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Based on observation, document review, and staff interview, the facility failed to properly inspect and maintain the corridor doors in accordance with NFPA 101. This deficient practice could affect 1 resident and all staff and visitors in 1 of 6 smoke zones. The facility has a capacity of 16 with a census of 3 residents at the time of survey.
Findings include:

During the survey conducted on 9/22/16 the following deficiencies are noted:

1. During the survey at approximately 3:15 PM it is observed that the smoke barrier door to outpatient exam room 2 would not completely close and latch when tested.
2. During the survey at approximately 3:20 PM it is observed that the smoke barrier door to the respiratory therapy room would not completely close and latch when tested.

Maintenance staff was present and acknowledged that the smoke barrier doors did not completely close and latch.
NFPA Standard: Doors in corridor walls of sprinkled 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-sprinkled 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 assure that hazardous areas properly protected in the event of a fire and to resist the passage of smoke. The deficient practice could affect no residents and all visitors and staff in 1 of 6 smoke zones. The facility has a capacity of 16 with a census of 3 residents at the time of the survey.
Findings Include:

During the survey conducted on 9/22/16 the following deficiencies are noted:

1. During the survey at approximately 3:25 PM it is observed that there are penetrations by IT wires and an HVAC Pipe that are unsealed in the air handler mechanical room.

Maintenance Staff was present and acknowledged the penetrations in the air handler mechanical room.
NFPA Standard: 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

Based on observation, document review, and staff interview, the facility failed to properly inspect and maintain the sprinkler system in accordance with NFPA 25. This deficient practice could affect all occupants, visitors, and staff in 6 of 6 smoke zones. The facility has a capacity of 16 and a census of 3 at the time of the survey.

Findings include:

During the survey conducted on 9/22/16 the following deficiencies are noted:

1. During document review at approximately 12:00 PM it is observed that there is no documentation for a quarterly inspection of the sprinkler system in the 2nd quarter of 2016.
2. During the survey at approximately 3:00 PM it is observed that there is a sprinkler head with paint on it in the basement conference room.

Maintenance Staff was present and acknowledged the missed monthly inspection and the painted sprinkler head.
NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. 1999 NFPA 13, 12.1

Based on observation, the facility did not post warning signs on a room where oxygen was being stored. The deficient practice could affect 1 resident and all staff and visitors in 1 of 6 smoke zones. This facility has a capacity of 16 and a census of 3 residents at the time of survey.
Findings include:

During the survey conducted on 9/22/16 the following deficiencies are noted:

1. During the survey at approximately 3:20 PM it is observed that there are no signs on the door to the respiratory therapy room where oxygen is being used and stored.

Maintenance Staff was present and acknowledged the needed signage for the oxygen in use and stored in the respiratory therapy room.

NFPA Standard: "No smoking" signs are required where oxygen is used or stored. 2000 NFPA 101, 18/19.7.4

Based on staff interview and record review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice would affect all residents, visitors, and staff in 6 of 6 smoke zones. The facility has a capacity of 16 with a census of 3 residents at the time of the survey.
Findings include:

During the survey conducted on 9/22/16 the following deficiency is noted:

1. During document review at approximately 12:30 PM it is observed that proper testing of the generator weekly inspections and run times has not been maintained. There is no documentation for any weekly tests of the generator since August 2016.

Maintenance staff was present and acknowledged the missed weekly tests of the generator.


NFPA Standard: Level 1 and level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes. 1999 NFPA 110, 6.4.1 and 6.4.2

Based on observation and staff interview the facility fails to assure that all electrical wiring complies with NFPA 70. This deficient practice could result in an electrical short causing a fire, affecting no patients and all visitors and staff in 3 of 6 smoke zones. The facility has a capacity of 16 with a census of 3 at the time of this survey.
Findings Include:

During the tour conducted on 9/22/16 the following deficiency is noted:

1. During the survey at approximately 2:45 PM it is observed in the maintenance office that there is an open junction box on the ceiling over the desk.
2. During the survey at approximately 2:50 PM it is observed that there is an open junction box on the wall near the boilers in the boiler room.
3. During the survey at approximately 3:10 PM it is observed that there is a power strip powered by a surge protector in the outpatient coordinators office.

Maintenance Staff was present and acknowledged the open junction boxes and the power strip powered by a surge protector.
NFPA Standard: Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2

Based on observation, document review, and staff interview, the facility failed to properly inspect and maintain the corridor doors in accordance with NFPA 101. This deficient practice could affect 1 resident and all staff and visitors in 1 of 6 smoke zones. The facility has a capacity of 16 with a census of 3 residents at the time of survey.
Findings include:

During the survey conducted on 9/22/16 the following deficiencies are noted:

1. During the survey at approximately 3:15 PM it is observed that the smoke barrier door to outpatient exam room 2 would not completely close and latch when tested.
2. During the survey at approximately 3:20 PM it is observed that the smoke barrier door to the respiratory therapy room would not completely close and latch when tested.

Maintenance staff was present and acknowledged that the smoke barrier doors did not completely close and latch.
NFPA Standard: Doors in corridor walls of sprinkled 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-sprinkled 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 assure that hazardous areas properly protected in the event of a fire and to resist the passage of smoke. The deficient practice could affect no residents and all visitors and staff in 1 of 6 smoke zones. The facility has a capacity of 16 with a census of 3 residents at the time of the survey.
Findings Include:

During the survey conducted on 9/22/16 the following deficiencies are noted:

1. During the survey at approximately 3:25 PM it is observed that there are penetrations by IT wires and an HVAC Pipe that are unsealed in the air handler mechanical room.

Maintenance Staff was present and acknowledged the penetrations in the air handler mechanical room.
NFPA Standard: 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

Based on observation, document review, and staff interview, the facility failed to properly inspect and maintain the sprinkler system in accordance with NFPA 25. This deficient practice could affect all occupants, visitors, and staff in 6 of 6 smoke zones. The facility has a capacity of 16 and a census of 3 at the time of the survey.

Findings include:

During the survey conducted on 9/22/16 the following deficiencies are noted:

1. During document review at approximately 12:00 PM it is observed that there is no documentation for a quarterly inspection of the sprinkler system in the 2nd quarter of 2016.
2. During the survey at approximately 3:00 PM it is observed that there is a sprinkler head with paint on it in the basement conference room.

Maintenance Staff was present and acknowledged the missed monthly inspection and the painted sprinkler head.
NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. 1999 NFPA 13, 12.1

Based on observation, the facility did not post warning signs on a room where oxygen was being stored. The deficient practice could affect 1 resident and all staff and visitors in 1 of 6 smoke zones. This facility has a capacity of 16 and a census of 3 residents at the time of survey.
Findings include:

During the survey conducted on 9/22/16 the following deficiencies are noted:

1. During the survey at approximately 3:20 PM it is observed that there are no signs on the door to the respiratory therapy room where oxygen is being used and stored.

Maintenance Staff was present and acknowledged the needed signage for the oxygen in use and stored in the respiratory therapy room.

NFPA Standard: "No smoking" signs are required where oxygen is used or stored. 2000 NFPA 101, 18/19.7.4

Based on staff interview and record review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice would affect all residents, visitors, and staff in 6 of 6 smoke zones. The facility has a capacity of 16 with a census of 3 residents at the time of the survey.
Findings include:

During the survey conducted on 9/22/16 the following deficiency is noted:

1. During document review at approximately 12:30 PM it is observed that proper testing of the generator weekly inspections and run times has not been maintained. There is no documentation for any weekly tests of the generator since August 2016.

Maintenance staff was present and acknowledged the missed weekly tests of the generator.


NFPA Standard: Level 1 and level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes. 1999 NFPA 110, 6.4.1 and 6.4.2

Based on observation and staff interview the facility fails to assure that all electrical wiring complies with NFPA 70. This deficient practice could result in an electrical short causing a fire, affecting no patients and all visitors and staff in 3 of 6 smoke zones. The facility has a capacity of 16 with a census of 3 at the time of this survey.
Findings Include:

During the tour conducted on 9/22/16 the following deficiency is noted:

1. During the survey at approximately 2:45 PM it is observed in the maintenance office that there is an open junction box on the ceiling over the desk.
2. During the survey at approximately 2:50 PM it is observed that there is an open junction box on the wall near the boilers in the boiler room.
3. During the survey at approximately 3:10 PM it is observed that there is a power strip powered by a surge protector in the outpatient coordinators office.

Maintenance Staff was present and acknowledged the open junction boxes and the power strip powered by a surge protector.
NFPA Standard: Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2