, affecting five of five smoke zones. The facility has a capacity of 25 with a census of 12 at the time of survey.

Findings Include:

During the tour from 8/29/16 to 8/30/16 it is noted that:


1. At 9:45 AM on 8/29/16 generator load transfer time are not documented.
2. At 11:07 AM on 8/29/16 no remote generator shutoff provided.

The maintenance director was present during the findings.



NFPA Standard: All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building. 1999 NFPA 110 3-5.5.6*
NFPA Standard: For Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified. 1999 NFPA 110 A-3-5.5.6
NFPA Standard: The generator shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. 1999 NFPA 99, 3-4.1.1.8, 3-5.1 and 3-6.1

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 one of five smoke zones. This facility has a capacity of 25 and a census of 12.

Findings Include:

During the tour from 8/29/16 to 8/30/16 it is noted that:

1. Combustible materials stored within 36 " of the electrical panel in the emergency electrical room.

The maintenance director was present during the findings.

NFPA Standard: The width of the working space in front of the electrical equipment shall be the width of the equipment or 30 in. (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of the equipment doors or hinged panels. Minimum clear distance required for the working space of an electrical panel is 3 to 4 feet. 1999 NFPA 70, 110-26 (a)(1)(2).