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Based on observation and staff interview the facility is not ensuring that room doors latch properly. This deficient practice of not ensuring that room doors latch properly prevents the ability of the facility to properly confine fire and smoke products and to properly defend occupants in place, affecting four of six smoke zones. The facility has a capacity of 49 and census of 8.

Findings include:

During the survey on 2-15-16 and 2-16-16 the following is observed:

1. Corridor doors throughout the facility are on automatic closers and these doors are being held open by magnetic hold open devices not tied into the fire alarm system.

2. At 2:40 PM room 202 has a leaf for the door to close into taking this door multiple motions to close. Leaf does not lock in place and does not close on its own.

3. At 2:43 PM the door to room 120 does not latch.


The Maintenance Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: 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 smoke barriers to at least one hour fire resistance. This deficient practice would prevent containment of fire and smoke, affecting four of six smoke zones. The facility has a capacity of 49 and census of 8.

Findings include:

During the survey on 2-15-16 and 2-16-16 the following is observed:

1. It is observed that the smoke barriers throughout the facility have penetrations around hvac ducting and wire trays.


The Maintenance Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1 hour.

Exception No. 1: Where an atrium is used, smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with Exception No. 2 to 8.2.5.6(1). Not less than two separate smoke compartments shall be provided on each floor.
Exception No. 2:* Dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems. 2000 NFPA 101, 18.3.7.3

Review of the following NFPA Standard revealed: 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 ensure proper separation of hazardous areas from other spaces. This deficient practice would allow for the spread of smoke and fire to travel into the adjacent area, affecting one of six smoke zones. The facility has a capacity of 49 and census of 8.

Findings include:

During the survey on 2-15-16 and 2-16-16 the following is observed:

1. At 2:40 PM it is observed that the door to room 202 is not equipped with a closer and is being used as storage. This room is over 100sqft.


The Maintenance Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Hazardous areas shall be safeguarded by a fire barrier of one hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Review of the following NFPA Standard revealed: 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. 2000 NFPA 101, 8.4.1

Based on record review and staff interview, the facility is not conducting fire drills as required 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 four of six smoke zones. The facility has a capacity of 49 and census of 8.

Findings include:

During record review on 2-15-16 and 2-16-16 the following is observed:

1. Review of fire drill records for the last 5 quarters revealed that the drill last four quarters of the second shift drills were all performed between 5:30am and 5:35am.

2. Review of fire drill records for the last 5 quarters revealed that the drills performed in January, February, April, August, and December did not have the fire alarm activated with the drill. The silent drills performed did not activated within 24 hours of the fire drill.


The Maintenance Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: 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, interview and record review, the facility failed to provide and maintain documentation of annual inspection and testing of the fire alarm system as required by NFPA 72. The absence of complete, verifiable documented maintenance and repair history on the fire alarm system fails to ensure reliability of the alarm system in the event of an emergency, affecting all six smoke zones. The facility has a capacity of 49 and census of 8.

Findings include:

During record review on 2-15-16 and 2-16-16 the following is observed:

1. Fire alarm report for 2015 was performed on 1-12-15. The report for 2016 was performed on 1-22-16 which is ten days overdue.


The Maintenance Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: 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, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction. 2000 NFPA 101, 9.6.1.4

Review of the following NFPA Standard revealed: Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7 2.2. 1999 NFPA 72, 7-2.2

Based on record review and staff interviews, the facility failed to assure that the sprinkler system is maintained and inspected in accordance with NFPA 25. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting four of six smoke zones. The facility has a capacity of 49 and census of 8.

Findings include:

During record review on 2-15-16 and 2-16-16 the following is observed:

1. The annual sprinkler report states that the backflow testing is overdue.


The Maintenance Director was present and acknowledged the findings.


Review of the following NFPA Standard revealed: Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. 2000 NFPA 101, 4.6.12.1

Review of the following NFPA Standard revealed: All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2000 NFPA 101, 9.7.5

Review of the following NFPA Standard revealed: To ensure that piping remains clear of all obstructive foreign matter, an obstruction investigation shall be conducted for system or yard main piping wherever any of the following conditions exist:

(a) Defective intake for fire pumps taking suction from open bodies of water
(b) The discharge of obstructive material during routine water tests
(c) Foreign materials in fire pumps, in dry pipe valves, or in check valves
(d) Foreign material in water during drain tests or plugging of inspector ' s test connection(s)
(e) Plugged sprinklers
(f) Plugged piping in sprinkler systems dismantled during building alterations
(g) Failure to flush yard piping or surrounding public mains following new installations or repairs
(h) A record of broken public mains in the vicinity
(i) Abnormally frequent false tripping of a dry pipe valve(s)

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 six smoke zones. The facility has a capacity of 49 and census of 8.

Findings include:

During the survey on 2-15-16 and 2-16-16 the following is observed:

1. At 2:23 PM it is observed that a space heater is in use in the O.B. office. This office is located in the O.B. patient care area.


The Maintenance Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Portable space-heating devices shall be prohibited in all health care occupancies.

Exception: Portable space-heating devices shall be permitted to be used in non-sleeping staff and employee areas where the heating elements of such devices do not exceed 212°F (100°C). 2000 NFPA 101, 19.7.8

Based on observation and staff interview the facility fails to ensure that all means of egress are free of all obstructions or impediments to a full instant use. This deficient practice could impede occupants from exiting in the event of a fire or other emergency situation, affecting one of six smoke zones. The facility has a capacity of 49 and census of 8.

Findings include:

During the survey on 2-15-16 and 2-16-16 the following is observed:

1. At 2:00 PM it is observed that a bed is being stored in the exit corridor in recovery area.


The Maintenance Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: 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

Review of the following NFPA Standard revealed: No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress from, or visibility thereof. 2000 NFPA 101, 7.1.10.2.1

Review of the following NFPA Standard revealed: Exits shall terminate directly at a public way or an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. 2000 NFPA 101, 7.7.1

Based on observation and staff interview the facility is not ensuring that room doors latch properly. This deficient practice of not ensuring that room doors latch properly prevents the ability of the facility to properly confine fire and smoke products and to properly defend occupants in place, affecting four of six smoke zones. The facility has a capacity of 49 and census of 8.

Findings include:

During the survey on 2-15-16 and 2-16-16 the following is observed:

1. Corridor doors throughout the facility are on automatic closers and these doors are being held open by magnetic hold open devices not tied into the fire alarm system.

2. At 2:40 PM room 202 has a leaf for the door to close into taking this door multiple motions to close. Leaf does not lock in place and does not close on its own.

3. At 2:43 PM the door to room 120 does not latch.


The Maintenance Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: 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 smoke barriers to at least one hour fire resistance. This deficient practice would prevent containment of fire and smoke, affecting four of six smoke zones. The facility has a capacity of 49 and census of 8.

Findings include:

During the survey on 2-15-16 and 2-16-16 the following is observed:

1. It is observed that the smoke barriers throughout the facility have penetrations around hvac ducting and wire trays.


The Maintenance Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1 hour.

Exception No. 1: Where an atrium is used, smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with Exception No. 2 to 8.2.5.6(1). Not less than two separate smoke compartments shall be provided on each floor.
Exception No. 2:* Dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems. 2000 NFPA 101, 18.3.7.3

Review of the following NFPA Standard revealed: 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 ensure proper separation of hazardous areas from other spaces. This deficient practice would allow for the spread of smoke and fire to travel into the adjacent area, affecting one of six smoke zones. The facility has a capacity of 49 and census of 8.

Findings include:

During the survey on 2-15-16 and 2-16-16 the following is observed:

1. At 2:40 PM it is observed that the door to room 202 is not equipped with a closer and is being used as storage. This room is over 100sqft.


The Maintenance Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Hazardous areas shall be safeguarded by a fire barrier of one hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Review of the following NFPA Standard revealed: 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. 2000 NFPA 101, 8.4.1

Based on record review and staff interview, the facility is not conducting fire drills as required 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 four of six smoke zones. The facility has a capacity of 49 and census of 8.

Findings include:

During record review on 2-15-16 and 2-16-16 the following is observed:

1. Review of fire drill records for the last 5 quarters revealed that the drill last four quarters of the second shift drills were all performed between 5:30am and 5:35am.

2. Review of fire drill records for the last 5 quarters revealed that the drills performed in January, February, April, August, and December did not have the fire alarm activated with the drill. The silent drills performed did not activated within 24 hours of the fire drill.


The Maintenance Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: 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, interview and record review, the facility failed to provide and maintain documentation of annual inspection and testing of the fire alarm system as required by NFPA 72. The absence of complete, verifiable documented maintenance and repair history on the fire alarm system fails to ensure reliability of the alarm system in the event of an emergency, affecting all six smoke zones. The facility has a capacity of 49 and census of 8.

Findings include:

During record review on 2-15-16 and 2-16-16 the following is observed:

1. Fire alarm report for 2015 was performed on 1-12-15. The report for 2016 was performed on 1-22-16 which is ten days overdue.


The Maintenance Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: 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, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction. 2000 NFPA 101, 9.6.1.4

Review of the following NFPA Standard revealed: Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7 2.2. 1999 NFPA 72, 7-2.2

Based on record review and staff interviews, the facility failed to assure that the sprinkler system is maintained and inspected in accordance with NFPA 25. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting four of six smoke zones. The facility has a capacity of 49 and census of 8.

Findings include:

During record review on 2-15-16 and 2-16-16 the following is observed:

1. The annual sprinkler report states that the backflow testing is overdue.


The Maintenance Director was present and acknowledged the findings.


Review of the following NFPA Standard revealed: Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. 2000 NFPA 101, 4.6.12.1

Review of the following NFPA Standard revealed: All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2000 NFPA 101, 9.7.5

Review of the following NFPA Standard revealed: To ensure that piping remains clear of all obstructive foreign matter, an obstruction investigation shall be conducted for system or yard main piping wherever any of the following conditions exist:

(a) Defective intake for fire pumps taking suction from open bodies of water
(b) The discharge of obstructive material during routine water tests
(c) Foreign materials in fire pumps, in dry pipe valves, or in check valves
(d) Foreign material in water during drain tests or plugging of inspector ' s test connection(s)
(e) Plugged sprinklers
(f) Plugged piping in sprinkler systems dismantled during building alterations
(g) Failure to flush yard piping or surrounding public mains following new installations or repairs
(h) A record of broken public mains in the vicinity
(i) Abnormally frequent false tripping of a dry pipe valve(s)

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 six smoke zones. The facility has a capacity of 49 and census of 8.

Findings include:

During the survey on 2-15-16 and 2-16-16 the following is observed:

1. At 2:23 PM it is observed that a space heater is in use in the O.B. office. This office is located in the O.B. patient care area.


The Maintenance Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Portable space-heating devices shall be prohibited in all health care occupancies.

Exception: Portable space-heating devices shall be permitted to be used in non-sleeping staff and employee areas where the heating elements of such devices do not exceed 212°F (100°C). 2000 NFPA 101, 19.7.8

Based on observation and staff interview the facility fails to ensure that all means of egress are free of all obstructions or impediments to a full instant use. This deficient practice could impede occupants from exiting in the event of a fire or other emergency situation, affecting one of six smoke zones. The facility has a capacity of 49 and census of 8.

Findings include:

During the survey on 2-15-16 and 2-16-16 the following is observed:

1. At 2:00 PM it is observed that a bed is being stored in the exit corridor in recovery area.


The Maintenance Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: 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

Review of the following NFPA Standard revealed: No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress from, or visibility thereof. 2000 NFPA 101, 7.1.10.2.1

Review of the following NFPA Standard revealed: Exits shall terminate directly at a public way or an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. 2000 NFPA 101, 7.7.1