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Based on observation and interview, facility failed to ensure fire separation was maintained in mechanical room located adjacent to emergency room entrance. Not maintaining fire/smoke barriers from floor level to the ceiling, could result in a fire spreading from one area to another. This failed practice presents a risk of injury by fire to all three (3), patients of the hospital as identified by the daily census list provided by the Administrator on 08/15/17. The findings are:

A. On 08/15/17, at 2:35 pm, observation of 1, 1 inch. diameter hole, and 1, 4 inch. diameter hole located on the north wall. And 1, 1 inch. diameter hole located on the east wall of mechanical room.

B. On 08/15/17, at 2:40 pm, Environmental Director stated he would have these penetrations sealed right away, acknowledging the finding.

NFPA 101 Life Safety Code (2012 Edition)

19.3.2.5 Cooking Facilities.
19.3.2.5.1 Cooking facilities shall be protected in accordance with 9.2.3, unless other wise permitted by 19.3.2.5.2, 19.3.2.5.3 or 19.3.2.5.2.

9.2.3 Commercial Cooking Equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations (2011 Edition)

11.7 Cooking Equipment Maintenance.
11.7.1 Inspection and servicing of the cooking equipment shall be made at least annually by properly trained and qualified persons.

Based on interview and record review of commercial cooking equipment (appliances), facility failed to ensure an annual inspection and servicing of cooking equipment had been conducted. Not having commercial cooking equipment serviced annually, could result in a fire from possible failure of the equipment. This failed practice presents a risk of potential harm by fire to all three (3), patients and staff within the facility. The findings are:

A. On 08/15/17 at 12:40 pm, record review of commercial cooking equipment indicated no annual servicing of appliances had been conducted.

B. On 08/15/17 at 12:45 pm, during interview, Environmental Director stated he was unaware this was required and would schedule servicing, acknowledging the finding.




NFPA 101 Life Safety Code (2010 Edition)

19.5.2 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

9.2.3 Commercial Cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.

10.2.3* Automatic fire-extinguishing systems shall comply with ANSI/UL 300 or other equivalent standards and shall be
installed in accordance with the requirements of the listing.

NFPA 72 National Fire and Signaling Code (2010 Edition)
14.5.3.1 Sensitivity shall be checked within 1 year after installation.

14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3

14.4.5.3.3 After the second required calibration test, if sensitivity tests indicate that the device has remained within its
listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between
calibration tests shall be permitted to be extended to a maximum of 5 years.


Based on observation and interview, facility failed to ensure smoke detection devices were tested for sensitivity every two (2) years as required. Not testing detection devices for proper sensitivity levels, could result in the delay of detecting a fire. This failed practice presents a risk of potential harm by fire to all three (3) patients of the facility, as identified by the census list provided by the Environmental Director on 08/15/17. The findings are:

A. On 08/15/17, at 10:50 am, during fire alarm record review, no documentation was provided to indicate sensitivity testing had been conducted within the last two (2) years.

B. On 08/15/17 at 10:55 am, during interview, the Environmental Director acknowledged the findings.

NFPA 13 Installation of Sprinkler Systems (2010 EDITION)

8.1* Basic Requirements.
8.1.1* The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers shall be installed throughout the premises.
(2) Sprinklers shall be located so as not to exceed the maximum protection area per sprinkler.
(3) Sprinklers shall be positioned and located so as to provide satisfactory performance with respect to activation time
and distribution.
(4) Sprinklers shall be permitted to be omitted from areas specifically allowed by this standard.
(5) When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements
to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning
and locating in accordance with the test results shall be permitted.
(6) Clearance between sprinklers and ceilings exceeding the maximums specified in this standard shall be permitted,
provided that tests or calculations demonstrate comparable sensitivity and performance of the sprinklers to
those installed in conformance with these sections.
(7) Furniture, such as portable wardrobe units, cabinets, trophy cases, and similar features not intended for occupancy,
does not require sprinklers to be installed in them. This type of feature shall be permitted to be attached to
the finished structure.




Based on observation and interview, facility failed to have fire sprinkler protection installed in the laundry room clean entrance, directly off of service corridor. Not having sprinkler protection in all spaces within the facility, could result in a rapid spreading fire. This failed practice presents a risk of potential harm to all three (3), patients of the facility as identified by the daily census list provided by the Administrator on 08/15/17. The findings are:

A. On 08/15/17, at 2:30 pm, during tour of facility, observation of no sprinkler head installed in the laundry room clean entrance, located directly off of the service corridor..

B. On 08/15/17, during interview, Environmental Director stated, "I will get one installed". Acknowledging the finding.

Based on observation and interview, facility failed to ensure medical vacuum pump (provides suction for medical procedures), was in proper working order. Not having vacuum pump maintained in proper working order could result in the failure of the pump during medical procedures. This failed practice presents a risk of injury to all three (3) patients of the facility. Identified by the daily census list provided by the Administrator on 08/15/17. The findings are:

A. On 08/15/17, at 2:35 pm, observation of medical vacuum pump leaking oil from unit. A catch pan was also placed on the floor under the damaged area, with oil in it.

B. On 08/15/17, at 2:45 pm, during interview, Environmental Director stated the unit is old and needs repair, acknowledging the finding.

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

9.1 Utilities
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.

NFPA 110 Standard for Emergency and Standby Power Systems (2010 Edition)

8.3.8 A fuel quality test shall be performed at least annually using tests approved by ASTM standards. (American Section of the International Association for Testing Materials).



Based on interview and record review of Generator log and maintenance documentation, facility failed to ensure a fuel quality test was conducted annually, as per requirements of NFPA 110 and ASTM (American Section of the International Association for Testing Materials). Not conducting annual fuel quality tests as required, could result in the failure of the Emergency Generator not supplying power to the facility in the event of a main power outage. This failed practice presents a risk of injury, by the lack of emergency stand-by power, to all three (3), patients as identified by the census list provided by the Administrator on 08/15/17. The findings are:

A. On 08/15/17 at 12:55 pm, during record review of Emergency Generator log and maintenance, there was no documentation indicating that a fuel quality test had been conducted within the last 12 months.

B. On 08/15/17 at 1:05 pm, during interview, Environmental Director stated he did not know about the fuel quality test, stating he would schedule testing during next annual servicing, acknowledging the finding.