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Based on observation and interview, the facility failed to ensure that a corridor door to a hazardous area was equipped with a self-closing device.

The findings include:

During the Life Safety Code tour on October 21, 2010, at 9:55 a.m., with the Director of Maintenance, a corridor door to the Medical Records room was observed not to have a door closing device. Door closing devices are required on doors to rooms deemed to be a hazardous area. An interview on October 21, 2010, at 9:55 a.m., revealed the Director of Maintenance was unsure which rooms were considered hazardous areas that would require a door closing device.

Reference: NFPA 101 (2000 Edition).

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 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. 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) Soiled linen rooms
(6) Trash collection rooms
(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.
Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

19.3.6.3.4
Door-closing devices shall not be required on doors in corridor wall openings other than those serving required exits, smoke barriers, or enclosures of vertical openings and hazardous areas.

Based on observation and interview, the facility failed to ensure that the building fire alarm system functioned and was maintained as required by NFPA standards. This deficient practice would have the potential to affect all of the smoke compartments, staff, and other occupants of the building. The facility has the capacity for 25 beds with a census of 9 on the day of the survey.

The findings include:

During the Life Safety Code survey on October 21, 2010, at 10:50 a.m., with the Director of Maintenance (DOM) a test of the fire alarm automatic dialer component revealed when placed in trouble from phone line failure the unit did not send a trouble signal to the main fire alarm control panel. The fire alarm panel showed all systems were normal. A call by the DOM to an individual at the monitoring station revealed the monitoring station also did not receive a phone line trouble signal.

At 11:05 a.m., a test of the fire alarm system revealed after the initial alarm was silenced the fire alarm system would not reactivate when tested in another fire zone. An interview with the DOM on October 21, 2010, revealed the DOM was not aware of the problems associated with the fire alarm system.

Reference: NFPA 72 (1999 Edition).

5-5.3.2.1.6.2
The following requirements shall apply to all combinations in 5-5.3.2.1.6.1:
(1) Both channels shall be supervised in a manner approved for the means of transmission employed.
(3) The failure of either channel shall send a trouble signal on the other channel within 4 minutes.
(8) Failure of telephone lines (numbers) or cellular service shall be annunciated locally.

1-5.4.4 Distinctive Signals.
Fire alarms, supervisory signals, and trouble signals shall be distinctively and descriptively annunciated.

1-5.4.6 Trouble Signals.
Trouble signals and their restoration to normal shall be indicated within 200 seconds at the locations identified in 1-5.4.6.1 or 1-5.4.6.2. Trouble signals required to indicate at the protected premises shall be indicated by distinctive audible signals. These audible trouble signals shall be distinctive from alarm signals. If an intermittent signal is used, it shall sound at least once every 10 seconds, with a minimum duration of 1/2 second. An audible trouble signal shall be permitted to be common to several supervised circuits. The trouble signal(s) shall be located in an area where it is likely to be heard.

5-2.6.1.4
Upon receipt of trouble signals or other signals pertaining solely to matters of equipment maintenance of the fire alarm systems, the central station shall perform the following actions:
(1) *Communicate immediately with persons designated by the subscriber
A-5-2.6.1.4(1)
The term immediately in this context is intended to mean " without unreasonable delay. " Routine handling should take a maximum of 4 minutes from receipt of a trouble signal by the central station until initiation of the investigation by telephone.


1-5.4.8 Alarm Signal Deactivation.
A means for turning off activated alarm notification appliances shall be permitted only where it is key-operated, located within a locked cabinet, or arranged to provide equivalent protection against unauthorized use. Such means shall be permitted only if a visible zone alarm indication or the equivalent has been provided as specified in 1-5.7.1, and subsequent actuation of initiating devices on other initiating device circuits or subsequent actuation of addressable initiating devices on signaling line circuits cause the notification appliances to reactivate. A means that is left in the " off " position when there is no alarm shall operate an audible trouble signal until the means is restored to normal. If automatically turning off the alarm notification appliances is permitted by the authority having jurisdiction, the alarm shall not be turned off in less than 5 minutes.
Exception No. 1: If otherwise permitted by the authority having jurisdiction, the 5-minute requirement shall not apply.
Exception No. 2: If permitted by the authority having jurisdiction, subsequent actuation of another addressable initiating device of the same type in the same room or space shall not be required to cause the notification appliance(s) to reactivate.

Based on interview and records review, the facility failed to maintain their sprinkler system by NFPA standards. This deficient practice would have the potential to affect all of the smoke compartments, staff, and other occupants of the building. The facility has the capacity for 25 beds with a census of 9 on the day of the survey.

The findings include:

During the Life Safety Code tour on October 21, 2010, at 10:45 a.m., an interview with the Director of Maintenance at the facility's sprinkler room revealed the Director of Maintenance did not think the gauges to the sprinkler system had been replaced or recalibrated within five years as required.

On October 21, 2010, at 1:45 p.m., a record review of the sprinkler system inspection reports did not reveal if the gauges had been serviced or replaced in the past.

Reference: NFPA 25 (1998 Edition).

2-3.2* Gauges. Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

Based on observation and interview, the facility failed to ensure that a corridor door to a hazardous area was equipped with a self-closing device.

The findings include:

During the Life Safety Code tour on October 21, 2010, at 9:55 a.m., with the Director of Maintenance, a corridor door to the Medical Records room was observed not to have a door closing device. Door closing devices are required on doors to rooms deemed to be a hazardous area. An interview on October 21, 2010, at 9:55 a.m., revealed the Director of Maintenance was unsure which rooms were considered hazardous areas that would require a door closing device.

Reference: NFPA 101 (2000 Edition).

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 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. 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) Soiled linen rooms
(6) Trash collection rooms
(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.
Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

19.3.6.3.4
Door-closing devices shall not be required on doors in corridor wall openings other than those serving required exits, smoke barriers, or enclosures of vertical openings and hazardous areas.

Based on observation and interview, the facility failed to ensure that the building fire alarm system functioned and was maintained as required by NFPA standards. This deficient practice would have the potential to affect all of the smoke compartments, staff, and other occupants of the building. The facility has the capacity for 25 beds with a census of 9 on the day of the survey.

The findings include:

During the Life Safety Code survey on October 21, 2010, at 10:50 a.m., with the Director of Maintenance (DOM) a test of the fire alarm automatic dialer component revealed when placed in trouble from phone line failure the unit did not send a trouble signal to the main fire alarm control panel. The fire alarm panel showed all systems were normal. A call by the DOM to an individual at the monitoring station revealed the monitoring station also did not receive a phone line trouble signal.

At 11:05 a.m., a test of the fire alarm system revealed after the initial alarm was silenced the fire alarm system would not reactivate when tested in another fire zone. An interview with the DOM on October 21, 2010, revealed the DOM was not aware of the problems associated with the fire alarm system.

Reference: NFPA 72 (1999 Edition).

5-5.3.2.1.6.2
The following requirements shall apply to all combinations in 5-5.3.2.1.6.1:
(1) Both channels shall be supervised in a manner approved for the means of transmission employed.
(3) The failure of either channel shall send a trouble signal on the other channel within 4 minutes.
(8) Failure of telephone lines (numbers) or cellular service shall be annunciated locally.

1-5.4.4 Distinctive Signals.
Fire alarms, supervisory signals, and trouble signals shall be distinctively and descriptively annunciated.

1-5.4.6 Trouble Signals.
Trouble signals and their restoration to normal shall be indicated within 200 seconds at the locations identified in 1-5.4.6.1 or 1-5.4.6.2. Trouble signals required to indicate at the protected premises shall be indicated by distinctive audible signals. These audible trouble signals shall be distinctive from alarm signals. If an intermittent signal is used, it shall sound at least once every 10 seconds, with a minimum duration of 1/2 second. An audible trouble signal shall be permitted to be common to several supervised circuits. The trouble signal(s) shall be located in an area where it is likely to be heard.

5-2.6.1.4
Upon receipt of trouble signals or other signals pertaining solely to matters of equipment maintenance of the fire alarm systems, the central station shall perform the following actions:
(1) *Communicate immediately with persons designated by the subscriber
A-5-2.6.1.4(1)
The term immediately in this context is intended to mean " without unreasonable delay. " Routine handling should take a maximum of 4 minutes from receipt of a trouble signal by the central station until initiation of the investigation by telephone.


1-5.4.8 Alarm Signal Deactivation.
A means for turning off activated alarm notification appliances shall be permitted only where it is key-operated, located within a locked cabinet, or arranged to provide equivalent protection against unauthorized use. Such means shall be permitted only if a visible zone alarm indication or the equivalent has been provided as specified in 1-5.7.1, and subsequent actuation of initiating devices on other initiating device circuits or subsequent actuation of addressable initiating devices on signaling line circuits cause the notification appliances to reactivate. A means that is left in the " off " position when there is no alarm shall operate an audible trouble signal until the means is restored to normal. If automatically turning off the alarm notification appliances is permitted by the authority having jurisdiction, the alarm shall not be turned off in less than 5 minutes.
Exception No. 1: If otherwise permitted by the authority having jurisdiction, the 5-minute requirement shall not apply.
Exception No. 2: If permitted by the authority having jurisdiction, subsequent actuation of another addressable initiating device of the same type in the same room or space shall not be required to cause the notification appliance(s) to reactivate.

Based on interview and records review, the facility failed to maintain their sprinkler system by NFPA standards. This deficient practice would have the potential to affect all of the smoke compartments, staff, and other occupants of the building. The facility has the capacity for 25 beds with a census of 9 on the day of the survey.

The findings include:

During the Life Safety Code tour on October 21, 2010, at 10:45 a.m., an interview with the Director of Maintenance at the facility's sprinkler room revealed the Director of Maintenance did not think the gauges to the sprinkler system had been replaced or recalibrated within five years as required.

On October 21, 2010, at 1:45 p.m., a record review of the sprinkler system inspection reports did not reveal if the gauges had been serviced or replaced in the past.

Reference: NFPA 25 (1998 Edition).

2-3.2* Gauges. Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.