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Based on observation and interview, the facility failed to provide evidence that all areas of the facility are protected by the fire sprinkler system. This deficient practice would allow fire, smoke and gases to spread affecting all occupants in 2 of 9 smoke compartments. The facility census was 2 and licensed for 25 at time of survey.

Findings are:
Observation and staff interview on 8-14-2019 at 1:25 PM revealed the following:

Old Nurses Station located at the end of the east wing was surrounded by approximate 10 inch deep bulk heads above and approximately 48 inch tall cabinets below creating spaces that were not fire sprinkler protected.

During an interview on 8-14-2019 at 1:25 PM, Maintenance Staff A confirmed no sprinkler protection was provided.

Code reference:
2010 edition NFPA 13.4.1 Level of Protection. A building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas except where specific sections of this standard permit the omission of sprinklers.

Based on observation and interview, the facility did not ensure that fire rated smoke barrier separation doors would resist the passage of smoke from one compartment to another. This deficient practice would not prevent the spread of fire and smoke from one smoke compartment to another. This deficient practice would affect all occupants in 2 of 9 smoke compartments. The facility census was 2 and licensed for 25 at time of survey.

Findings are:
Observation and staff interview on 8-14-2019 at 12:55 PM revealed the following:

Corridor smoke doors at the medical records room failed to completely close and would not be smoke tight.

During an interview on 8-14-2019 at 12:55 PM, Maintenance Staff A confirmed the door did not close tight.