HospitalInspections.org

LSC 101/2000
7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self closing or automatic closing in accordance with 7.2.1.8.2

Based on observation and staff interview, the facility failed to ensure the stairway door located on first floor, west wing was self closing and relatching. In the event of a fire, this stairwell may become contaminated with smoke and allow the fire to spread to the second floor, which may lead to potential harm by fire/smoke to staff. The findings are:

A. On 09/28/15 at 4:20 pm, observation of the door to the stairwell in the west wing at the first floor level did not close and relatch.

B. On 09/28/15 at 4:22 pm, during interview, the Maintenance Manager stated the door needs to be adjusted, confirming that it does not close and relatch.

Based on observation and interview, the facility failed to ensure that the smoke barriers were sealed with no penetrations in two locations. This failed practice allows the spread of fire/smoke to other areas, which has the potential to harm all nine (9) patients, as identified by the patient census list provided by the Quality Assurance Officer on 09/28/15. The findings are:

A. On 09/28/15 at 1:55 pm, observation of penetrations and opening around piping, conduit and cables in the smoke barrier above the ceiling at the smoke doors of the Operating Room (OR) suite.

B. On 09/28/15 at 2:22 pm, observation of penetrations and openings around piping, conduit and cables in the smoke barrier above the ceiling at the smoke doors, North/South wings.

C. On 09/28/15 at 1:55 pm and 2:22 pm, the Maintenance Manager viewed the penetrations at the OR suite and North/South wings, confirming these findings.

Based on record review and interview, the facility failed to provide fire drill records from August to Decmber 2014, which indicates that fire drills have not been conducted. Federal regulations require that fire drills be conducted every 90 days on each shift. This failed practice may lead to the staff not being proficient in fire and evacuation procedures, in the event of a fire or other emergency. This has the potential to harm the nine (9) patients as identified by the patient census list provided by the Quality Assurance Officer on 09/28/15 including staff and vistors. The findings are:

A. Record review of Fire Drill records and staff interview with Maintenance Manager, indicates the facility has two (2) shifts:
Shift 1: 6 am to 6 pm
Shift 2: 6 pm to 6 am

B. During record review of the Fire Drill records, the Maintenance Manager was not able to provide fire drill records for August to December 2014 to show the fire drills were conducted as required.

C. On 09/28/15 at 12:30 pm, the Maintenance Manager stated he was not responsible for conducting fire drills during that period. The safety officer, who left employment two months ago was responsible and, I cannot find the fire drill records, confirming no fire drill records for that period (August to December 2014).

Reference NFPA 101, 2000 Edition

9.6.2.9 Where a partial smoke detection system is required by another section of this Code, automatic detection of smoke in accordance with NFPA 72, National Fire Alarm Code, shall be provided in all common areas and work spaces, such as corridors, lobbies, storage rooms, equipment rooms, and other tenantless spaces in those environments suitable for proper smoke detector operation. Selective smoke detection unique to other sections of this Code shall be provided as required by those sections.

Reference NFPA 72, 1999 Edition

2-3.4.5 Smooth Ceiling Spacing.
2-3.4.5.1 Spot-Type Detectors.
2-3.4.5.1.1
On smooth ceilings, spacing of 30 ft (9.1 m) shall be permitted to be used as a guide. In all cases, the manufacturer's documented instructions shall be followed. Other spacing shall be permitted to be used depending on ceiling height, different conditions, or response requirements.


Based on observation and interview, the facility failed to ensure five (5) locations in the facility, were provided with automatic smoke detection as required by NFPA 72 (National Fire Alarm Code). Not providing automatic smoke detection within these 5 areas, could result in an undetected fire at these locations, which would delay notification of a fire, presenting a risk of potential harm to all nine (9) patients within the facility as identified by the patient census list provided by the Quality Assurance Officer on 09/28/15. The findings are:

A. On 09/28/15 at 2:22 pm, observation of a skylight (32 inches X 32 inches X 43 inches), located in the Anesthesia Office on the second floor without smoke detection device.

B. On 09/28/15 at 2:28 pm, observation of a skylight (48 inches X 48 inches X 43 inches), locate above the ceiling on the North side of the smoke doors seperating the North/South wings on the second floor, without smoke detection device.

C. On 09/28/15 at 4:30 pm, observation of the medical records room located in the west wing on the first floor, having a large quantity of combustible materials stored, with no smoke detection device.

D. On 09/28/15 at 5:40 pm, observation of the record storage room located behind the reception area on the first floor, having a large quantity of combustible materials stored, with no smoke detection device.

E. On 09/28/15 at 5:45 pm, observation of the records storage room (last room on the east side of corridor) in the south wing first floor, having a large quantity of combustible materials stored, with no smoke detection device.

F. On 09/28/15 at 5:50 pm, during interview, the Maintenance Manager stated there was a large quantity of combustible material stored in each location and, smoke detectors should be installed, confirming these findings.

Based on record review and staff interview, the facility failed to ensure the fire alarm system is inspected and tested annually in accordance with the requirements of NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm and Signaling Code). This failed practice may prevent the fire alarm system from functioning in the event of a fire or other emergency, leading to potential harm from fire/smoke to nine (9) patients as identified by the patient census list provided by the Quality Assurance Officer on 09/28/15 including staff and visitors. The findings are:

A. During record review of the fire alarm system records, the Maintenance Manager was unable to provide documentation showing the fire alarm system has been inspected/tested annuallyfor the years 2014 and 2015.

B. On 09/28/15 at 12:50 pm, during interview, the Maintenance Manager stated the safety officer was responsible but he left employment two months ago and, I am unable to locate the records, confirming that the fire alarm system inspection records were not available.


Based on observation and staff interview, the facility failed to ensure the Fire Alarm System was fully operational and not in "Trouble" mode. This failed practice may prevent the fire alarm system from initiating an alarm and notifying the occupants of an alarm, in the event of fire, leading to potential harm by fire/smoke, to nine (9) patients as identified by the patient census list provided by the Quality Assurance Officer on 09/28/15 including staff and visitors. The findings are:

A. On 09/28/15 at 1:30 pm, observation of the fire alarm panel indicated trouble and supervisory modes.

B. On 09/28/15 at 1:31 pm, during interview, the Maintenance Manager stated the alarm company is working on the fire alarm system at this time, confirming the system being in the trouble/supervisory mode.

C. On 09/28/15 at 6:55 pm, observation of the fire alarm panel still indicating trouble mode.

D. On 09/28/15 at 6:57 pm, during interview, the Maintenance Manager observed the system showing trouble mode, confirming the system is still in trouble mode.

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.

7-5.2.2
A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, tests performed in accordance with Section 7-2 and 7-3
(8) Functional test of detectors
(9) * Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15) Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place)


Based on record review and interview, the facility failed to ensure smoke detectors were tested for sensitivity at least every two years as required by NFPA 72 (National Fire Alarm Code). Without this testing, the facility has no assurance the smoke detectors would detect smoke within their listed sensitivity, which in the event of fire, presents a risk of potential harm to all nine (9) patients as identified by a patient census list provided by the Quality Assurance Officer on 09/28/15. The findings are:

A. During record review of the smoke detector sensitivity testing records, there were no records available to show the smoke detectors were sensitivity tested every two years as required.

B. On 09/28/15 at 1:05pm, during interview, the Maintenance Manager stated that he was unable to locate any records, confirming the smoke detector sensitivity testing was not conducted.

Based on record review and staff interview, the facility failed to ensure the automatic sprinkler system was inspected quarterly as required by NFPA 25 (Inspection, Testing and Maintenance of Water Based Fire Protection Systems). This failed practice may result in the sprinkler system failure in the event of a fire incident, which has the potential to harm, all nine (9) patients as identified by the patient census list provided by the Quality Assurance Officer on 09/28/15 including staff and visitors. The findings are:

A. During record review of the sprinkler maintenance records, the quarterly inspection records for the last quarterly inspection in 2014 was not available.

B. On 09/28/15 at 12:20 pm, during interview, the Maintenance Manager confirmed the 2014 quarterly inspection records were not avaiable.


NFPA 25/1998
10-2.2 Obstruction Prevention

Systems shall be examined internally for obstructions where conditions exist that could cause obstructed piping. If the condition has not been corrected or the condition is one that result in obstruction of piping despite any previous flushing procedures that have been performed, the system shall be examined internally for obstructions every five years. This investigation shall be accommplished by examining the interior of a dry valve or preaction valve and by removing two cross main flushing connections.

Based on record review and interview, the facility failed to ensure that a five (5) year piping obstruction test was performed on the automatic fire sprinkler system. This failed practice may result in the failure of the sprinkler system in the event of a fire, resulting in injury/death by fire to all nine (9) patients as identified by the patient census list provided by the Quality Assurance Officer on 09/28/15 and, staff and visitors. The findings are:

A. During record review of the sprinkler maintenance records, there were no records available to indicate the 5 year piping obstruction inspection was conducted.

B. On 09/28/15 at 12:20 pm, during interview, the Maintenance Manager stated he was unable to locate any records, confirming there were no records to indicate the 5 year piping obstruction inspection was conducted.

Based on observation and interview, the facility failed to ensure the exhaust fans in two (2) Housekeeping closets were functioning. This failed practice may lead to potential harm from toxic fumes escaping from the chemicals stored within, to all nine (9) patients as identified by the patient census list provided by the Quality Assurance Officer ob 09/28/15 including staff and visitors. The findings are:

A. On 09/28/15 at 2:40 pm, observation of the exhaust fan located in the second floor housekeeping closet was not functioning.

B. On 09/28/15 at 4:35 pm, observation of the exhaust fan located in the first floor housekeeping closet was not functioning.

C. On 09/28/15 at 4:37 pm, during interview, the Maintenance Manager witnessed the fans not functioning, confirming the fans were not functioning.

NFPA 101/2000
9.2.3 Commercial Cooking Equipment.
Commercial cooking equipment shall be inaccordance with NFPA 96 (Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 96/1998 Chapter 2 Exhaust Hoods
2-1 Construction
2-1.1 The hood or that portion of a primary collection means designed for collecting cooking vavoprs and residues shall be constructed of and be supported by steel not less than 0,043 in. (1.09 mm)(No. 18 MSG) in thickness, stainless steel not less than 0,037 in. (0.94mm) (No. 20 MSG) in thickness, or other approved material of equivalent strength and fire and corrosion resistance.
Exception: Listed exhaust hoods with or without exhaust dampers

2-1.2 All seams, joints, and penetrations of the hood enclosure that direct and capture grease laden vapors and exhaust gases shall have a liquidtight continuous external weld to the hood's lower outermost perimeter. Internal hood joints, seams, filter support frames and appendages attached inside the hood need not be welded but shall be sealed or otherwise made grease tight.

Exception 1: Penetrations shall be permitted to be sealed by devices that are listed for such use and whose presence does not detract from the hood's or duct's structural integrity.

Exception 2: Eyebrow type hoods over gas or electric ovens shall be permitted to have a duct constructed as in Chapter 4 from the oven flue(s) connected to the hood canopy upstream of the exhaust plenum as shown in figure 2-1.2. The duct shall be connected to the hood with a continuous weld or have a duct to duct connection as shown in figure 5-1.2 (b), (c) or (d).

Exception 3: Seams, joints and penetrations of the hood shall be permitted to be internally welded, provided that the weld is formed smooth or ground smooth, so as not to trap grease, and is reaily cleanable.2-2 Hood Size: Hoods shall be sized and configured to provide for the capture and removal of grease laden vapors

Chapter 3 Grease Removal Devices in Hoods
3-1 Grease Removal Devices
Listed grease filters, baffles or other approved grease removal devices for use with commercial cooking equipment shall be provided. Listed grease filters shall be tested in accordance with UL 1046, Grease Filters for Exhaust Ducts. Mesh filters shall not be used.

3-2 Installation
The distance between the grease removal device and the cooking surfaceshall be as great as possible but not less than 18 in. Where used in conjunction with charcoal or charcoal type broilers, including gas or electrically heated char broilers, a minimum vertical distance of 4 ft. shall be maintained between the lower edge of the grease removal device and the cooking surface.

Exception 1: Grease removal devices supplied as part of listed hood assemblies shall be installed in accordance with the terms of the listing and manufacturer's instructions.

Exception 2: For cooking equipment without exposed flame and where flu gases by pass grease removal devices, the minimum vertical distance shall be permitted to be reduced to not less than 6 inches.

3-2.2
Grease removaldevices shall be protected from combustion gas outlets and from direct flame impingement occurring during normal operation of cooking appliances producing high flu gas temperatures, such as deep fat fryers or upright or high broilers (salamanders), where the distance between the grease removal device and the appliance flue outlet (heat source) is less than 18 inches, This protection shall be permitted to be accomplished by the installation of a steel or stainless steel baffle plate between the heat source and the grease removal device. The baffle plate shall be sized and located so that flames or combustion gases shall travel a distance not less than 18 inches from the heat source to the grease removal device. The baffle shall be located not less than 6 inches from the grease removal device.

3-2.3 Grease filters shall be listed and constructed of steel or listed equivalent material and shall be of rigid construction that will not distort or crush under normal operation, handling and cleaning conditions. Filters shall be tight fitting and firmly held in place.

3-2.4 Filters shall be easily accessible and removeable for cleaning.

3-2.5 Filters shall be installed at an angle not less than 45 degrees from the horizontal.

3-2.6 Filters shall be equipped with a drip tray beneath their lower edges. The tray shall be kept to the minimum size needed to collect grease and shall be pitched to drain into an enclosed metal container having a capacity not exceeding 1 gallon.

3-2.7Grease filters that require a specific orientation to drain grease shall be clearly so designated, or the hood shall be constructed so that the filters cannot be installed in the wrong orientation.

Based on observation and interview, the facility failed to ensure that an approved cooking exhaust hood and filter bank is installed in the kitchen over the appliances. This failed practice allows the cooking grease to drip back onto the appliances and floor. This is not only a fire hazard but, a health hazard. Potential harm by fire or food born illness may harm all nine (9) patients as identified by the patient census list provided by the Quality Assurance Officer on 09/28/15 including staff and visitors. The findings are:

A. On 09/28/15 at 6:00 pm, observation of an non approved cooking exhaust hood installed over the cooking appliance in the kitchen. This hood has improperly installed filter bank (installed horizontally), not on the 45 degree installation as required. The filters do not have the grease collection devices and the exhaust hood is open in the center allowing the grease to drip onto the appliances and the floor.

B. On 09/28/15 at 6:02 pm, during interview, the Maintenance Manager stated he was not aware of the cooking exhaust system Codes, confirming the non approved hood.

NFPA 25/1998
3-2 Inspection
3-2.1 Components of standpipe and hose systems shall be visually inspected quarterly or as specified in Table 3-1.

3-2.2 Check points and corrective actions outlined in Table 3-2.3 shall be followed to determine that components are free of corrosion, foreign material, physical damage, tampering, or other conditions that could prevent operation.

3-2.2 Table 3-2.3 shall be used for the inspection, testing and maintenance of all classes of standpipe and hose systems.

3-2.3 Testing. The tests shall be conducted by a qualified person.
Where water damage is a possibility, an air test shall be conducted on the system at 25 psi prior to introducing water to the system.

3-3.1 Flow tests
3-3.1.1A flow test shall be conducted at the hydraulically most remote hose connection of each zone of a standpipe system to verify the water supply will adequately provides the design pressure at the required flow. Where a flow test of the hydralically most remote outlet(s) is not practical, the authority having jurisdiction shall be consulted for the appropriate location of the test.
A flow test shall be conducted every 5 years.

Based on record review and interview, the facility failed to maintain the standpipe fire protection system. This failed practice may result in the failure of the system during a fire event, causing a delay in the firefighters getting water on the fire, which may lead to potential harm to all nine (9) patients as identified by the patient census list provided by the Quality Assurance Officer on 09/28/15 including staff and visitors. The findings are:

A. During record review of the fire protection system records, there were no records available to indicate that the standpipe system has been inspected/tested/maintained.

B. On 09/28/15 at 1:11 pm, during interview, the Maintenance Manager stated that he could not locate any records to indicate the standpipe system has been inspected/tested/maintained, confirming this finding.


Based on observation and interview, the facility failed to provide access to storage room 21, located on the first floor off the lobby area. This failed practice prevented the surveyor from inspecting the contents and protection devices within for combustible and hazardius storage. In the event of a fire, the unkown detection device may delay the notification of a fire and, the unkown contents may present a high risk to all nine (9) patients as identified. by the patient census list provided by the Quality Assurance Officer on 09/28/15 including staff and visitors. The findings are:

A. On 09/28/15 at 5:55 pm, observation of Maintenance Manager not having a key to access storage room 21.

B. On 09/28/15 at 5:57 pm, during interview, the Maintenance Manager stated he tried all keys available and one key labeled room 21, but none worked to unlock the door, confirming this finding.



Reference NFPA 101, 2000 Edition

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.


Based on observation and interview, the facility failed to ensure all resident room restroom doors were capable of being unlocked by health care personnel from the outside in the event of emergency. Staff not being able to unlock these doors could result in delay and ineffective response of health care personnel in the event of emergency such as fire, which presents a risk of potential harm to all nine (9) patients as identified by the patient census list provided by the Quality Assurance Officer on 09/28/15. The findings are:

A. On 09/28/15 at 3:00 pm, during observation the restroom which serves patient rooms 226 was provided with locking hardware that required the use of a special tool to unlock from the outside.

B. On 09/28/15 at 3:05 pm, a simulated emergency evacuation was conducted. This simulation consisted of locking the restroom door from the inside and having the first available staff open the door as if to rescue a resident. When staff #1 was asked to rescue the resident from the inside of the restroom, she could not open the restroom door from the outside to evacuate the resident.

C. On 09/28/15 at 3:06 pm, during interview, staff #1 stated she was unaware how to open the door in the event it was locked from the inside.

D. On 09/28/15 at 3:07 pm, during interview, the Maintenance Manager stated that all patient room bathrooms have the same type of locking devices that requires a special tool to unlock the door from the outside.

NFPA 70, 1999 Edition
384-13 ...All panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors.


Based on observation and interview, the facility failed to ensure electrical panels and circuit breakers were identified in accordance with NFPA 70 (National Electrical Code). It is essential all circuit breakers within electrical panels are properly identified as to what they serve, so in the event of emergency, selected electrical circuits can be turned off. This failed practice could result in the incorrect breakers being turned off in the event of fire or other emergency, which presents a risk of potential harm to all nine (9) patients as identified by the patient census list provided by the Quality Assurance Officer on 09/28/15. The findings are:

A. On 09/28/15 at 2:45 pm, observation of two (2) electric panels located in room 086 on the second floor were not identified as to what they serve and the circuit breakers within the panels were also not identifed.

B. On 09/28/15 at 2:47 pm, during interview, the Maintenance Manager stated these are newly installed, confirming the panels and circuit breakers are not identified.

LSC 101/2000
9,4,6 Elevator shall be subject to routine and periodic inspections and tests as specified in ASME/ANSI A17.1 (Safety Code for Elevators and Escalators). All elevators equipped with fire fighter service in accordance with 9.4.4 and 9.4.5 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required for ASME/ANSI A17.1.

Based on record review, observation and interview, the facility failed to ensure that the elevators were inspected and tested as required. This failed practice may result in failure of the elevators, resulting in patients, staff and visitors becomming trapped inside the elevators. The findings are:

A. During record review of the elevator maintenance records and subsequent walkthrough of the elevators, there were no records available to indicate the periodic inspection/testing has been conducted and no inspection record posted in the elevators, as sometimes found.

B. On 09/28/15 at 1:07 pm, during interview, the Maintenance Manager stated he was unable to locate any elevator inspection/test records, confirming this finding.

LSC 101/2000
7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self closing or automatic closing in accordance with 7.2.1.8.2

Based on observation and staff interview, the facility failed to ensure the stairway door located on first floor, west wing was self closing and relatching. In the event of a fire, this stairwell may become contaminated with smoke and allow the fire to spread to the second floor, which may lead to potential harm by fire/smoke to staff. The findings are:

A. On 09/28/15 at 4:20 pm, observation of the door to the stairwell in the west wing at the first floor level did not close and relatch.

B. On 09/28/15 at 4:22 pm, during interview, the Maintenance Manager stated the door needs to be adjusted, confirming that it does not close and relatch.

Based on observation and interview, the facility failed to ensure that the smoke barriers were sealed with no penetrations in two locations. This failed practice allows the spread of fire/smoke to other areas, which has the potential to harm all nine (9) patients, as identified by the patient census list provided by the Quality Assurance Officer on 09/28/15. The findings are:

A. On 09/28/15 at 1:55 pm, observation of penetrations and opening around piping, conduit and cables in the smoke barrier above the ceiling at the smoke doors of the Operating Room (OR) suite.

B. On 09/28/15 at 2:22 pm, observation of penetrations and openings around piping, conduit and cables in the smoke barrier above the ceiling at the smoke doors, North/South wings.

C. On 09/28/15 at 1:55 pm and 2:22 pm, the Maintenance Manager viewed the penetrations at the OR suite and North/South wings, confirming these findings.

Based on record review and interview, the facility failed to provide fire drill records from August to Decmber 2014, which indicates that fire drills have not been conducted. Federal regulations require that fire drills be conducted every 90 days on each shift. This failed practice may lead to the staff not being proficient in fire and evacuation procedures, in the event of a fire or other emergency. This has the potential to harm the nine (9) patients as identified by the patient census list provided by the Quality Assurance Officer on 09/28/15 including staff and vistors. The findings are:

A. Record review of Fire Drill records and staff interview with Maintenance Manager, indicates the facility has two (2) shifts:
Shift 1: 6 am to 6 pm
Shift 2: 6 pm to 6 am

B. During record review of the Fire Drill records, the Maintenance Manager was not able to provide fire drill records for August to December 2014 to show the fire drills were conducted as required.

C. On 09/28/15 at 12:30 pm, the Maintenance Manager stated he was not responsible for conducting fire drills during that period. The safety officer, who left employment two months ago was responsible and, I cannot find the fire drill records, confirming no fire drill records for that period (August to December 2014).

Reference NFPA 101, 2000 Edition

9.6.2.9 Where a partial smoke detection system is required by another section of this Code, automatic detection of smoke in accordance with NFPA 72, National Fire Alarm Code, shall be provided in all common areas and work spaces, such as corridors, lobbies, storage rooms, equipment rooms, and other tenantless spaces in those environments suitable for proper smoke detector operation. Selective smoke detection unique to other sections of this Code shall be provided as required by those sections.

Reference NFPA 72, 1999 Edition

2-3.4.5 Smooth Ceiling Spacing.
2-3.4.5.1 Spot-Type Detectors.
2-3.4.5.1.1
On smooth ceilings, spacing of 30 ft (9.1 m) shall be permitted to be used as a guide. In all cases, the manufacturer's documented instructions shall be followed. Other spacing shall be permitted to be used depending on ceiling height, different conditions, or response requirements.


Based on observation and interview, the facility failed to ensure five (5) locations in the facility, were provided with automatic smoke detection as required by NFPA 72 (National Fire Alarm Code). Not providing automatic smoke detection within these 5 areas, could result in an undetected fire at these locations, which would delay notification of a fire, presenting a risk of potential harm to all nine (9) patients within the facility as identified by the patient census list provided by the Quality Assurance Officer on 09/28/15. The findings are:

A. On 09/28/15 at 2:22 pm, observation of a skylight (32 inches X 32 inches X 43 inches), located in the Anesthesia Office on the second floor without smoke detection device.

B. On 09/28/15 at 2:28 pm, observation of a skylight (48 inches X 48 inches X 43 inches), locate above the ceiling on the North side of the smoke doors seperating the North/South wings on the second floor, without smoke detection device.

C. On 09/28/15 at 4:30 pm, observation of the medical records room located in the west wing on the first floor, having a large quantity of combustible materials stored, with no smoke detection device.

D. On 09/28/15 at 5:40 pm, observation of the record storage room located behind the reception area on the first floor, having a large quantity of combustible materials stored, with no smoke detection device.

E. On 09/28/15 at 5:45 pm, observation of the records storage room (last room on the east side of corridor) in the south wing first floor, having a large quantity of combustible materials stored, with no smoke detection device.

F. On 09/28/15 at 5:50 pm, during interview, the Maintenance Manager stated there was a large quantity of combustible material stored in each location and, smoke detectors should be installed, confirming these findings.

Based on record review and staff interview, the facility failed to ensure the fire alarm system is inspected and tested annually in accordance with the requirements of NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm and Signaling Code). This failed practice may prevent the fire alarm system from functioning in the event of a fire or other emergency, leading to potential harm from fire/smoke to nine (9) patients as identified by the patient census list provided by the Quality Assurance Officer on 09/28/15 including staff and visitors. The findings are:

A. During record review of the fire alarm system records, the Maintenance Manager was unable to provide documentation showing the fire alarm system has been inspected/tested annuallyfor the years 2014 and 2015.

B. On 09/28/15 at 12:50 pm, during interview, the Maintenance Manager stated the safety officer was responsible but he left employment two months ago and, I am unable to locate the records, confirming that the fire alarm system inspection records were not available.


Based on observation and staff interview, the facility failed to ensure the Fire Alarm System was fully operational and not in "Trouble" mode. This failed practice may prevent the fire alarm system from initiating an alarm and notifying the occupants of an alarm, in the event of fire, leading to potential harm by fire/smoke, to nine (9) patients as identified by the patient census list provided by the Quality Assurance Officer on 09/28/15 including staff and visitors. The findings are:

A. On 09/28/15 at 1:30 pm, observation of the fire alarm panel indicated trouble and supervisory modes.

B. On 09/28/15 at 1:31 pm, during interview, the Maintenance Manager stated the alarm company is working on the fire alarm system at this time, confirming the system being in the trouble/supervisory mode.

C. On 09/28/15 at 6:55 pm, observation of the fire alarm panel still indicating trouble mode.

D. On 09/28/15 at 6:57 pm, during interview, the Maintenance Manager observed the system showing trouble mode, confirming the system is still in trouble mode.

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.

7-5.2.2
A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, tests performed in accordance with Section 7-2 and 7-3
(8) Functional test of detectors
(9) * Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15) Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place)


Based on record review and interview, the facility failed to ensure smoke detectors were tested for sensitivity at least every two years as required by NFPA 72 (National Fire Alarm Code). Without this testing, the facility has no assurance the smoke detectors would detect smoke within their listed sensitivity, which in the event of fire, presents a risk of potential harm to all nine (9) patients as identified by a patient census list provided by the Quality Assurance Officer on 09/28/15. The findings are:

A. During record review of the smoke detector sensitivity testing records, there were no records available to show the smoke detectors were sensitivity tested every two years as required.

B. On 09/28/15 at 1:05pm, during interview, the Maintenance Manager stated that he was unable to locate any records, confirming the smoke detector sensitivity testing was not conducted.

Based on record review and staff interview, the facility failed to ensure the automatic sprinkler system was inspected quarterly as required by NFPA 25 (Inspection, Testing and Maintenance of Water Based Fire Protection Systems). This failed practice may result in the sprinkler system failure in the event of a fire incident, which has the potential to harm, all nine (9) patients as identified by the patient census list provided by the Quality Assurance Officer on 09/28/15 including staff and visitors. The findings are:

A. During record review of the sprinkler maintenance records, the quarterly inspection records for the last quarterly inspection in 2014 was not available.

B. On 09/28/15 at 12:20 pm, during interview, the Maintenance Manager confirmed the 2014 quarterly inspection records were not avaiable.


NFPA 25/1998
10-2.2 Obstruction Prevention

Systems shall be examined internally for obstructions where conditions exist that could cause obstructed piping. If the condition has not been corrected or the condition is one that result in obstruction of piping despite any previous flushing procedures that have been performed, the system shall be examined internally for obstructions every five years. This investigation shall be accommplished by examining the interior of a dry valve or preaction valve and by removing two cross main flushing connections.

Based on record review and interview, the facility failed to ensure that a five (5) year piping obstruction test was performed on the automatic fire sprinkler system. This failed practice may result in the failure of the sprinkler system in the event of a fire, resulting in injury/death by fire to all nine (9) patients as identified by the patient census list provided by the Quality Assurance Officer on 09/28/15 and, staff and visitors. The findings are:

A. During record review of the sprinkler maintenance records, there were no records available to indicate the 5 year piping obstruction inspection was conducted.

B. On 09/28/15 at 12:20 pm, during interview, the Maintenance Manager stated he was unable to locate any records, confirming there were no records to indicate the 5 year piping obstruction inspection was conducted.

Based on observation and interview, the facility failed to ensure the exhaust fans in two (2) Housekeeping closets were functioning. This failed practice may lead to potential harm from toxic fumes escaping from the chemicals stored within, to all nine (9) patients as identified by the patient census list provided by the Quality Assurance Officer ob 09/28/15 including staff and visitors. The findings are:

A. On 09/28/15 at 2:40 pm, observation of the exhaust fan located in the second floor housekeeping closet was not functioning.

B. On 09/28/15 at 4:35 pm, observation of the exhaust fan located in the first floor housekeeping closet was not functioning.

C. On 09/28/15 at 4:37 pm, during interview, the Maintenance Manager witnessed the fans not functioning, confirming the fans were not functioning.

NFPA 101/2000
9.2.3 Commercial Cooking Equipment.
Commercial cooking equipment shall be inaccordance with NFPA 96 (Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 96/1998 Chapter 2 Exhaust Hoods
2-1 Construction
2-1.1 The hood or that portion of a primary collection means designed for collecting cooking vavoprs and residues shall be constructed of and be supported by steel not less than 0,043 in. (1.09 mm)(No. 18 MSG) in thickness, stainless steel not less than 0,037 in. (0.94mm) (No. 20 MSG) in thickness, or other approved material of equivalent strength and fire and corrosion resistance.
Exception: Listed exhaust hoods with or without exhaust dampers

2-1.2 All seams, joints, and penetrations of the hood enclosure that direct and capture grease laden vapors and exhaust gases shall have a liquidtight continuous external weld to the hood's lower outermost perimeter. Internal hood joints, seams, filter support frames and appendages attached inside the hood need not be welded but shall be sealed or otherwise made grease tight.

Exception 1: Penetrations shall be permitted to be sealed by devices that are listed for such use and whose presence does not detract from the hood's or duct's structural integrity.

Exception 2: Eyebrow type hoods over gas or electric ovens shall be permitted to have a duct constructed as in Chapter 4 from the oven flue(s) connected to the hood canopy upstream of the exhaust plenum as shown in figure 2-1.2. The duct shall be connected to the hood with a continuous weld or have a duct to duct connection as shown in figure 5-1.2 (b), (c) or (d).

Exception 3: Seams, joints and penetrations of the hood shall be permitted to be internally welded, provided that the weld is formed smooth or ground smooth, so as not to trap grease, and is reaily cleanable.2-2 Hood Size: Hoods shall be sized and configured to provide for the capture and removal of grease laden vapors

Chapter 3 Grease Removal Devices in Hoods
3-1 Grease Removal Devices
Listed grease filters, baffles or other approved grease removal devices for use with commercial cooking equipment shall be provided. Listed grease filters shall be tested in accordance with UL 1046, Grease Filters for Exhaust Ducts. Mesh filters shall not be used.

3-2 Installation
The distance between the grease removal device and the cooking surfaceshall be as great as possible but not less than 18 in. Where used in conjunction with charcoal or charcoal type broilers, including gas or electrically heated char broilers, a minimum vertical distance of 4 ft. shall be maintained between the lower edge of the grease removal device and the cooking surface.

Exception 1: Grease removal devices supplied as part of listed hood assemblies shall be installed in accordance with the terms of the listing and manufacturer's instructions.

Exception 2: For cooking equipment without exposed flame and where flu gases by pass grease removal devices, the minimum vertical distance shall be permitted to be reduced to not less than 6 inches.

3-2.2
Grease removaldevices shall be protected from combustion gas outlets and from direct flame impingement occurring during normal operation of cooking appliances producing high flu gas temperatures, such as deep fat fryers or upright or high broilers (salamanders), where the distance between the grease removal device and the appliance flue outlet (heat source) is less than 18 inches, This protection shall be permitted to be accomplished by the installation of a steel or stainless steel baffle plate between the heat source and the grease removal device. The baffle plate shall be sized and located so that flames or combustion gases shall travel a distance not less than 18 inches from the heat source to the grease removal device. The baffle shall be located not less than 6 inches from the grease removal device.

3-2.3 Grease filters shall be listed and constructed of steel or listed equivalent material and shall be of rigid construction that will not distort or crush under normal operation, handling and cleaning conditions. Filters shall be tight fitting and firmly held in place.

3-2.4 Filters shall be easily accessible and removeable for cleaning.

3-2.5 Filters shall be installed at an angle not less than 45 degrees from the horizontal.

3-2.6 Filters shall be equipped with a drip tray beneath their lower edges. The tray shall be kept to the minimum size needed to collect grease and shall be pitched to drain into an enclosed metal container having a capacity not exceeding 1 gallon.

3-2.7Grease filters that require a specific orientation to drain grease shall be clearly so designated, or the hood shall be constructed so that the filters cannot be installed in the wrong orientation.

Based on observation and interview, the facility failed to ensure that an approved cooking exhaust hood and filter bank is installed in the kitchen over the appliances. This failed practice allows the cooking grease to drip back onto the appliances and floor. This is not only a fire hazard but, a health hazard. Potential harm by fire or food born illness may harm all nine (9) patients as identified by the patient census list provided by the Quality Assurance Officer on 09/28/15 including staff and visitors. The findings are:

A. On 09/28/15 at 6:00 pm, observation of an non approved cooking exhaust hood installed over the cooking appliance in the kitchen. This hood has improperly installed filter bank (installed horizontally), not on the 45 degree installation as required. The filters do not have the grease collection devices and the exhaust hood is open in the center allowing the grease to drip onto the appliances and the floor.

B. On 09/28/15 at 6:02 pm, during interview, the Maintenance Manager stated he was not aware of the cooking exhaust system Codes, confirming the non approved hood.

NFPA 25/1998
3-2 Inspection
3-2.1 Components of standpipe and hose systems shall be visually inspected quarterly or as specified in Table 3-1.

3-2.2 Check points and corrective actions outlined in Table 3-2.3 shall be followed to determine that components are free of corrosion, foreign material, physical damage, tampering, or other conditions that could prevent operation.

3-2.2 Table 3-2.3 shall be used for the inspection, testing and maintenance of all classes of standpipe and hose systems.

3-2.3 Testing. The tests shall be conducted by a qualified person.
Where water damage is a possibility, an air test shall be conducted on the system at 25 psi prior to introducing water to the system.

3-3.1 Flow tests
3-3.1.1A flow test shall be conducted at the hydraulically most remote hose connection of each zone of a standpipe system to verify the water supply will adequately provides the design pressure at the required flow. Where a flow test of the hydralically most remote outlet(s) is not practical, the authority having jurisdiction shall be consulted for the appropriate location of the test.
A flow test shall be conducted every 5 years.

Based on record review and interview, the facility failed to maintain the standpipe fire protection system. This failed practice may result in the failure of the system during a fire event, causing a delay in the firefighters getting water on the fire, which may lead to potential harm to all nine (9) patients as identified by the patient census list provided by the Quality Assurance Officer on 09/28/15 including staff and visitors. The findings are:

A. During record review of the fire protection system records, there were no records available to indicate that the standpipe system has been inspected/tested/maintained.

B. On 09/28/15 at 1:11 pm, during interview, the Maintenance Manager stated that he could not locate any records to indicate the standpipe system has been inspected/tested/maintained, confirming this finding.


Based on observation and interview, the facility failed to provide access to storage room 21, located on the first floor off the lobby area. This failed practice prevented the surveyor from inspecting the contents and protection devices within for combustible and hazardius storage. In the event of a fire, the unkown detection device may delay the notification of a fire and, the unkown contents may present a high risk to all nine (9) patients as identified. by the patient census list provided by the Quality Assurance Officer on 09/28/15 including staff and visitors. The findings are:

A. On 09/28/15 at 5:55 pm, observation of Maintenance Manager not having a key to access storage room 21.

B. On 09/28/15 at 5:57 pm, during interview, the Maintenance Manager stated he tried all keys available and one key labeled room 21, but none worked to unlock the door, confirming this finding.



Reference NFPA 101, 2000 Edition

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.


Based on observation and interview, the facility failed to ensure all resident room restroom doors were capable of being unlocked by health care personnel from the outside in the event of emergency. Staff not being able to unlock these doors could result in delay and ineffective response of health care personnel in the event of emergency such as fire, which presents a risk of potential harm to all nine (9) patients as identified by the patient census list provided by the Quality Assurance Officer on 09/28/15. The findings are:

A. On 09/28/15 at 3:00 pm, during observation the restroom which serves patient rooms 226 was provided with locking hardware that required the use of a special tool to unlock from the outside.

B. On 09/28/15 at 3:05 pm, a simulated emergency evacuation was conducted. This simulation consisted of locking the restroom door from the inside and having the first available staff open the door as if to rescue a resident. When staff #1 was asked to rescue the resident from the inside of the restroom, she could not open the restroom door from the outside to evacuate the resident.

C. On 09/28/15 at 3:06 pm, during interview, staff #1 stated she was unaware how to open the door in the event it was locked from the inside.

D. On 09/28/15 at 3:07 pm, during interview, the Maintenance Manager stated that all patient room bathrooms have the same type of locking devices that requires a special tool to unlock the door from the outside.

NFPA 70, 1999 Edition
384-13 ...All panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors.


Based on observation and interview, the facility failed to ensure electrical panels and circuit breakers were identified in accordance with NFPA 70 (National Electrical Code). It is essential all circuit breakers within electrical panels are properly identified as to what they serve, so in the event of emergency, selected electrical circuits can be turned off. This failed practice could result in the incorrect breakers being turned off in the event of fire or other emergency, which presents a risk of potential harm to all nine (9) patients as identified by the patient census list provided by the Quality Assurance Officer on 09/28/15. The findings are:

A. On 09/28/15 at 2:45 pm, observation of two (2) electric panels located in room 086 on the second floor were not identified as to what they serve and the circuit breakers within the panels were also not identifed.

B. On 09/28/15 at 2:47 pm, during interview, the Maintenance Manager stated these are newly installed, confirming the panels and circuit breakers are not identified.

LSC 101/2000
9,4,6 Elevator shall be subject to routine and periodic inspections and tests as specified in ASME/ANSI A17.1 (Safety Code for Elevators and Escalators). All elevators equipped with fire fighter service in accordance with 9.4.4 and 9.4.5 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required for ASME/ANSI A17.1.

Based on record review, observation and interview, the facility failed to ensure that the elevators were inspected and tested as required. This failed practice may result in failure of the elevators, resulting in patients, staff and visitors becomming trapped inside the elevators. The findings are:

A. During record review of the elevator maintenance records and subsequent walkthrough of the elevators, there were no records available to indicate the periodic inspection/testing has been conducted and no inspection record posted in the elevators, as sometimes found.

B. On 09/28/15 at 1:07 pm, during interview, the Maintenance Manager stated he was unable to locate any elevator inspection/test records, confirming this finding.