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Based upon a review of records and staff interview, the facility fails to assure that the automatic sprinkler system is inspected, tested, and maintained in accordance with NFPA 25. The deficient practice could result in the unexpected failure of the automatic fire sprinkler system, affecting all patients, visitors and staff in 4 of 4 smoke zones. This facility has a capacity of 25 with a census of 10 at the time of the survey.

Findings include:

During the tour conducted on 04/21/2016, between 1:00 and 4:00 p.m., a review of records for the last 5 quarters revealed the following:

-- 1. No documented monthly visual inspections of the wet pipe sprinkler system for the months of January through December 2015.

-- 2. No documented quarterly flow tests of the wet pipe sprinkler system for the 1st, 2nd or 4th quarters of 2015.

Maintenance Supervisor was present and acknowledged the findings.

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

NFPA Standard: Automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25 per NFPA 101, 9.7.5. Obstructions shall not prevent sprinkler discharge from reaching the protected area. Continuous or non-continuous obstructions that interrupt the water discharge in a horizontal plane more than 18 inches below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with this section. The requirements of this section shall also apply to obstructions 18 in. or less below the sprinkler for light and ordinary hazard occupancies per NFPA 13, 5-6.5.3. Water flow alarm devices including, but not limited to, mechanical water motor gongs, vane-type water flow devices, and pressure switches that provide audible or visual signals shall be tested quarterly per 1998 NFPA 25, 2-3.3

Based upon a review of records and staff interview, the facility fails to assure that anesthetizing locations are protected in accordance with NFPA 99, Standard for Health Care Facilities. The deficient practice could result in an increased risk of fire and injury affecting 1 patient and any visitors or staff in 1 of 4 smoke zones. The facility has a capacity of 25 with a census of 10 at the time of this survey.

During the tour conducted on 04/21/2016, between 1:00 p.m. and 4:00 p.m., a review of the computerized relative humidity logs revealed that at varying times and dates between 01/02/2016 and 04/14/2016, the Relative Humidity was not maintained equal to or greater than 35% as required.

Administrator and Maintenance Supervisor were present and acknowledged the findings.

NFPA Standard: Anesthetizing locations are protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA Standard: The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Based upon a review of records and staff interview, the facility fails to assure that the automatic sprinkler system is inspected, tested, and maintained in accordance with NFPA 25. The deficient practice could result in the unexpected failure of the automatic fire sprinkler system, affecting all patients, visitors and staff in 4 of 4 smoke zones. This facility has a capacity of 25 with a census of 10 at the time of the survey.

Findings include:

During the tour conducted on 04/21/2016, between 1:00 and 4:00 p.m., a review of records for the last 5 quarters revealed the following:

-- 1. No documented monthly visual inspections of the wet pipe sprinkler system for the months of January through December 2015.

-- 2. No documented quarterly flow tests of the wet pipe sprinkler system for the 1st, 2nd or 4th quarters of 2015.

Maintenance Supervisor was present and acknowledged the findings.

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

NFPA Standard: Automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25 per NFPA 101, 9.7.5. Obstructions shall not prevent sprinkler discharge from reaching the protected area. Continuous or non-continuous obstructions that interrupt the water discharge in a horizontal plane more than 18 inches below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with this section. The requirements of this section shall also apply to obstructions 18 in. or less below the sprinkler for light and ordinary hazard occupancies per NFPA 13, 5-6.5.3. Water flow alarm devices including, but not limited to, mechanical water motor gongs, vane-type water flow devices, and pressure switches that provide audible or visual signals shall be tested quarterly per 1998 NFPA 25, 2-3.3

Based upon a review of records and staff interview, the facility fails to assure that anesthetizing locations are protected in accordance with NFPA 99, Standard for Health Care Facilities. The deficient practice could result in an increased risk of fire and injury affecting 1 patient and any visitors or staff in 1 of 4 smoke zones. The facility has a capacity of 25 with a census of 10 at the time of this survey.

During the tour conducted on 04/21/2016, between 1:00 p.m. and 4:00 p.m., a review of the computerized relative humidity logs revealed that at varying times and dates between 01/02/2016 and 04/14/2016, the Relative Humidity was not maintained equal to or greater than 35% as required.

Administrator and Maintenance Supervisor were present and acknowledged the findings.

NFPA Standard: Anesthetizing locations are protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA Standard: The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.