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Based on observation and staff interview the facility fails to ensure that all means of egress are free of all obstructions or impediments to a full instant use. This deficient practice could impede all occupants from exiting in the event of a fire or other emergency situation, affecting all three smoke zones. This facility has a capacity of 25 and a census of 2 at the time of the survey.

Findings Include:

During the survey on 9/13/17 between 8:45 AM and 4:30 PM:

1. On 9/13/17 at 11:24 AM: The employee entrance is equipped with an access control magentic locking device to secure the door. There is a key pad on the exterior and a manual release device on the interior however, there is no sensor installed as required. The magnet releases upon loss of power and activation of the fire alarm system.

The Maintenance Supervisor was present and acknowledged the finding.

NFPA Standard: NFPA 101 2012 ed. 7.2.1.6.2* Access-Controlled Egress Door Assemblies. Where
permitted in Chapters 11 through 43, door assemblies in the means of egress shall be permitted to be equipped with electrical lock hardware that prevents egress, provided that all of the following criteria are met: (1) A sensor shall be provided on the egress side, arranged to unlock the door leaf in the direction of egress upon detection of an approaching occupant. (2) Door leaves shall automatically unlock in the direction of egress upon loss of power to the sensor or to the part of the access control system that locks the door leaves. (3) Door locks shall be arranged to unlock in the direction of egress from a manual release device complying with all of the following criteria: (a) The manual release device shall be located on the egress side, 40 in. to 48 in. (1015 mm to 1220 mm ) vertically above the floor, and within 60 in. (1525 mm) of the secured door openings. (b) The manual release device shall be readily accessible and clearly identified by a sign that reads as follows: PUSH TO EXIT. (c) When operated, the manual release device shall result in direct interruption of power to the lock - independent of the locking system electronics-and the lock shall remain unlocked for not less than 30 seconds. (4) Activation of the building fire-protective signaling system, if provided, shall automatically unlock the door leaves in the direction of egress, and the door leaves shall remain unlocked until the fire-protective signaling system has been manually reset. (5) The activation of manual fire alarm boxes that activate the building fire-protective signaling system specified in 7.2.1.6.2(4) shall not be required to unlock the door leaves. (6) Activation of the building automatic sprinkler or fire detection system, if provided, shall automatically unlock the door leaves in the direction of egress, and the door leaves shall remain unlocked until the fire-protective signaling system has been manually reset. (7) The egress side of access-controlled egress doors, other than existing access-controlled egress doors, shall be provided with emergency lighting in accordance with Section 7.9.

Based on observation and staff interview the facility failed to provide emergency lighting as required for the medication room. This deficiency affects all occupants in one of three smoke zones. This facility has a capacity of 25 and a census of 2 at the time of the survey.

Findings Include:

During the survey on 9/13/17 between 8:45 AM and 4:30 PM:

1. On 9/13/17 at 3:32 PM: The medication room light is on a switch. There is no other lighting in the room.

The Maintenance Supervisor was present and acknowledged the finding.

NFPA Standard: 101 2012 ed. 7.9.1.1* Emergency lighting facilities for means of egress shall be provided in accordance with Section 7.9 for the following: (1) Buildings or structures where required in Chapters 11 through 43 (2) Underground and limited access structures as addressed in Section 11.7 (3) High-rise buildings as required by other sections of this Code (4) Doors equipped with delayed-egress locks (5) Stair shafts and vestibules of smokeproof enclosures, for which the following also apply: (a) The stair shaft and vestibule shall be permitted to include a standby generator that is installed for the smokeproof enclosure mechanical ventilation equipment. (b) The standby generator shall be permitted to be used for the stair shaft and vestibule emergency lighting power supply. (6) New access-controlled egress doors in accordance with 7.2.1.6.2

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other spaces. The area of deficient practice would provide a path for smoke and fire to travel into the basement office and kitchen area, affecting one of three smoke zones. This facility has a capacity of 25 and a census of 2 patients.

Findings Include:

During the survey on 9/13/17 between 8:45 AM and 4:30 PM:

1. On 9/13/17 at 3:18 PM: The basement records room is filled with cardboard boxes and paper files from floor to ceiling. The room is approximately 24 ft by 28 ft in area and is without sprinkler protection and a self-closing device on the fire rated door.

The Maintenance Supervisor was present and acknowledged the finding.


NFPA Standard: NFPA 101 2012 ed. 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 8.7.1. 19.3.2.1.1 An automatic extinguishing system, where used in hazardous areas, shall be permitted to be in accordance with19.3.5.9. 19.3.2.1.2* Where the sprinkler option of 19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4. 19.3.2.1.3 The doors shall be self-closing or automatic-closing. 19.3.2.1.4 Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more than 48 in. (1220 mm) above the bottom of the door. 19.3.2.1.5 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) Rooms with soiled linen in volume exceeding 64 gal (242 L) (6) Rooms with collected trash in volume exceeding 64 gal (242 L) (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

Based on observation, interview and record review, the facility failed to provide and maintain documentation of annual inspection and testing of the fire alarm system as required by NFPA 72. The absence of complete, verifiable documented maintenance and device listing on the fire alarm system fails to ensure reliability of the alarm system in the event of an emergency, affecting all three smoke zones. The facility has a capacity of 25 with a census of 2.

Findings Include:

During the survey on 9/13/17 between 8:45 AM and 4:30 PM:

1. On 9/13/17 at 11:42 AM: The fire alarm inspection report dated 6/29/17 does not include a detailed initiating device listing to include the range hood suppression system. The inspection report does indicate the access control door at the employee entrance.

The Maintenance Supervisor was present and acknowledged the finding.

NFPA Standard: NFPA 72 2010 ed. 14.4.5* Testing Frequency. Unless otherwise permitted by other sections of this Code, testing shall be performed in accordance with the schedules in Table 14.4.5, or more often if required by the authority having jurisdiction.

NFPA Standard: NFPA 72 2010 ed. 14.6.2.4* Arecord of all inspections, testing, and maintenance
shall be provided that includes the following information regarding
tests and all the applicable information requested in
Figure 14.6.2.4: (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 (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) Functional test of mass notification system control units (13) Functional test of signal transmission to mass notification systems (14) Functional test of ability of mass notification system to silence fire alarm notification appliances (15) Tests of intelligibility of mass notification system speakers (16) Other tests as required by the equipment manufacturer ' s published instructions (17) Other tests as required by the authority having jurisdiction (18) Signatures of tester and approved authority representative (19) Disposition of problems identified during test (e.g., system owner notified, problem corrected/successfully retested, device abandoned in place)

Based on observation, record review and interview the facility does not assure a fire watch procedure and policy is written and available for implementation when fire alarm system is out of service for more than 4 hours in a 24 hour period. This deficient practice would allow facility exposure to undetected smoke and/or fire without an automatic detection compensatory provision when it occurred, and without appropriately prepared staff response. affecting all three smoke zones. The facility has a capacity of 25 with a census of 2 patients.

Findings Include:

During the survey on 9/13/17 between 8:45 AM and 4:30 PM:

1. On 9/13/17 at 9:50 AM: The facility is without a fire watch plan.

The Maintenance Supervisor was present and acknowledged the finding.

NFPA 101 2012 ed.

9.6.1.6* Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated, or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

Based on record review and staff interviews, the facility failed to assure that the sprinkler system is maintained and tested in accordance with the NFPA 13 and NFPA 25. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting all occupants in all three smoke zones. This facility has a capacity of 25 and a census of 2 patients.

Findings Include:

During the survey on 9/13/17 between 8:45 AM and 4:30 PM:

1. On 9/13/17 at 1:23 PM: There is no documentation of monthly sprinkler inspections for the wet sprinkler system.

2. On 9/13/17 at 3:14 PM: The sprinklers in the basement shredding room are dated 1957. There is no documenation of sprinkler sample testing.

The Maintenance Supervisor was present and acknowledged the finding.

NFPA Standard: NFPA 101 2012 ed. 19.3.5.1 Buildings containing nursing homes shall be protected
throughout by an approved, supervised automatic
sprinkler system in accordance with Section 9.7, unless otherwise
permitted by 19.3.5.5.

19.3.5.3 Where required by 19.1.6, buildings containing hospitals
or limited care facilities shall be protected throughout by an
approved, supervised automatic sprinkler system in accordance
with Section 9.7, unless otherwise permitted by 19.3.5.5. 9.7.5 Maintenance and Testing. All automatic sprinkler and
standpipe systems required by this Code shall be inspected,
tested, and maintained in accordance with NFPA 25, Standard
for the Inspection, Testing, and Maintenance of Water-Based Fire Protection
Systems. Table 13.1.1.2 Summary of Valves, Valve Components, and Trim Inspection, Testing,
and Maintenance

Based on observation, record review and interview the facility does not assure a fire watch procedure and policy is written and available for implementation when the fire sprinkler system is out of service for more than 10 hours in a 24 hour period. This deficient practice would allow facility exposure to undetected smoke and/or fire without an automatic sprinkler compensatory provision when it occurred, and without appropriately prepared staff response. The facility has a capacity of 25 with a census of 2.

Findings Include:

During the survey on 9/13/17 between 8:45 AM and 4:30 PM:

1. At 9:50 AM: The facility is without a fire watch policy.

The Maintenance Supervisor was present and acknowledged the finding.

NFPA Standard: 101, 2012 ed.19.3.5.1, 9.7.5, 15.5.2 (NFPA 25) Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

9.7.6 Sprinkler 15.5.1 All preplanned impairments shall be authorized by
the impairment coordinator.

NFPA 25 2011 ed. 15.5.2 Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented: (1) The extent and expected duration of the impairment have been determined. (2) The areas or buildings involved have been inspected and the increased risks determined. (3) Recommendations have been submitted to management or the property owner or designated representative. (4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following: (a) Evacuation of the building or portion of the building affected by the system out of service (b)*An approved fire watch (c)*Establishment of a temporary water supply (d)*Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire (5) The fire department has been notified. (6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified. (7) The supervisors in the areas to be affected have been notified. (8) A tag impairment system has been implemented. (See Section 15.3.) (9) All necessary tools and materials have been assembled on the impairment site.

Based on observation, record review and staff interview the facility failed to provide a written fire safety plan that addresses the evacuation of the smoke compartment, triangle evacuation, and bariatric evacuation. The deficient practice may prevent the staff in identifying the need to evacuate occupants beyond the compartment of origin to another smoke compartment affecting all three smoke zones. This facility has a capacity of 25 and a census of 2.

Findings Include:

During the survey on 9/13/17 between 8:45 AM and 4:30 PM:

1. On 9/13/17 at 10:09 AM: The facility fire plan does not address smoke zone evacuation, triangle (immediate area) evacuation, or bariatric patient evacuation.

The Maintenance Supervisor was present and acknowledged the finding.


NFPA Standard:NFPA 101 2012 ed. 19.7.2.2 Fire Safety Plan. Awritten health care occupancy fire safety plan shall provide for all of the following: (1) Use of alarms (2) Transmission of alarms to fire department (3) Emergency phone call to fire department (4) Response to alarms (5) Isolation of fire (6) Evacuation of immediate area (7) Evacuation of smoke compartment (8) Preparation of floors and building for evacuation (9) Extinguishment of fire

Based on record review and staff interview, the facility is not conducting fire drills as required quarterly on each shift and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency and affects all occupants in all three smoke zones. This facility has a capacity of 25 and a census of 2 patients.

Findings Include:

During the survey on 9/13/17 between 8:45 AM and 4:30 PM:

1. On 9/13/17 at 1:59 PM: There are no scenarios given for the recorded fire drill.

2. On 9/13/17 at 2:10 PM : The 2nd shift fire drills for the past 12 months have been ran between 7:28 PM and 8:33 PM.

The Maintenance Supervisor was present and acknowledged the finding.


NFPA Standard: 101, 2012 Ed. 19.7.1.4* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 19.7.1.5 Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.
19.7.1.7 When drills are conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.