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Based on observation and staff interview, the facility failed to provide delayed egress device's that would release with the sprinkler system activation and within 15 seconds of application of force that is continuously applied for more than 3 seconds. This deficient practice affects all residents, staff and visitors in 2 of 5 smoke zones, in. The facility has 25 certified beds at the time of the survey the census was 5.

Findings include:

During the survey conducted on 12/6/18 the following deficiency is noted:

1) At 2:40 p.m. It was observed that in the hallway to the patient care unit, 15 second delayed egress not functioning properly when tested.

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

NFPA Standard: Approved, listed, delayed-egress locks shall be permitted to be installed on doors serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7, provided that the following criteria are met: doors shall unlock upon actuation of an approved, supervised automatic sprinkler system or any heat detector or activation of not more than two smoke detectors of an approved, supervised automatic fire detection system; the doors shall unlock upon loss of power; an irreversible process shall release the lock within 15 seconds upon application of a force not to exceed 15 pounds nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only; on the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 inch high and not less than 1/8 inch wide on a contrasting background that reads as follows: PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS. 2012 NFPA 101, 7.2.1.6.1

NFPA Standard: Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side, except delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path. 2012 NFPA 101, 19.2.2.2.4

Based on observation and staff interview, the facility fails to maintain their stairway enclosures as required in Life Safety Code 101. The deficient practice would affect approximately some residents, visitors and staff in 1 of 5 smoke zones. The facility has 25 certified beds at the time of the survey the census was 5

Findings include:

During the survey conducted on 12/6/18 the following deficiency is noted:

1. During the survey at 3:10 PM, it is observed that there is an unsealed penetration in the hallway between pharmacy and imaging northwest of the waiting area around the sprinkler head.

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


Maintenance and Administrative staff were present and acknowledged finding.
NFPA Standard: Life Safety Code 101 2012 7.2.2 Stairs. 7.2.2.1 General. 7.2.2.1.1 Stairs used as a component in the means of egress shall conform to the general requirements of Section 7.1 and
to the special requirements of 7.2.2, unless otherwise specified in 7.2.2.1.2. 7.2.2.5.1.1 All inside stairs serving as an exit or exit component shall be enclosed in accordance with 7.1.3.2. 7.1.3.2 Exits.
7.1.3.2.1 Where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following: (1)*The separation shall have a minimum 1-hour fire resistance rating where the exit connects three or fewer stories. (2) The separation specified in 7.1.3.2.1(1), other than an existing separation, shall be supported by construction having not less than a 1-hour fire resistance rating. (3)*The separation shall have a minimum 2-hour fire resistance rating where the exit connects four or more stories, unless one of the following conditions exists: (a) In existing non-high-rise buildings, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating. (b) In existing buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating. (c) The minimum 1-hour enclosures in accordance
with 28.2.2.1.2, 29.2.2.1.2, 30.2.2.1.2, and 31.2.2.1.2 shall be permitted as an alternative to the requirement of 7.1.3.2.1(3). (4) Reserved. (5) The minimum 2-hour fire resistance-rated separation
required by 7.1.3.2.1(3) shall be constructed of an assembly of noncombustible or limited-combustible materials and shall be supported by construction having a minimum 2-hour fire resistance rating, unless otherwise permitted by 7.1.3.2.1(7). (6)*Structural elements, or portions thereof, that support
exit components and either penetrate into a fire resistance-rated assembly or are installed within a fire
resistance-rated wall assembly shall be protected, as a minimum, to the fire resistance rating required by 7.1.3.2.1(1) or (3). (7) In Type III, Type IV, and Type V construction, as defined in NFPA220, Standard on Types of Building Construction (see 8.2.1.2), fire-retardant-treated wood enclosed in noncombustible
or limited-combustible materials shall be permitted. (8) Openings in the separation shall be protected by fire door assemblies equipped with door closers complying with 7.2.1.8. (9)*Openings in exit enclosures shall be limited to door assemblies from normally occupied spaces and corridors and door assemblies for egress from the enclosure, unless one of the following conditions exists: (a) Openings in exit passageways in mall buildings as provided in Chapters 36 and 37 shall be permitted. (b) In buildings of Type I or Type II construction, as defined in NFPA 220, Standard on Types of Building Construction (see 8.2.1.2), existing fire protection- rated door assemblies to interstitial spaces shall be permitted, provided that such spaces meet all of the following criteria: i. The space is used solely for distribution of pipes, ducts, and conduits. ii. The space contains no storage. iii. The space is separated from the exit enclosure in accordance with Section 8.3. (c) Existing openings to mechanical equipment spaces
protected by approved existing fire protection- rated door assemblies shall be permitted, provided
that the following criteria are met: i. The space is used solely for non-fuel-fired mechanical equipment.
ii. The space contains no storage of combustible materials. iii. The building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. (10) Penetrations into, and openings through, an exit enclosure assembly shall be limited to the following: (a) Door assemblies permitted by 7.1.3.2.1(9) (b)*Electrical conduit serving the exit enclosure (c) Required exit door openings (d) Ductwork and equipment necessary for independent stair pressurization (e) Water or steam piping necessary for the heating or cooling of the exit enclosure (f) Sprinkler piping (g) Standpipes
(h) Existing penetrations protected in accordance with 8.3.5
(i) Penetrations for fire alarm circuits, where the circuits are installed in metal conduit and the penetrations are protected in accordance with 8.3.5 (11) Penetrations or communicating openings shall be prohibited between adjacent exit enclosures. (12) Membrane penetrations shall be permitted on the exit access side of the exit enclosure and shall be protected in accordance with 8.3.5.6. 8.3.5.6.1 Membrane penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through membrane of a wall, floor, or floor/ceiling assembly constructed
as a fire barrier shall be protected by a firestop system or device and shall comply with 8.3.5.1 through 8.3.5.5.2.

Sprinkler System Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
This REQUIREMENT is not met as evidenced by:

Based on record review, observation and staff interview, this facility is not maintaining the sprinkler system in accordance with the 2011 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 patients, visitors and staff in 1 of 5 smoke zones. The facility has 25 certified beds at the time of the survey the census was 5

Findings include:

During the survey conducted on 12/6/18 the following deficiency is noted:

1.) At varying times throughout the tour, it is discovered that multiple fire sprinkler heads throughout the kitchen area are dirty.

Staff A-1 and Staff M-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.