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Based on observation and interview, the facility failed to ensure that cross-corridor fire/smoke barrier doors were maintained according to National Fire Protection Association (NFPA) standards. This deficient practice affected one (1) of ten (10) smoke compartments, staff, and approximately three (3) residents. The facility has the capacity for forty-nine (49) beds with a census of twenty-nine (29) on the day of the survey.

The findings include:

During the Life Safety Code tour on 10/29/14 at 9:00 AM with the Director of Maintenance (DOM), a set of cross-corridor fire/smoke barrier doors located in Zone 1 were observed to have an approximate 1/2-inch gap when closed. These doors must have a minimum gap to help prevent fire/smoke from spreading to other parts of the building in case of a fire situation.

An interview with the DOM on 10/29/14 at 9:00 AM revealed the gap was approximately 1/2 inch. The DOM stated he was not aware of the minimum standard for fire/smoke barrier doors of 1/8 inch.

The findings were revealed to Administration upon exit.

Reference: NFPA 101 (2000 Edition).

19.3.7.6*
Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6. Such doors in smoke barriers shall not be required to swing with egress travel. Positive latching hardware shall not be required.

8.3.4.1*
Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

A.8.3.4.1
The clearance for proper operation of smoke doors is defined as 1/8 in. (0.3 cm). For additional information on the installation of smoke-control door assemblies, see NFPA 105, Recommended Practice for the Installation of Smoke-Control Door Assemblies.

Based on observation and interview, the facility failed to ensure exit doors were maintained according to NFPA standards. This deficient practice affected two (2) of ten (10) smoke compartments, staff, and approximately eleven (11) residents. The facility has the capacity for forty-nine (49) beds with a census of twenty-nine (29) on the day of the survey.

The findings include:

During the Life Safety Code tour conducted on 10/29/14 at 8:45 AM with the Director of Maintenance (DOM) an exit door with a magnetic locking device located in Zone 5 was observed not to have the appropriate signage on how to release the lock in an emergency.

An interview with the DOM on 10/29/14 at 8:45 AM revealed the lock only released on the activation of the fire alarm system or a coded key pad located near the exit door. The DOM was not aware the exit door should be accessible by all people, even those not having knowledge on how to exit the facility. During the survey, an exit door located in Zone 1 was observed to have the same type of locking arrangement.

The findings were revealed to Administration upon exit.

Reference: NFPA 101 (2000 Edition).

19.2.2.2.4
Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.
Exception No. 1: Door-locking arrangements without delayed egress shall be permitted in health care occupancies, or portions of health care occupancies, where the clinical needs of the patients require specialized security measures for their safety, provided that staff can readily unlock such doors at all times. (See 19.1.1.1.5 and 19.2.2.2.5.)
Exception No. 2*: Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path.
Exception No. 3: Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted.

Based on observation and interview the facility failed to ensure that sprinkler heads were maintained according to National Fire Protection Association (NFPA) standards. This deficient practice affected one (1) of ten (10) smoke compartments, staff, and other occupants of the building. The facility has the capacity for forty-nine (49) beds with a census of twenty-nine (29) on the day of the survey.

The findings include:

During the Life Safety Code survey on 10/29/14 at 10:00 AM with the Director of Maintenance (DOM), quick-response and standard-response rated sprinkler heads were observed at the Cross Halls area near the Cafeteria and Emergency Room corridors. The facility failed to ensure the sprinkler heads located in the above compartmental space were the same type. This condition may adversely affect the way the sprinkler system reacts in a fire situation.

An interview with the DOM on 10/29/14 at 10:00 AM revealed that a Joint Commission survey this year revealed the same concern with the sprinkler heads; however, the facility had not taken action to make the appropriate repairs.

The findings were revealed to Administration upon exit.

Reference: NFPA 13 (1999 Edition).

5-3.1.5.2
When existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartmented space shall be changed.

Based on interview and record review, the facility failed to ensure the emergency generator was maintained according to National Fire Protection Agency (NFPA) standards. This deficient practice affected ten (10) of ten (10) smoke compartments, staff, and other occupants of the building. The facility has the capacity for forty-nine (49) beds with a census of twenty-nine (29) on the day of the survey.

The findings include:

During the Life Safety Code survey on 10/29/14 at 10:50 AM, a record review with the Director of Maintenance (DOM) revealed there was no written weekly maintenance record associated with the generator. Weekly inspections are designed to help ensure the emergency generator operates as intended.

An interview on 10/29/14 at 10:50 AM revealed the DOM kept monthly generator maintenance records but was unaware there should be a written weekly maintenance schedule as well.

The findings were revealed to Administration upon exit.

Reference: NFPA 110 (1999 Edition).

6-1.1*
The routine maintenance and operational testing program shall be based on the manufacturer's recommendations, instruction manuals, and the minimum requirements of this chapter and the authority having jurisdiction
6-3.3
A written schedule for routine maintenance and operational testing of the EPSS shall be established
6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

Based on observation and interview, the facility failed to ensure that cross-corridor fire/smoke barrier doors were maintained according to National Fire Protection Association (NFPA) standards. This deficient practice affected one (1) of ten (10) smoke compartments, staff, and approximately three (3) residents. The facility has the capacity for forty-nine (49) beds with a census of twenty-nine (29) on the day of the survey.

The findings include:

During the Life Safety Code tour on 10/29/14 at 9:00 AM with the Director of Maintenance (DOM), a set of cross-corridor fire/smoke barrier doors located in Zone 1 were observed to have an approximate 1/2-inch gap when closed. These doors must have a minimum gap to help prevent fire/smoke from spreading to other parts of the building in case of a fire situation.

An interview with the DOM on 10/29/14 at 9:00 AM revealed the gap was approximately 1/2 inch. The DOM stated he was not aware of the minimum standard for fire/smoke barrier doors of 1/8 inch.

The findings were revealed to Administration upon exit.

Reference: NFPA 101 (2000 Edition).

19.3.7.6*
Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6. Such doors in smoke barriers shall not be required to swing with egress travel. Positive latching hardware shall not be required.

8.3.4.1*
Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

A.8.3.4.1
The clearance for proper operation of smoke doors is defined as 1/8 in. (0.3 cm). For additional information on the installation of smoke-control door assemblies, see NFPA 105, Recommended Practice for the Installation of Smoke-Control Door Assemblies.

Based on observation and interview, the facility failed to ensure exit doors were maintained according to NFPA standards. This deficient practice affected two (2) of ten (10) smoke compartments, staff, and approximately eleven (11) residents. The facility has the capacity for forty-nine (49) beds with a census of twenty-nine (29) on the day of the survey.

The findings include:

During the Life Safety Code tour conducted on 10/29/14 at 8:45 AM with the Director of Maintenance (DOM) an exit door with a magnetic locking device located in Zone 5 was observed not to have the appropriate signage on how to release the lock in an emergency.

An interview with the DOM on 10/29/14 at 8:45 AM revealed the lock only released on the activation of the fire alarm system or a coded key pad located near the exit door. The DOM was not aware the exit door should be accessible by all people, even those not having knowledge on how to exit the facility. During the survey, an exit door located in Zone 1 was observed to have the same type of locking arrangement.

The findings were revealed to Administration upon exit.

Reference: NFPA 101 (2000 Edition).

19.2.2.2.4
Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.
Exception No. 1: Door-locking arrangements without delayed egress shall be permitted in health care occupancies, or portions of health care occupancies, where the clinical needs of the patients require specialized security measures for their safety, provided that staff can readily unlock such doors at all times. (See 19.1.1.1.5 and 19.2.2.2.5.)
Exception No. 2*: Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path.
Exception No. 3: Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted.

Based on observation and interview the facility failed to ensure that sprinkler heads were maintained according to National Fire Protection Association (NFPA) standards. This deficient practice affected one (1) of ten (10) smoke compartments, staff, and other occupants of the building. The facility has the capacity for forty-nine (49) beds with a census of twenty-nine (29) on the day of the survey.

The findings include:

During the Life Safety Code survey on 10/29/14 at 10:00 AM with the Director of Maintenance (DOM), quick-response and standard-response rated sprinkler heads were observed at the Cross Halls area near the Cafeteria and Emergency Room corridors. The facility failed to ensure the sprinkler heads located in the above compartmental space were the same type. This condition may adversely affect the way the sprinkler system reacts in a fire situation.

An interview with the DOM on 10/29/14 at 10:00 AM revealed that a Joint Commission survey this year revealed the same concern with the sprinkler heads; however, the facility had not taken action to make the appropriate repairs.

The findings were revealed to Administration upon exit.

Reference: NFPA 13 (1999 Edition).

5-3.1.5.2
When existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartmented space shall be changed.

Based on interview and record review, the facility failed to ensure the emergency generator was maintained according to National Fire Protection Agency (NFPA) standards. This deficient practice affected ten (10) of ten (10) smoke compartments, staff, and other occupants of the building. The facility has the capacity for forty-nine (49) beds with a census of twenty-nine (29) on the day of the survey.

The findings include:

During the Life Safety Code survey on 10/29/14 at 10:50 AM, a record review with the Director of Maintenance (DOM) revealed there was no written weekly maintenance record associated with the generator. Weekly inspections are designed to help ensure the emergency generator operates as intended.

An interview on 10/29/14 at 10:50 AM revealed the DOM kept monthly generator maintenance records but was unaware there should be a written weekly maintenance schedule as well.

The findings were revealed to Administration upon exit.

Reference: NFPA 110 (1999 Edition).

6-1.1*
The routine maintenance and operational testing program shall be based on the manufacturer's recommendations, instruction manuals, and the minimum requirements of this chapter and the authority having jurisdiction
6-3.3
A written schedule for routine maintenance and operational testing of the EPSS shall be established
6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.