HospitalInspections.org

Based on observations and interview, it was determined the facility failed to maintain smoke barriers that would resist the passage of smoke between smoke compartments in accordance with NFPA standards. The deficiency had the potential to affect four (4) of four (4) smoke compartments, all residents, staff and visitors. The facility is certified for twenty-five (25) beds and the census was eighteen (18) on the day of the survey. The facility failed to ensure four (4) smoke barriers were sealed around pipes and wires to resist the passage of smoke.

The findings include:

Observations, on 03/11/14 between 12:45 PM and 2:00 PM with the Maintenance Supervisor, revealed the smoke partitions, extending above the ceiling located throughout the facility were penetrated by pipes and wires and not sealed properly to resist the passage of smoke.

Interview, on 03/11/14 between 12:45 PM and 2:00 PM with the Maintenance Supervisor, revealed the facility does routine checks on the smoke barriers but was unaware of the penetrations.


Reference: NFPA 101 (2000 Edition).

8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(a) The space between the penetrating item and the smoke barrier shall
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(b) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(c) Where designs take transmission of vibration into consideration, any vibration isolation shall
1. Be made on either side of the smoke barrier, or
2. Be made by an approved device designed for the specific purpose.

8.3.6.2 Openings occurring at points where floors or smoke
barriers meet the outside walls, other smoke barriers, or fire
barriers of a building shall meet one of the following conditions:
(1) It shall be filled with a material that is capable of maintaining
the smoke resistance of the floor or smoke barrier.
(2) It shall be protected by an approved device that is
designed for the specific purpose.

Based on observation and interview, the facility failed to maintain smoke doors that would self-close and resist the passage of smoke in accordance with NFPA standards. The deficiency had the potential to affect four (4) of four (4) smoke compartments, all residents, staff and visitors. The facility is certified for twenty-five (25) beds and the census was eighteen (18) on the day of the survey. The facility failed to ensure the doors located in the smoke barriers would self-close and resist the passage of smoke.

The findings include:

Observation, on 03/11/14 between 12:45 PM and 4:00 PM with the Maintenance Supervisor, revealed that the doors in the smoke barriers at the x-ray check-in area, x-ray, lab entry door, and the back door to the dry storage area for the kitchen would not close and latch with the current hardware installed. The doors are required to be self-closing and substantial doors due to the fact they are located in the smoke barriers of the facility.

Interview, on 03/11/14 between 12:45 PM and 4:00 PM with the Maintenance Supervisor, revealed that he was not aware the doors were required to be self-closing and substantial doors to resist the passage of smoke.


NFPA Standard: NFPA 101 (2000 edition),
19.3.7.5 Openings in smoke barriers shall be protected by
fire-rated glazing; by wired glass panels and steel frames; by
substantial doors, such as 13/4-in. (4.4-cm) thick, solid-bonded
wood core doors; or by construction that resists fire for not less
than 20 minutes. Nonrated factory- or field-applied protective
plates extending not more than 48 in. (122 cm) above the bottom
of the door shall be permitted.
Exception: Doors shall be permitted to have fixed fire window assemblies
in accordance with 8.2.3.2.2.
19.3.7.6* Doors in smoke barriers shall comply with 8.3.4 and
shall be self-closing or automatic-closing in accordance with
19.2.2.2.6. Such doors in smoke barriers shall not be required
to swing with egress travel. Positive latching hardware shall not
be required.

Based on observation and interview, it was determined the facility failed to meet the requirements of Protection of Hazards in accordance with NFPA Standards. The deficiency had the potential to affect two (2) of four (4) smoke compartments, sixteen (16) residents, staff and visitors. The facility is certified for twenty-five (25) beds and the census was eighteen (18) on the day of the survey. The facility failed to ensure two (2) rooms were properly protected due to the storage in the rooms.

The findings include:

Observation, on 03/11/14 between 12:45 PM and 4:00 PM with the Maintenance Supervisor, revealed the steam generator room in surgery and the dry storage room in the kitchen did not have a closer added to the door. This requirement is due to the storage of combustible items inside the areas. Further observation revealed the storage room in the surgery area was being propped by an unapproved kick down device.

Interview, on 03/11/14 between 12:45 PM and 4:00 PM with the Maintenance Supervisor, revealed he was unaware the storage rooms were not properly protected.

Reference: NFPA 101 (2000 Edition).

19.3.2 Protection from Hazards.

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 8.4.1. The automatic
extinguishing shall be permitted to be in
accordance with 19.3.5.4. Where the sprinkler
option is used, the areas shall be separated
from other spaces by smoke-resisting partitions
and doors. The doors shall be self-closing or
automatic-closing. Hazardous areas shall
include, but shall not be restricted to, the
following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2
(9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2),
including repair shops, used for storage of
combustible supplies
and equipment in quantities deemed hazardous
by the authority having jurisdiction
(8) Laboratories employing flammable or
combustible materials in quantities less than
those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be
permitted to have nonrated, factory or field-applied
protective plates extending not more than
48 in. (122 cm) above the bottom of the door.

Based on interview and fire policy review, it was determined the facility failed to implement a proper Fire Safety Plan and Procedure Policy in the event of an emergency in accordance with NFPA standards. The deficiency had the potential to affect four (4) of four (4) smoke compartments, all residents, staff and visitors. The facility is certified for twenty-five (25) beds and the census was eighteen (18) on the day of the survey. The facility failed to ensure all parts of the fire safety plan were addressed in the policy.

The findings include:

Fire Safety Plan review, on 03/11/14 at 2:50 PM with the Maintenance Supervisor, revealed the facility's Fire Safety Plan and Procedure Policy failed to address the evacuation of smoke compartments in the facility, isolation of fire, evacuation of immediate area, and the extinguishment of the fire.

Interview, on 03/11/14 at 2:50 PM with the Maintenance Supervisor, revealed he was unaware the policy did not include all the necessary steps of the fire safety plan. The facility does practice all the steps but the policy was incomplete.

Reference: NFPA 101 (2000 edition)
Actual NFPA Standard: 19.7.1 Evacuation and Relocation Plan and Fire Drills.
19.7.1.1
The administration of every healthcare occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator ' s position or at the security center.
The provisions of 19.7.1.2 through 19.7.2.3 shall apply.
19.7.1.2*
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.
19.7.1.3
Employees of health care occupancies shall be instructed in life safety procedures and devices.
19.7.2 Procedure in Case of Fire.
19.7.2.1*
For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy ' s fire safety plan.
19.7.2.2
A written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
19.7.2.3
All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system
Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and

Based on fire alarm inspections and interview, it was determined the facility failed to ensure the fire alarm system was inspected and tested in accordance with NFPA Standards. The deficiency had the potential to affect four (4) of four (4) smoke compartments, all residents, staff and visitors. The facility is certified for twenty-five (25) beds and the census was eighteen (18) on the day of the survey. The facility failed to ensure all smoke detectors at the facility were properly tested at least once in the last two years.

The findings include:

Fire Alarm Inspection Review, on 03/11/14 at 2:15 PM with the Maintenance Supervisor, revealed N/A on Smoke Detector Sensitivity Testing being performed. Further review revealed the discharge test, load voltage test, and charger test were not documented on the inspection reports.

Interview, on 03/11/14 at 2:15 PM with the Maintenance Supervisor, revealed he was unaware the facility did not have a current sensitivity test on all fire alarm smoke detectors. Further interview revealed he was under the impression that the vendor for checking the fire alarm was completing the required testing of the fire alarm system.

Reference: NFPA 72 (1999 edition)

7-3.2.1* Detector sensitivity shall be checked within 1 year after
installation and every alternate year thereafter. After the second
required calibration test, if sensitivity tests indicate that the
detector has remained within its listed and marked sensitivity
range (or 4 percent obscuration light gray smoke, if not
marked), the length of time between calibration tests shall be
permitted to be extended to a maximum of 5 years. If the frequency
is extended, records of detector-caused nuisance alarms
and subsequent trends of these alarms shall be maintained. In
zones or in areas where nuisance alarms show any increase over
the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and
marked sensitivity range, it shall be tested using any of the following
methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the
detector causes a signal at the control unit where its sensitivity
is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the
authority having jurisdiction
Detectors found to have a sensitivity outside the listed and
marked sensitivity range shall be cleaned and recalibrated or
be replaced.

Exception No. 1: Detectors listed as field adjustable shall be permitted
to be either adjusted within the listed and marked sensitivity range and
cleaned and recalibrated, or they shall be replaced.

Exception No. 2: This requirement shall not apply to single station detectors
referenced in 7-3.3 and Table 7-2.2.

The detector sensitivity shall not be tested or measured
using any device that administers an unmeasured concentration
of smoke or other aerosol into the detector.

Reference: NFPA 101 (2000 ed.)
9.6.1.4. A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.

Based on observation and interview, it was determined the facility failed to maintain the emergency generator according to NFPA standards. The deficiency had the potential to affect four (4) of four (4) smoke compartments, all residents, staff and visitors. The facility is certified for twenty-five (25) beds and the census was eighteen (18) on the day of the survey. The facility failed to ensure there was battery backup lighting at the generator transfer switch.

The findings include:

Observation, on 03/11/14 at 2:30 PM with the Maintenance Supervisor, revealed the facility did not have any battery-powered lighting installed in the area where the transfer switch for the emergency generator was located.

Interview on 03/11/14 at 2:30 PM with the Maintenance Supervisor, revealed he was not aware of the requirement for the battery backup lighting at the emergency generator transfer switch.


Reference: NFPA 110 (1999 Edition).

5-3.1 The Level 1 or Level 2 EPS equipment location shall be
provided with battery-powered emergency lighting. The emergency
lighting charging system and the normal service room
lighting shall be supplied from the load side of the transfer
switch.

Based on interview and facility policy and procedure review, the facility failed to develop a fire watch policy in accordance with NFPA standards. The deficiency had the potential to affect four (4) of four (4) smoke compartments, all residents, staff and visitors. The facility is certified for twenty-five (25) beds and the census was eighteen (18) on the day of the survey. The facility failed to have a fire watch policy for the automatic sprinkler system if the system is not functioning properly.

The findings include:

Policy and Procedure review, on 03/11/14 at 2:55 PM with the Maintenance Supervisor, revealed the facility had no written fire watch policy for the automatic sprinkler system not functioning for 4 or more hours in a 24 hour period.

Interview, on 03/11/14 at 2:55 PM with the Maintenance Supervisor, revealed he has a log to record the fire watch rounds but there is not an actual policy on when to implement the use of the logs.


Reference; NFPA 101 (2000 edition)
9.7.6* Sprinkler System Shutdown.
9.7.6.1
Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.

Based on interview and facility policy and procedure review, the facility failed to develop a fire watch policy in accordance with NFPA standards. The deficiency had the potential to affect four (4) of four (4) smoke compartments, all residents, staff and visitors. The facility is certified for twenty-five (25) beds and the census was eighteen (18) on the day of the survey. The facility failed to have a fire watch policy for the fire alarm system if the system is not functioning properly.

The findings include:

Policy and Procedure review, on 03/11/14 at 2:55 PM with the Maintenance Supervisor, revealed the facility had no written fire watch policy for the fire alarm system not functioning for 4 or more hours in a 24 hour period.

Interview, on 03/11/14 at 2:55 PM with the Maintenance Supervisor, revealed he has a log to record the fire watch rounds but there is not an actual policy on when to implement the use of the logs.


Reference; NFPA 101 (2000 edition)
9.6.1.8* Where a required fire alarm system is out of service
for more than 4 hours in a 24-hour period, the authority having
jurisdiction shall be notified, and the building shall be
evacuated or an approved fire watch shall be provided for all
parties left unprotected by the shutdown until the fire alarm
system has been returned to service.

Based on observations and interview, it was determined the facility failed to maintain smoke barriers that would resist the passage of smoke between smoke compartments in accordance with NFPA standards. The deficiency had the potential to affect four (4) of four (4) smoke compartments, all residents, staff and visitors. The facility is certified for twenty-five (25) beds and the census was eighteen (18) on the day of the survey. The facility failed to ensure four (4) smoke barriers were sealed around pipes and wires to resist the passage of smoke.

The findings include:

Observations, on 03/11/14 between 12:45 PM and 2:00 PM with the Maintenance Supervisor, revealed the smoke partitions, extending above the ceiling located throughout the facility were penetrated by pipes and wires and not sealed properly to resist the passage of smoke.

Interview, on 03/11/14 between 12:45 PM and 2:00 PM with the Maintenance Supervisor, revealed the facility does routine checks on the smoke barriers but was unaware of the penetrations.


Reference: NFPA 101 (2000 Edition).

8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(a) The space between the penetrating item and the smoke barrier shall
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(b) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(c) Where designs take transmission of vibration into consideration, any vibration isolation shall
1. Be made on either side of the smoke barrier, or
2. Be made by an approved device designed for the specific purpose.

8.3.6.2 Openings occurring at points where floors or smoke
barriers meet the outside walls, other smoke barriers, or fire
barriers of a building shall meet one of the following conditions:
(1) It shall be filled with a material that is capable of maintaining
the smoke resistance of the floor or smoke barrier.
(2) It shall be protected by an approved device that is
designed for the specific purpose.

Based on observation and interview, the facility failed to maintain smoke doors that would self-close and resist the passage of smoke in accordance with NFPA standards. The deficiency had the potential to affect four (4) of four (4) smoke compartments, all residents, staff and visitors. The facility is certified for twenty-five (25) beds and the census was eighteen (18) on the day of the survey. The facility failed to ensure the doors located in the smoke barriers would self-close and resist the passage of smoke.

The findings include:

Observation, on 03/11/14 between 12:45 PM and 4:00 PM with the Maintenance Supervisor, revealed that the doors in the smoke barriers at the x-ray check-in area, x-ray, lab entry door, and the back door to the dry storage area for the kitchen would not close and latch with the current hardware installed. The doors are required to be self-closing and substantial doors due to the fact they are located in the smoke barriers of the facility.

Interview, on 03/11/14 between 12:45 PM and 4:00 PM with the Maintenance Supervisor, revealed that he was not aware the doors were required to be self-closing and substantial doors to resist the passage of smoke.


NFPA Standard: NFPA 101 (2000 edition),
19.3.7.5 Openings in smoke barriers shall be protected by
fire-rated glazing; by wired glass panels and steel frames; by
substantial doors, such as 13/4-in. (4.4-cm) thick, solid-bonded
wood core doors; or by construction that resists fire for not less
than 20 minutes. Nonrated factory- or field-applied protective
plates extending not more than 48 in. (122 cm) above the bottom
of the door shall be permitted.
Exception: Doors shall be permitted to have fixed fire window assemblies
in accordance with 8.2.3.2.2.
19.3.7.6* Doors in smoke barriers shall comply with 8.3.4 and
shall be self-closing or automatic-closing in accordance with
19.2.2.2.6. Such doors in smoke barriers shall not be required
to swing with egress travel. Positive latching hardware shall not
be required.

Based on observation and interview, it was determined the facility failed to meet the requirements of Protection of Hazards in accordance with NFPA Standards. The deficiency had the potential to affect two (2) of four (4) smoke compartments, sixteen (16) residents, staff and visitors. The facility is certified for twenty-five (25) beds and the census was eighteen (18) on the day of the survey. The facility failed to ensure two (2) rooms were properly protected due to the storage in the rooms.

The findings include:

Observation, on 03/11/14 between 12:45 PM and 4:00 PM with the Maintenance Supervisor, revealed the steam generator room in surgery and the dry storage room in the kitchen did not have a closer added to the door. This requirement is due to the storage of combustible items inside the areas. Further observation revealed the storage room in the surgery area was being propped by an unapproved kick down device.

Interview, on 03/11/14 between 12:45 PM and 4:00 PM with the Maintenance Supervisor, revealed he was unaware the storage rooms were not properly protected.

Reference: NFPA 101 (2000 Edition).

19.3.2 Protection from Hazards.

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 8.4.1. The automatic
extinguishing shall be permitted to be in
accordance with 19.3.5.4. Where the sprinkler
option is used, the areas shall be separated
from other spaces by smoke-resisting partitions
and doors. The doors shall be self-closing or
automatic-closing. Hazardous areas shall
include, but shall not be restricted to, the
following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2
(9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2),
including repair shops, used for storage of
combustible supplies
and equipment in quantities deemed hazardous
by the authority having jurisdiction
(8) Laboratories employing flammable or
combustible materials in quantities less than
those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be
permitted to have nonrated, factory or field-applied
protective plates extending not more than
48 in. (122 cm) above the bottom of the door.

Based on interview and fire policy review, it was determined the facility failed to implement a proper Fire Safety Plan and Procedure Policy in the event of an emergency in accordance with NFPA standards. The deficiency had the potential to affect four (4) of four (4) smoke compartments, all residents, staff and visitors. The facility is certified for twenty-five (25) beds and the census was eighteen (18) on the day of the survey. The facility failed to ensure all parts of the fire safety plan were addressed in the policy.

The findings include:

Fire Safety Plan review, on 03/11/14 at 2:50 PM with the Maintenance Supervisor, revealed the facility's Fire Safety Plan and Procedure Policy failed to address the evacuation of smoke compartments in the facility, isolation of fire, evacuation of immediate area, and the extinguishment of the fire.

Interview, on 03/11/14 at 2:50 PM with the Maintenance Supervisor, revealed he was unaware the policy did not include all the necessary steps of the fire safety plan. The facility does practice all the steps but the policy was incomplete.

Reference: NFPA 101 (2000 edition)
Actual NFPA Standard: 19.7.1 Evacuation and Relocation Plan and Fire Drills.
19.7.1.1
The administration of every healthcare occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator ' s position or at the security center.
The provisions of 19.7.1.2 through 19.7.2.3 shall apply.
19.7.1.2*
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.
19.7.1.3
Employees of health care occupancies shall be instructed in life safety procedures and devices.
19.7.2 Procedure in Case of Fire.
19.7.2.1*
For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy ' s fire safety plan.
19.7.2.2
A written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
19.7.2.3
All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system
Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and

Based on fire alarm inspections and interview, it was determined the facility failed to ensure the fire alarm system was inspected and tested in accordance with NFPA Standards. The deficiency had the potential to affect four (4) of four (4) smoke compartments, all residents, staff and visitors. The facility is certified for twenty-five (25) beds and the census was eighteen (18) on the day of the survey. The facility failed to ensure all smoke detectors at the facility were properly tested at least once in the last two years.

The findings include:

Fire Alarm Inspection Review, on 03/11/14 at 2:15 PM with the Maintenance Supervisor, revealed N/A on Smoke Detector Sensitivity Testing being performed. Further review revealed the discharge test, load voltage test, and charger test were not documented on the inspection reports.

Interview, on 03/11/14 at 2:15 PM with the Maintenance Supervisor, revealed he was unaware the facility did not have a current sensitivity test on all fire alarm smoke detectors. Further interview revealed he was under the impression that the vendor for checking the fire alarm was completing the required testing of the fire alarm system.

Reference: NFPA 72 (1999 edition)

7-3.2.1* Detector sensitivity shall be checked within 1 year after
installation and every alternate year thereafter. After the second
required calibration test, if sensitivity tests indicate that the
detector has remained within its listed and marked sensitivity
range (or 4 percent obscuration light gray smoke, if not
marked), the length of time between calibration tests shall be
permitted to be extended to a maximum of 5 years. If the frequency
is extended, records of detector-caused nuisance alarms
and subsequent trends of these alarms shall be maintained. In
zones or in areas where nuisance alarms show any increase over
the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and
marked sensitivity range, it shall be tested using any of the following
methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the
detector causes a signal at the control unit where its sensitivity
is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the
authority having jurisdiction
Detectors found to have a sensitivity outside the listed and
marked sensitivity range shall be cleaned and recalibrated or
be replaced.

Exception No. 1: Detectors listed as field adjustable shall be permitted
to be either adjusted within the listed and marked sensitivity range and
cleaned and recalibrated, or they shall be replaced.

Exception No. 2: This requirement shall not apply to single station detectors
referenced in 7-3.3 and Table 7-2.2.

The detector sensitivity shall not be tested or measured
using any device that administers an unmeasured concentration
of smoke or other aerosol into the detector.

Reference: NFPA 101 (2000 ed.)
9.6.1.4. A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.

Based on observation and interview, it was determined the facility failed to maintain the emergency generator according to NFPA standards. The deficiency had the potential to affect four (4) of four (4) smoke compartments, all residents, staff and visitors. The facility is certified for twenty-five (25) beds and the census was eighteen (18) on the day of the survey. The facility failed to ensure there was battery backup lighting at the generator transfer switch.

The findings include:

Observation, on 03/11/14 at 2:30 PM with the Maintenance Supervisor, revealed the facility did not have any battery-powered lighting installed in the area where the transfer switch for the emergency generator was located.

Interview on 03/11/14 at 2:30 PM with the Maintenance Supervisor, revealed he was not aware of the requirement for the battery backup lighting at the emergency generator transfer switch.


Reference: NFPA 110 (1999 Edition).

5-3.1 The Level 1 or Level 2 EPS equipment location shall be
provided with battery-powered emergency lighting. The emergency
lighting charging system and the normal service room
lighting shall be supplied from the load side of the transfer
switch.

Based on interview and facility policy and procedure review, the facility failed to develop a fire watch policy in accordance with NFPA standards. The deficiency had the potential to affect four (4) of four (4) smoke compartments, all residents, staff and visitors. The facility is certified for twenty-five (25) beds and the census was eighteen (18) on the day of the survey. The facility failed to have a fire watch policy for the automatic sprinkler system if the system is not functioning properly.

The findings include:

Policy and Procedure review, on 03/11/14 at 2:55 PM with the Maintenance Supervisor, revealed the facility had no written fire watch policy for the automatic sprinkler system not functioning for 4 or more hours in a 24 hour period.

Interview, on 03/11/14 at 2:55 PM with the Maintenance Supervisor, revealed he has a log to record the fire watch rounds but there is not an actual policy on when to implement the use of the logs.


Reference; NFPA 101 (2000 edition)
9.7.6* Sprinkler System Shutdown.
9.7.6.1
Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.

Based on interview and facility policy and procedure review, the facility failed to develop a fire watch policy in accordance with NFPA standards. The deficiency had the potential to affect four (4) of four (4) smoke compartments, all residents, staff and visitors. The facility is certified for twenty-five (25) beds and the census was eighteen (18) on the day of the survey. The facility failed to have a fire watch policy for the fire alarm system if the system is not functioning properly.

The findings include:

Policy and Procedure review, on 03/11/14 at 2:55 PM with the Maintenance Supervisor, revealed the facility had no written fire watch policy for the fire alarm system not functioning for 4 or more hours in a 24 hour period.

Interview, on 03/11/14 at 2:55 PM with the Maintenance Supervisor, revealed he has a log to record the fire watch rounds but there is not an actual policy on when to implement the use of the logs.


Reference; NFPA 101 (2000 edition)
9.6.1.8* Where a required fire alarm system is out of service
for more than 4 hours in a 24-hour period, the authority having
jurisdiction shall be notified, and the building shall be
evacuated or an approved fire watch shall be provided for all
parties left unprotected by the shutdown until the fire alarm
system has been returned to service.