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Based on observation and interview, the facility failed to ensure that smoke barriers would resist the passage of smoke. Failure to maintain smoke barriers would allow smoke and dangerous gases to pass freely between smoke compartments affecting egress during a fire. This deficient practice affected 8 patients, staff and visitors in 5 of 5 smoke compartments on the date of the survey. The facility is licensed for 21 beds and had a census of 8 on the day of the survey.

Findings include:

1) During the facility tour conducted on July 22, 2014 from 10:15 AM to 11:45 AM, observation of the ceiling in the electrical room located in the partial basement revealed (3) unsealed holes in the ceiling through to the Laboratory. Interview of the Maintenance Director revealed these holes had been drilled to accommodate the construction in progress and had not yet been sealed.
2) During the facility tour conducted on July 22, 2014 from 11:45 AM to 12:30 PM, observation of the walls separating the Electrical room, the Dietary Storage room and the Dry Storage room revealed (2) unsealed pipes approximately three inches in diameter penetrating all three walls. When asked, the Maintenance Director stated these unsealed penetrations were done as part of the current construction project and had not yet been sealed.
3) During the facility tour conducted on July 22, 2014 from 11:45 AM to 12:30 PM, observation of the ceiling in the dialysis unit located in the partial basement revealed (3) ceiling tiles with approximately 1/2" gaps around sprinkler pendants. When questioned, the Maintenance Director stated he was not aware of these gaps.
4) During the facility tour conducted on July 22, 2014 from 11:45 AM to 12:30 PM, observation of the storage room next to the elevator equipment room revealed a missing ceiling tile. Interview of the Maintenance Director revealed he was not aware this ceiling tile was missing.
5) During the facility tour conducted on July 22, 2014 from 11:45 AM to 12:30 PM, observation of the Dietary Services office ceiling revealed the sprinkler escutcheon was missing. When asked, the Maintenance Director stated he was unaware this escutcheon was gone.
6) During the facility tour conducted on July 22, 2014 from 11:45 AM to 12:30 PM, an above the ceiling inspection of the 2-hour fire wall separating the maintenance department and central supply from the support services and dialysis corridor revealed (2) pipes approximately three inches in diameter passing through unsealed penetrations in the wall. When asked, the Maintenance Director stated these were plumbing pipes installed during the current construction project and had not yet been sealed.
7) During the facility tour conducted on July 22, 2014 from 1:30 PM to 3:00 PM, observation of the sprinkler escutcheons in the ceilings of patient rooms #1, #2, #3 and the converted CCU area adjacent to the nurses station, revealed (4) of these escutcheons had separated from the ceiling leaving a gap between the ceiling tile and the escutcheon of approximately 1/2". Interview of the Maintenance Director revealed he was not aware these escutcheons had been dislodged.
8) During the facility tour conducted on July 22, 2014 from 1:30 PM to 3:00 PM, observation of the floor of the Laboratory revealed (5) holes drilled through the floor into the partial basement below. (3) of these holes were those indicated in finding #1. When asked, the Maintenance Director reaffirmed these were due to the construction project and had not yet been sealed.

Actual NFPA standard:

8.3 SMOKE BARRIERS
8.3.2* Continuity.
Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
Exception: A smoke barrier required for an occupied space below an interstitial space shall not be required to extend through the interstitial space, provided that the construction assembly forming the bottom of the interstitial space provides resistance to the passage of smoke equal to that provided by the smoke barrier.

Based on observation, operational testing and interview, the facility failed to ensure hazardous areas were protected with self-closing doors. Failure to ensure hazardous area protection would allow smoke and dangerous gases to travel freely into corridors and hinder egress. This deficient practice affected all patients accessing the X-ray department, cafeteria, dialysis and physical therapy, staff and visitors in 3 of 5 smoke compartments on the date of the survey. The facility is licensed for 21 beds and had a census of 8 on the day of the survey.

Findings include:

1) During the facility tour conducted on July 22, 2014 from 11:45 AM to 12:30 PM, observation and operational testing of the ground floor storage room door adjacent to the Dietary office revealed it rubbed on the floor and would not self-close. When asked, the Maintenance Director stated he was aware this door would not self-close.
2) During the facility tour conducted on July 22, 2014 from 12:30 PM to 2:30 PM, observation and operational testing of the door from the main kitchen to the cafeteria revealed it would not self-close. Testing of the kitchen door leading from the dishwashing area to the corridor demonstrated it would not self close. This finding was acknowledged by Maintenance staff.
3) During the facility tour conducted on July 22, 2014 from 12:30 PM to 2:30 PM, investigation of the roll-down pass-through door from the kitchen into the cafeteria revealed that if activated, the door would be obstructed from closing by a silverware dispenser and a toaster. Interview of the Maintenance Director indicated he was aware that all doors from the kitchen are required to self-close.
4) During the facility tour conducted on July 22, 2014 from 11:45 AM to 12:30 PM, observation and operational testing of the corridor doors into the laundry demonstrated that 1 of 2 doors was not equipped with a self-closing device and was blocked from closing by a clean laundry cart. When asked, the Maintenance Director stated this doorway is used as a pass-through for staging laundry.
5) During the facility tour conducted on July 22, 2014 from 1:30 PM to 2:00 PM, observation and operational testing of the door from the corridor into the housekeeping storage room adjacent to the laboratory revealed it would not self-close. Further investigation revealed this room was larger than 50 ft2 with storage of combustible supplies and equipment. When interviewed the Maintenance Director stated he was not aware this door was required to self-close.
6) During the facility tour conducted on July 22, 2014 from 2:00 PM to 3:00 PM, observation and operational testing of the door to Soiled Linen in the Operating egress corridor revealed it was not equipped with a self-closing device. When asked, the Maintenance Director stated he was not aware this door was required to self-close.
7) During the facility tour conducted on July 22, 2014 from 2:00 PM to 3:00 PM, observation and operational testing of the corridor door into the soiled linen directly across from patient room #4 revealed the latch for the door had been removed. When asked, the Maintenance Director stated he had removed this latch for the current phase of the construction project.
8) During the facility tour conducted on July 22, 2014 from 1:30 PM to 2:30 PM, observation and operational testing of the door from the corridor into the Laboratory revealed it would not self-close. Further observation revealed it was equipped with a throw bolt on the Laboratory side which would impede exiting. Interview of the Laboratory staff revealed the throw bolt was installed to keep building occupants from entering. When asked, the Maintenance Directore stated he was having problems with this door self-closing.

Actual NFPA standard:

3.3.13.2 Area, Hazardous.
An area of a structure or building that poses a degree of hazard greater than that normal to the general occupancy of the building or structure, such as areas used for the storage or use of combustibles or flammables; toxic, noxious, or corrosive materials; or heat-producing appliances.
19.3.2.1 Hazardous Areas.
Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Based on observation, operational testing and interview, the facility failed to ensure exit enclosures remained free of obstacles. Failure to ensure exit enclosures have a continuous path of egress would prevent the evacuation of occupants during an emergency. This deficient practice affected 8 patients, staff and visitors in 3 of 5 smoke compartments on the date of the survey. The survey is licensed for 21 beds and had a census of 8 on the day of the survey.

Findings include:

1) During the facility tour conducted on July 22, 2014 from 10:30 AM to 11:30 AM, observation of the stairway exit enclosure at the rear of Central Supply revealed it was blocked with haphazard trash including a chair and stack of empty boxes. This finding was acknowledged by the Maintenance staff.
2) During the facility tour conducted on July 22, 2014 from 2:00 PM to 3:00 PM, observation and operational testing of the exit doors to the loading dock revealed storage of supplies inside the exit vestibule. Further investigation revealed this exit was signed as a primary path of egress. Interview of the Maintenance Director revealed the supplies were recently delivered and the exit was normally kept clear.
3) During the facility tour conducted on July 22, 2014 from 2:00 PM to 3:00 PM, observation and operational testing of the exit doors located next to the Pharmacy revealed that the exit was obstructed by the storage of wheelchairs not in use. Interview of the Maintenance Director indicated these wheelchairs were stored in this location due to inadequate space. This finding was further acknowledged by the CFO during the exit conference conducted on July 22, 2014 at 4:30 PM.

Actual NFPA standard:

19.2 MEANS OF EGRESS REQUIREMENTS
19.2.1 General.
Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
Exception: As modified by 19.2.2 through 19.2.11.
7.1.3.2.2
An exit enclosure shall provide a continuous protected path of travel to an exit discharge.

Based on observation and interview the facility failed to ensure that fire alarm systems were properly maintained. Failure to ensure fire alarm systems are properly maintained would result in the systems failure to provide protection during a fire event. This deficient practice affected 8 patients in 1 of 5 smoke compartments on the date of the survey. The facility is licensed for 21 beds and had a census of 8 on the day of the survey.

Findings include:

During the facility tour conducted on July 22, 2014 from 2:00 PM to 3:00 PM, observation of the smoke detector in the recently renovated CCU area directly adjacent to the nurses station revealed the smoke detector was covered with masking tape. When questioned, the Maintenance Director stated that the smoke detector had been taped during construction.

Actual NFPA standard:

9.6.1.4
A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

Based on observation and interview, the facility failed to ensure that sprinkler controls were maintained free of obstructions. Failure to keep controls for automatic sprinkler systems clear and accessible would result in the inability to provide adequate suppression during a fire. This deficient practice affected no patients, staff and visitors to the main kitchen in 1 of 5 smoke compartments on the date of the survey. The facility is licensed for 21 beds and had a census of 8 on the day of the survey.

Findings include:

During the facility tour conducted on July 22, 2014 from 2:30 PM to 3:00 PM, observation of the pull station for the kitchen hood suppression system revealed it was blocked by the office door and a serving cart. When asked, the kitchen staff was not aware this pull station controlled the hood suppression system and was the secondary means of operating the system during a fire incident. Further interview of the Maintenance Director indicated he was aware that this pull station was to remain clear.

Actual NFPA standard:

4.6.12 Maintenance and Testing.
4.6.12.1
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.

Based on record review and interview, the facility failed to complete 4 year interval testing on its dampers as required under NFPA 90A. Failure to ensure dampers will operate to manufacturer's specifications would allow smoke and dangerous gases to pass freely throughout the facility during a fire. This deficient practice affected 8 patients, staff and visitors in 5 of 5 smoke compartments on the date of the survey. The facility is licensed for 21 beds and had a census of 8 on the day of the survey.

Findings include:

During record review conducted at the facility on July 22, 2014 from 9:15 AM to 11:00 AM, the facility failed to provide a 4-year interval testing report of its dampers. When interviewed, the Maintenance Director stated this testing had not been completed.

Actual NFPA standard:

NFPA 90A
3-4.7 Maintenance.
At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Based on record review and interview, the facility failed to ensure interim life safety measures were initiated, monitored, and training was completed by staff during the course of construction. Failure to train staff on interim life safety measures required would result in the inability of staff to be prepared for an emergency should normal systems be disabled due to construction. This deficient practice affected 8 patients, staff and visitors in 5 of 5 smoke compartments on the date of the survey. The facility is licensed for 21 beds and had a census of 8 on the day of the survey.

Findings include:

1) During record review conducted on July 22, 2014 from 10:00 AM to 10:30 AM, interview of the Maintenance Director revealed he was not aware of any interim life safety measures being documented or training having been performed with staff.
2) During the facility tour conducted on July 22, 2014 from 10:30 AM to 12:30 PM, interview of the Maintenance Director revealed that the contractor for the construction project could not provide documentation of staff training regarding interim life safety measures in place.
3) During the facility tour conducted on July 22, 2014 from 1:30 PM to 2:30 PM, observation of patient room #9 revealed that the door to the room was open to the hallway. Further investigation of the room showed the window of the room abutted the area of construction and was left open and unsealed to the construction project.
4) During the facility tour conducted on July 22, 2014 from 1:30 PM to 2:30 PM, observation of the exit adjacent to resident room #9 demonstrated that it was blocked off with construction tape. Interview of the Maintenance Director revealed that this exit was for construction personnel to enter the building during the course of the project. He further indicated that this exit was eliminated from the posted evacuation plan. When asked if staff had training on evacuation for this area, the Maintenance Director stated he was not aware of any training.
5) During the exit conference conducted on July 22, 2014 from 4:30 PM to 5:00 PM, the surveyor again requested all interim life safety measures documentation and training. The Maintenance Director stated no documented training was available.
6) During record review and facility tour conducted on July 22, 2014 from 10:00 AM to 5:00 PM, the facility failed to ensure interim life safety measures were conducted. Refer to K tag citing's K025; K054; K141; K147.

Actual NFPA standard:

19.1.1.4.6 Construction, Repair, and Improvement Operations.
(See 4.6.10.)
4.6.10 Construction, Repair, and Improvement Operations.
4.6.10.1*
Buildings or portions of buildings shall be permitted to be occupied during construction, repair, alterations, or additions only where required means of egress and required fire protection features are in place and continuously maintained for the portion occupied or where alternative life safety measures acceptable to the authority having jurisdiction are in place.

NFPA 241
7.1 Fire Safety Program.
An overall construction or demolition fire safety program shall be developed; essential items to be emphasized include the following:
(1) Good housekeeping
(2) On-site security
(3) Installation of new fire protection systems as construction progresses
(4) Preservation of existing systems during demolition
(5) Organization and training of an on-site fire brigade
(6) Development of a prefire plan with the local fire department
(7) Rapid communication
(8) Consideration of special hazards resulting from previous occupancies
(9) Protection of existing structures and equipment from exposure fires resulting from construction, alteration, and demolition operations
7.2 Owner ' s Responsibility for Fire Protection.
7.2.1*
The owner shall designate a person who shall be responsible for the fire prevention program and who shall ensure that it is carried out to completion.
7.2.1.1
This fire prevention program manager shall have the authority to enforce the provisions of this and other applicable fire protection standards.
7.2.1.2
The fire prevention program manager shall have knowledge of the applicable fire protection standards, available fire protection systems, and fire inspection procedures.
7.2.1.3
Inspection records shall be available for review by the authority having jurisdiction.
7.2.2
Where guard service is provided, the manager shall be responsible for the guard service.
7.2.3* Prefire Plans.
7.2.3.1
Where there is public fire protection or a private fire brigade, the manager shall be responsible for the development of prefire plans in conjunction with the fire agencies.
7.2.3.2
Prefire plans shall be updated as necessary.
7.2.3.3
The prefire plan shall include provisions for on-site visits by the fire agency.
7.2.4 Program Manager Responsibilities.
7.2.4.1
The manager shall be responsible for ensuring that proper training in the use of protection equipment has been provided.
7.2.4.2
The manager shall be responsible for the presence of adequate numbers and types of fire protection devices and appliances and for their proper maintenance.
7.2.4.3
The manager shall be responsible for supervising the permit system for hot work operations. (See Section 5.1.)
7.2.4.4
A weekly self-inspection program shall be implemented with records maintained and made available.
7.2.4.5*
Impairments to the fire protection systems or fire alarm, detection, or communications systems shall be authorized only by the fire prevention program manager.
7.2.4.6
Temporary protective coverings used on fire protection devices during renovations, such as painting, shall be removed promptly when work has been completed in the area.

Based on observation and interview, the facility failed to ensure that medical gases were stored with proper signage. Failure to ensure that signs are posted indicating oxygen is being stored or in use would expose occupants to fire or explosions. This deficient practice affected 8 patients, staff and visitors on the date of the survey. The facility is licensed for 21 beds and had a census of 8 on the day of the survey

Findings include:

During the facility tour conducted on July 22, 2014 from 1:45 PM to 2:30 PM, observation of patient room #9 revealed this room was being used to keep materials and supplies moved during the construction project from the renovated CCU area. Further investigation revealed (3) "E" size oxygen containers were stored in this room without proper signage. When asked, the Maintenance Director stated he was not aware that oxygen was being stored at this location.

Actual NFPA standard:

NFPA 99
8-3.1.11.3 Signs.
A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:
CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

Based on observation and interview, the facility failed to ensure electrical installations were in accordance with NFPA 70. Failure to ensure proper electrical installations would result in electrocution or fire. This deficient practice affected 8 patients, staff and visitors in 5 of 5 smoke compartments on the date of the survey. The facility is licensed for 21 beds and had a census of 8 on the day of the survey.

Findings include:

1) During the facility tour conducted on July 22, 2014 from 10:15 AM to 11:00 AM, observation of the Central supply storage room revealed (3) four inch square electrical conduit boxes without covers. Interview of the Maintenance Director indicated that the electrician had been relocating wiring and he was not aware of these being open.
2) During the facility tour conducted on July 22, 2014 from 10:15 AM to 11:00 AM, observation of the staircase enclosure at the rear of the Central supply storage area revealed a four inch square electrical conduit box which was missing the protective cover. This finding was acknowledged by the Assistant Maintenance staff member.
3) During the facility tour conducted on July 22, 2014 from 11:00 AM to 12:30 PM, observation of the storage area adjacent to the Dietary Services office revealed an extension cord in use supplying a battery charger to a demisting unit. When asked, the Maintenance Director stated he was unaware this extension cord was here.

Actual NFPA standard:

NFPA 70
110.12 Mechanical Execution of Work.
Electrical equipment shall be installed in a neat and workmanlike manner.
(A) Unused Openings. Unused cable or raceway openings in boxes, raceways, auxiliary gutters, cabinets, cutout boxes, meter socket enclosures, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment. Where metallic plugs or plates are used with nonmetallic enclosures, they shall be recessed at least 6 mm (¼ in.) from the outer surface of the enclosure.
(B) Subsurface Enclosures. Conductors shall be racked to provide ready and safe access in underground and subsurface enclosures into which persons enter for installation and maintenance.
(C) Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasives, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating.

314.17 Conductors Entering Boxes, Conduit Bodies, or Fittings.
Conductors entering boxes, conduit bodies, or fittings shall be protected from abrasion and shall comply with 314.17(A) through (D).
(A) Openings to Be Closed. Openings through which conductors enter shall be adequately closed.
...

400.8 Uses Not Permitted.
Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.8.
(5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
(6) Where installed in raceways, except as otherwise permitted in this Code