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NFPA 101, Life Safety Code, 2012 Edition

19.3.2 Protection from Hazards.
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

8.7 Special Hazard Protection.
8.7.1 General.
8.7.1.1* Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclosing the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.3
(2) Protecting the area with automatic extinguishing systems in accordance with Section 9.7
(3) Applying both 8.7.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 11 through 43.

8.7.1.3 Doors in barriers required to have a fire resistance rating shall have a minimum 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.

Based on observation and interview, facility failed to ensure all hazardous areas were protected by a 3/4 hour fire protection rating, which requires a 3/4 hour fire resistance rating for the door, in accordance with NFPA 101, Section 8.3. Not having all hazardous areas properly maintained (such as chemical storage), could result in the release of noxious/hazardous materials from one area to another. This deficient practice presents a risk of injury to any patient or staff member within the immediate area. The findings are:

A. On 07/31/19 at 7:45 am, during observation of the chemical storage room located in the operating room (O.R.) area, no door was installed, leaving the room open to the O.R. corridor.

B. On 07/31/19 at 7:50 am, during interview, the Maintenance Supervisor stated he didn't know when the door was removed.

NFPA (National Fire Protection Association) 101 Life Safety Code, 2012 Edition

19.3.5 Extinguishment Requirements.

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

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.

NFPA (National Fire Protection Association) 25 Standard for the Inspection, Testing and Maintenance for Water Based Fire Protection Systems (2011 Edition)

13.3.2 Inspection

13.3.2.1 All valves shall be inspected weekly.

13.3.2.1.2 Valves secured with locks or supervising in accordance with applicable NFPA standards shall be permitted to be inspected monthly.

13.3.2.1.2 After any alterations or repairs, an inspection shall be made by the property owner or designated representative to ensure that the system is in service and all valves are in the normal position and properly sealed, locked, or electrically supervised.

13.3.2.2 The valve inspection shall verify that the valves are in the following condition:
(1) In the normal open or closed position
(2) Sealed, locked, or supervised
(3) Accessible
(4) Provided with correct wrenches
(5) Free from external leaks
(6) Provided with applicable identification


Based on record review and interview, the facility failed to conduct and document monthly sprinkler control valve inspections. Not inspecting and maintaining documentation of supervised sprinkler system control valves could result in a control valve being damaged or moved from its proper working position and result in the failure of the sprinkler system to supply water in the event of a fire. This deficient practice presents a risk of injury by fire to any patient, and all occupants within the facility. The findings are:

A. On 07/30/19 at 11:20 am, during a record review of the sprinkler system documentation, facility was unable to provide documentation of monthly valve inspections.

B. On 05/14/19 at 11:25 am during an interview, Maintenance Supervisor said he could not locate the documentation.




NFPA (National Fire Protection Association), 101 Life Safety Code

19.3.5 Extinguishment Requirements.

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

9.7 Automatic Sprinklers and Other Extinguishing Equipment.
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.

NFPA 25, (2011 Edition)

14.2 Internal Inspection of Piping.
14.2.1 Except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material.
14.2.1.1 Alternative nondestructive examination methods shall be permitted.
14.2.1.2 Tubercules or slime, if found, shall be tested for indications of microbiologically influenced corrosion (MIC).
14.2.1.3* If the presence of sufficient foreign organic or inorganic material is found to obstruct pipe or sprinklers, an obstruction investigation shall be conducted as described
in Section 14.3.


Based on record review and interview, the facility failed to ensure an internal pipe inspection was conducted on fire sprinkler system every 5 years. Not having an internal pipe inspection conducted every 5 years could result in the failure of the sprinkler system due to damaged pipes, obstructions, or build up of organic or inorganic material, which could result in the failure of the sprinkler system, from a lack of water supply to the system. This deficient practice presents a risk of potential injury by fire to all patients, staff and occupants within the facility. The findings are:

A. On 07/30/19 at 11:05 am, during record review of sprinkler system servicing documentation, no documentation was provided to indicate the facility had a 5 year internal pipe inspection within the last 5 years.

B. On 07/30/19 at 11:10 am, during interview, the Maintenance Supervisor stated, "I believe the servicing company had conducted the test."

C. No further records were available for review.

NFPA 101 Life Safety Code, 2012 Edition
19.5 Building Services.
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.
19.5.1.2 Existing installations shall be permitted to be continued in service, provided that the systems do not present a serious hazard to life.
19.5.2 Heating, Ventilating, and Air-Conditioning.
19.5.2.1 Heating, ventilating, and air-conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer's specifications, unless otherwise modified by 19.5.2.2.

9.2

5.4.8 Maintenance.
5.4.8.1 Fire dampers and ceiling dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.

NFPA 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition

19.4* Periodic Inspection and Testing.
19.4.1.1 The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years.

Based on record review and interview, the facility failed to ensure fire/smoke dampers located within facility were maintained at least every six (6) years as required by NFPA 80 (Standard for Fire Doors and other Opening Protectives). Not maintaining the fire/smoke dampers per the NFPA frequency requirement could result in the distribution of smoke, hot gases and fire from area to area via the heating and ventilation air duct system in the event of fire, this deficient practice presents a risk of harm to all patients, staff and visitors. The findings are:

A. On 07/30/19 during record review of the Damper Inspections, no documentation was provided by facility to ensure dampers were inspected as required.

B. On 07/30/19 at 1:30 pm, during interview, the Maintenance Supervisor stated he could not locate the servicing documentation.

Based on record review and interview, the facility failed to ensure fire drills were conducted at least quarterly on all three nursing shifts to ensure preparedness for emergency response (Federal regulations require that fire drills shall not exceed 90-day spacing between drills on each shift). This deficient practice could likely result in staff not being adequately prepared to exercise their duties in accordance to the facility's fire preparedness plan in the event of fire, which presents a risk of potential harm to all patients, staff and occupants within the facility. The findings are:

A. On 07/30/19, record review of the fire drill log indicated the facility had two (2) nursing shifts:
First Shift (6:00 am - 6:00 pm)
Second Shift (6:00 pm - 6:00 am)


B. On 07/30/19, during record review of the fire drills, documentation was provided for the month of July, 2019. One (1), drill was conducted on the first shift, and one (1), drill was conducted on the second shift.

C. On 07/30/19 at 10:55 am during interview, the Maintenance Supervisor and maintenance staff, could not locate any other documentation.

NFPA 101, 2012 Edition

7.2.1.15 Inspection of Door Openings.

7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protective's. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protective's.


Reference NFPA 80, 2010 Edition

5.2* Inspections.
5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.

5.2.3 Functional Testing.
5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing.

5.2.3.2 Before testing, a visual inspection shall be performed to identify any damaged or missing parts that can create a hazard during testing or affect operation or resetting.

5.2.4 Swinging Doors with Builders Hardware or Fire Door Hardware.

5.2.4.1 Fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly.

5.2.4.2 As a minimum, the following items shall be verified:
(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.

Based on record review and interview, the facility failed to conduct and document annual fire door inspections using the 11-point verification checklist per NFPA 80 (Standard for Fire Doors and Other Opening Protective's). Not conducting an annual door inspection as required, could result in the passage of fire/smoke from one area of the facility to another. This deficient practice presents a risk of injury to patients, staff and other occupants within the facility. The findings are:


A. On 07/30/19 at 11:20 am, record review of the facility maintenance records revealed no documentation of fire door inspection using the 11-point check list per requirements of NFPA 80.

B. On 07/30/19 at 11:25 am during interview, the Maintenance Supervisor stated he could only locate the monthly door inspections.

NFPA 101, Life Safety Code, 2012 Edition

19.3.2.4 Medical Gas storage and administration areas shall be in accordance with Section 8.7 and the provisions NAPA 99, Health Care Facilities Code, applicable to administration, maintenance and testing.

NFPA 99, 2012 Edition

5.1.14.4 Medical Gas and Vacuum Systems Maintenance and Record Keeping.

5.1.14.4.4 Central supply systems for nonflammable medical gases shall conform to the following:
(1) They shall be inspected annually.
(2) They shall be maintained by a qualified representative of the equipment owner.
(3) A record of the annual inspection shall be available for review by the AHJ -
(Authority Having Jurisdiction).

Based on record review and interview, the facility failed to ensure the annual inspection of piped in medical gas and vacuum system was available for review by the AHJ annually per NFPA 99. Not having the vacuum piped system inspected annually could result in the failure of the system. This deficient practice presents a risk of injury to all patients within the facility. The findings are:

A. On 07/30/19 during record review of the medical gas and vacuum system, there was no documentation available for review that the system was inspected annually by a qualified agency.

B. On 07/30/19 at 11:40 am during interview, the Maintenance Supervisor stated he could not locate any documentation for the annual servicing, due to the Service Manager being on vacation.

NFPA (National Fire Protection Association),101 (2012 Edition)

19.5.1 Utilities
19.5.1.1 Utilities shall comply with the provisions of Section 9.1

9.1.3 Emergency Generators and Standby Power Systems. Where required for compliance with this Code, emergency generators and standby power systems shall comply with 9.1.3.1 and 9.1.3.2.
9.1.3.1 Emergency generators and standby power systems shall be installed, tested, and maintained in accordance with NFPA 110 (Standard for Emergency and Standby Power Systems) 2010 Edition.
9.1.3.2 New generator controllers shall be monitored by the fire alarm system, where provided, or at an attended location, for the following conditions:
(1) Generator running
(2) Generator Fault
(3) Generator switch in nonautomatic position

NFPA 110, 2010 Edition
5.6.5.6 All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building.

Based on observation and interview, the facility failed to ensure the Emergency Shut Off Switch (ESOS), was remotely installed on emergency generator. Not having the ESOS remotely installed on the emergency generator could result in the emergency generator not being able to be shut off if the unit malfunctioned/caught on fire, which would leave the entire facility without emergency electrical power. This presents a potential risk of injury to all patients, staff and occupants within the facility. The findings are.

A. On 07/30/19, during record review and interivew of emergency back-up power generators, Maintenance Supervisor indicated there were 2 units providing back-up power to different portions of the facility.

B. On 07/30/19 at 2:40 pm, during observation of emergency backup power generators (two units), and enclosure surrounding the unit. Both units require that the ESOS be remotely installed outside the generator enclosure.

C. On 07/30/19 at 2:45 pm during interview, the Maintenance Supervisor stated, "he had indicated to the Administrative Staff the installation should have been on the outside of the fenced area."



Reference; NFPA 110, 2010


8.3 Maintenance and Operational Testing.
8.3.1* The EPSS Emergency Power Supply System shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class.
8.3.2 A routine maintenance and operational testing program shall be initiated immediately after the EPSS has passed acceptance tests or after completion of repairs that impact the
operational reliability of the system.
8.3.2.1 The operational test shall be initiated at an ATS and shall include testing of each EPSS component on which maintenance or repair has been performed, including the transfer of
each automatic and manual transfer switch to the alternate power source, for a period of not less than 30 minutes under operating temperature.
8.3.3 A written schedule for routine maintenance and operational testing of the EPSS shall be established.
8.3.4 A permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available.
8.3.4.1 The permanent record shall include the following:
(1) The date of the maintenance report
(2) Identification of the servicing personnel
(3) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(4) Testing of any repair for the time as recommended by the manufacturer


Based on record review and interview, the facility failed to ensure documentation for servicing of emergency back-up electrical power (generators, 2 units), was made readily available for review. Not having documentation readily available for review, does not meet the general requirements on NFPA 110, Chapter 8 (Maintenance and Operational Testing). This deficient practice presents a risk of harm to all patients, staff and occupants within the facility. The findings are:

A. On 07/30/19, during record review of emergency back-up electrical power(generators, 2 units), no documentation (i.e. monthly testing for the last 12 months, annual servicing, annual load bank if required) was provided to ensure the 2 units were serviced as required.

B. On 07/30/19, at 3:00 pm, during interview the Maintenance Supervisor stated he could not locate the servicing documentation for the generators.