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Based on observation and interview, the facility is not maintaining a smoke tight ceiling. The building is composed of protected wood frame construction and is required by the Life Safety Code 18.1.6.2, to maintain smoke tight ceilings, if used for healthcare occupancy. This deficient practice affects all occupants of the four smoke zones. This facility has a capacity of 25 and a census of 5 residents.
Findings include:
Observation and interview on 6-19-17 at approximately 10:26 a.m., revealed that in the north east stairwell next to the loading dock there was a two inches sprinkler pipe penetration in the west wall with a 1/8 inch gap around the pipe.
Maintenance Staff (A) verified these observations.

Based on observation and interview, the facility failed to provide a fire rated separation between floors. The opening in the Mechanical Room #3 was located with in one smoke compartment in the the basement level. The deficient practice affected one of nineteen smoke compartments and the basement level. The facility has 25 certified beds and at the time of the survey the census was 5.

Findings include:

Observation and interview on 6-19-17 at 11:04 a.m., revealed the Mechanical Room #3 ceiling contained a two inches by two inches hole that opened into the Physical Therapy area in the floor above.

Maintenance Staff A confirmed this observation during the survey process.

Based on observation and interview, the facility did not assure that the fire alarm system is in accordance with NFPA 72 2010 Edition 10.5.5, and chapter 9.6.4 of NFPA 101 by ensuring that the fire alarm breaker is mechanically protected this would affect all of the building occupants.. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 25 with a census of 5.

Findings include:

Observation and interview on 6-19-17, the facility failed to provide a properly maintained fire alarm system. The fire alarm breaker located in the 1st Floor Mechanical room electrical panel LLS1 breaker #6 was not secured with a mechanical lock to assure that the breaker is not inadvertently shut off. All occupants would be directly affected by the deficient practice.

Maintenance Staff (A) verified this observation.

Based on observation and interview, the facility failed to maintain the sprinkler system in accordance with the 2010 edition of NFPA 13, by ensuring that the sprinkler system is maintained with all component parts. This item could effect the operation of the sprinkler system in the event of a fire emergency. This deficient practice affects all occupants in this facility with a capacity of 25 and a census of 5.

Findings include:

Observation and interview on 6-19-17 at 11:15 p.m., showed that the sprinkler head located on the corridor ceiling next to Exam Room #1 was missing the sprinkler head escutcheon ring.

Maintenance Staff (A) verified this observation.

Based on observation and interview, the facility failed to maintain the sprinkler system in accordance with the 2010 edition of NFPA 13, by ensuring that the sprinkler system is maintained with all component parts. This item could effect the operation of the sprinkler system in the event of a fire emergency. This deficient practice affects all occupants in this facility with a capacity of 25 and a census of 5.

Findings include:

Observation and interview on 6-19-17 at 11:42 a.m., showed that the sprinkler head located on the ceiling of resident room #312 was missing the sprinkler head escutcheon ring.

Maintenance Staff (A) verified this observation.

Based on observation and interview, the facility is not maintaining the sprinkler system in accordance with the 2011 edition of NFPA 25, 5.2.1.1*, by ensuring that sprinkler heads are free of foreign material. This can effect the operation of the heads by obstructing spray patterns, delay the response time or even cause the heads to be inoperable which can compromise the effectiveness of the fire suppression system and place occupants at risk of injury in the event of a fire. This deficient practice affects all occupants including staff, visitors and residents in one of nineteen smoke zones. The facility had a capacity of 25 and a census of 5 at the time of survey.

Findings include:

1. Observation and interview on 6-19-17 at approximately 11:45 a.m., revealed that in the resident room #313 the ceiling sprinkler head was covered with dust.

2. Observation and interview on 6-19-17 at approximately 11:47 a.m., revealed that in the resident room #311 one of two ceiling sprinkler heads was covered with dust.

3. Observation and interview on 6-19-17 at approximately 11:47 a.m., revealed that in the resident room #304 one of two ceiling sprinkler heads was covered with dust.

4. Observation and interview on 6-19-17 at approximately 11:57 a.m., revealed that in the 3rd floor Sun Room two of two ceiling sprinkler heads were covered with dust.


Maintenance Staff (A) verified these observations.

Based on observation and interview, the facility is not ensuring that doors are free of impediments that would prevent the door from closing tightly into the door frame. This deficient practice affects all occupants in one of nineteen smoke zones, as the doors would not prevent the spread of fire and smoke. This facility has a capacity of 25 and a census of 5 residents.

Findings include:

Observation and interview on 6-19-17 at approximately 11:24 a.m., revealed that the fire doors that separation the Hospital from the Clinic contained a 1/2 inch gap between the two leafs.

Maintenance Staff (A) verified this observation.

Based on observation and interview, the facility is not ensuring that doors to resident rooms are free of impediments that would prevent the door from closing tightly into the door frame. This deficient practice affects all occupants in one of nineteen smoke zones, as the doors would not prevent the spread of fire and smoke. This facility has a capacity of 25 and a census of 5 residents.

Findings include:

1. Observations and interview on 6-19-17 at approximately 11:53 a.m., revealed that the resident room doors of rooms #302 and #303 contained a 1/8 of an inch gap at the top of the door on the handle side.

Maintenance Staff (A) verified these observations.

Based on observation and interview, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 2011 edition, placing the Staff and Residents of the facility at risk in the event of a fire. The facility had a capacity of 25 and a census of 5 at the time of the survey.

Findings Include:

1. Observation and interview on 6-19-17 at 11:06 a.m., revealed the facility failed to maintain the electrical system in the Mechanical Room #3 Panel HMBS was missing the breaker directory.

1. Observation and interview on 6-19-17 at 10:42 a.m., revealed the facility failed to maintain the electrical system in the 1st floor Mechanical Room next to the elevator Panel EMA was missing the breaker designations for breakers 2, 4, 6, 9, 23 and 25. Also in electrical panel LN1E was missing the designation for breaker #21.

Maintenance Staff A verified these observations.

Based on observation and interview, the facility is not maintaining the fire department hoses in accordance with the 2011 edition of NFPA 25, 7.1.4, by ensuring that fire department hoses are inspected. This deficient practice affects all occupants including staff, visitors and residents in one of nineteen smoke zones. The facility had a capacity of 25 and a census of 5 at the time of survey.

Findings include:

Observation and interview on 6-19-17 at approximately 11:45 a.m., revealed that in the 3rd floor north stairwell landing there was a metal box containing old fire department fire hoses. These fire hoses are required to be test in accordance to NFPA 1962 every 5 years. Interview with Administration Staff (A) it could not be determined if the hoses were compliant with NFPA 1962.

Administration Staff (A) verified this observation.