HospitalInspections.org

Based on observation and interview, the facility failed to maintain exits in smoke zones and insure the exits are easily accessible at all times in accordance with Section 18.2.7, 19.2.7 and S&C Letter 05-38 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition. The facility had a capacity of 99 patience and a census of 26 patience on the date of inspection.
Findings Include:
Observations on 04/03/19 between 10:50 am and 11:56 am, revealed a missing exit sign in the Air Handling Room on the Third Floor. Further observations revealed there were no exit signs visible on the Third Floor by the sleep study room that would identify the West Stair Exit. No exit sign was visible at the by the east exit door in the First Floor Doctors Lounge. Exit signs were also required in the Boiler Room, the Loading Dock, the Main Supply Room.

Maintenance Staff A verified these observations.

Based on observation, interview and record review, the facility did not provide and maintain a complete fire alarm system to alert all occupants of an emergency as required by National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.3.4.1/19.3.4.1 and 9.6. The deficient practice of not providing a complete fire alarm system did not ensure all occupants would be alerted to a fire event affecting occupants. This facility had a capacity of 99 and a census of 26 residents at the time of the survey.

Findings include:

Observation on 4/03/19, between 11:01 am and 12:25 pm., revealed there were several smoke detectors that were located within 36 inches of a HVAC vent. These detectors were located at the following areas.
In the Lab by the East Exit.
In the Second Floor Air Handling Room by the box panel.
In the Second Floor Therapy Room next to the entry door.
In the Second Floor Corridor by Room 2514.
In the Second Floor Lobby By the Medical Surgery Room.
The Third Floor OB West of the Elevator Lobby needs detection installed.
In the Third Floor OB west of the Barrier Doors there is a detector within 36 inches of the HVAC vent.

Record review of the facility layout showed the fire alarm system covered fifteen of fifteen smoke zones.

This deficient practice was confirmed by Maintenance Staff A at the time of discovery.

Based on observations, record reviews and interviews the facility failed to provide an outage policy that contained all the necessary information in accordance with 9.6.1.6 of the National Fire Protection Association Code 101 Life Safety Code 2012 Edition. This deficient practice would affect all residents and staff and all smoke zones in the facility. The facility had a capacity of 99 and a census of 26 at the time of this survey.
Findings Include:
Observations, record reviews and staff interviews on 04/03/19 at 12:00 pm, revealed the facility did not have a policy in place to instruct the staff on how to proceed if the fire alarm would be out of service for more than 4 hours in a 24 hour period.
Maintenance Staff verified these observations.

Based on record review and interview, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, 5.1.1.2, by ensuring that the sprinkler system was inspected and tested at least quarterly. This deficient practice of failing to provide complete, verifiable documentation on the maintenance and repair history did not ensure proper operation and prompt repair of the system. This affected all occupants in fifteen of fifteen smoke zones, in this facility with a capacity of 99 and a census of 26 residents at the time of the survey.

Findings include:

Record review on 4/03/19 between 12:01pm and 2:30 pm, revealed the facility was not able to provide any documentation that the sprinkler system had had a 5 year internal inspection conducted on the sprinkler system and it was not being inspected quarterly. Further observations revealed the sprinkler valve in the old Laundry Room in the Basement was not equipped with a working tamper alarm.

This deficient practice was confirmed by Administrative Staff A and Maintenance Staff A at the time of exit.

Based on observation and interview, the facility failed to inspect and maintain the automatic sprinkler system within the facility by assuring the sprinkler system gauges are replaced or tested every five years in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Fire Protection Systems, 2011 edition, Chapter 15. Lack of complete written policies and procedures could result in staff failing to implement interim safety measures in the event of an emergency. This deficient practice affected all occupants of the building. This facility had a capacity of 99 and a census of 26 residents at the time of the survey.

Findings include:

Record review on 04/03/19, at 12:07 pm, of the fire watch procedures revealed the facility did not have a complete policy regarding the procedures to be taken in the event that the sprinkler system was out of service for more than 10 hours in a 24-hour period. The policy failed to have the following information included in their policy as required by NFPA 25, 2011 Edition (Chapter 15):

15.2.1 The property owner or designated representative shall assign an impairment coordinator to comply with the requirements of this chapter.
15.2.2 In the absence of a specific designee, the property owner or designated representative shall be considered the impairment coordinator.
15.2.3 Where the lease, written use agreement, or management contract specifically grants the authority for inspection, testing, and maintenance of the fire protection system(s) to the tenant, management firm, or managing individual, the tenant, management firm, or managing individual shall assign a person as impairment coordinator.
15.3 Tag Impairment System.
15.3.1* A tag shall be used to indicate that a system, or part thereof, has been removed from service.
15.3.2* The tag shall be posted at each fire department connection and the system control valve, and other locations required by the authority having jurisdiction, indicating which system, or part thereof, has been removed from service.
15.4 Impaired Equipment.
15.4.1 The impaired equipment shall be considered to be the water-based fire protection system, or part thereof, that is removed from service.
15.4.2 The impaired equipment shall include, but shall not be limited to, the following:
(1) Sprinkler systems
(2) Standpipe systems
(3) Fire hose systems
(4) Underground fire service mains
(5) Fire pumps
(6) Water storage tanks
(7) Water spray fixed systems
(8) Foam-water systems
(9) Fire service control valves

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

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.

15.6.1 Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure.

15.6.2 When emergency impairments occur, emergency action shall be taken to minimize potential injury and damage.

15.6.3 The coordinator shall implement the steps outlined in Section 15.5.

15.7 Restoring Systems to Service. When all impaired equipment is restored to normal working order, the impairment coordinator shall verify that the following procedures have been implemented:

(1) Any necessary inspections and tests have been conducted to verify that affected systems are operational. The appropriate chapter of this standard shall be consulted for guidance on the type of inspection and test required.
(2) Supervisors have been advised that protection is restored.
(3) The fire department has been advised that protection is restored.
(4) The property owner or designated representative, insurance carrier, alarm company, and other authorities having jurisdiction have been advised that protection is restored.
(5) The impairment tag has been removed.


Administrative Staff A confirmed the findings during the exit conference.

Based on record review and interview, the facility failed to adequately document and hold fire drills under varied conditions at different times of the day in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.7.1.6/19.7.1.6 for four of four quarters reviewed. The documentation did not show the drills have been held as required, including varying conditions (such as timing). This had the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This facility had a capacity of 60 and a census of 39 residents at the time of the survey.

Findings include:

Record review on 4/03/19, between 12:30 p.m., of the facility fire drill documentation conducted during 2018 revealed the following: three of the four second shift drills were conducted between at 3:05 p.m. and 4:10 p.m. Four of the four third shift drills were conducted between 6:15 a.m. and 6:50 a.m.

Results of the record review were acknowledged by Administrative Staff A at the time of exit.

Based on record review and interview, the facility failed to maintain the emergency generator power supply as required by National Fire Protection Association (NFPA) 110, Standard for Emergency and Standby Power Systems, 2010 edition, 8.3.8, by not ensuring a fuel quality test was performed at least annually using tests approved by ASTM standards. This deficient practice affects all smoke compartments throughout the building and all occupants. The facility had a capacity of 99 and a census of 26 residents at the time of the survey.

Findings include:

Record review and interview on 4/03/19 at 12:33 p.m., revealed the facility could not provide documentation of an annual fuel quality test for the generator diesel fuel.

Maintenance Staff A and the Administrator confirmed these findings at the time of the survey.


Based on record review and interview, the facility failed to maintain and test essential electrical system (EES) circuitry as required by National Fire Protection Association (NFPA) 99, Health Care Facilities Code, 2012 edition, 6.4.4.1.2 and 6.4.4.2. The deficient practice affects all of the smoke compartments throughout the building and all occupants. The facility had a capacity of 99 and a census of 26 residents at the time of the survey.

Findings include:

Record review and interview on 4/03/19, at 12:33 p.m., revealed the facility was unable to provide documentation of inspection and exercising the components of the essential electrical system (EES) main and feeder circuit breakers. Interview of Maintenance Staff A revealed an electrician had tested many of the facility's breakers and replaced any found to be non-functioning recently, but no documentation of inspection or exercising had been maintained.

Maintenance Staff A and the Administrator confirmed this finding at the time of the survey.