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Based on observation and interview, it was determined the facility failed to properly prop open doors in accordance with NFPA standards. The deficiency had the potential to affect three (3) of six (6) smoke compartments, thirty-eight (38) residents, staff and visitors. The facility is certified for ninety-seven (97) beds with a census of fifty-nine (59) on the day of the survey. The facility failed to ensure three (3) doors in the facility were being properly propped open.

The findings include:

Observation, on 10/24/12 between 2:30 PM and 5:00 PM with the Plant Operation Supervisor, revealed a door wedge propping the door open of the Director of Nursing Office, a table propping the door of the Medical Records file room, and a wire screwed to the wall of the IT room.

Interview, on 10/24/12 between 2:30 PM and 5:00 PM with the Plant Operation Supervisor, revealed he was unaware the items were being used to prop open doors in then facility. He was aware doors could not be propped open with items that do not release when the door is pushed or pulled.


Reference: NFPA 101 (2000 Edition)

18.3.6.3.3*
Hold-open devices that release when the door is pushed or pulled shall be permitted.

Based on observation and interview, it was determined the facility failed to ensure cross -corridor doors located in a smoke barrier would resist the passage of smoke in accordance with NFPA standards. The deficiency had the potential to affect five (5) of six (6) smoke compartments, all residents, staff and visitors. The facility is certified for ninety-seven (97) beds with a census of fifty-nine (59) on the day of the survey. The facility failed to ensure the cross corridor doors throughout the facility had a gap of less than 1/8 of an inch on the pull side of the door.

The findings include:

Observation, on 10/24/12 between 2:30 PM and 5:00 PM with the Plant Operation Supervisor, revealed the cross-corridor doors located next to room # 206 and next to the education administration office would not close completely when tested due to a rubber stripping placed on the doors. The cross corridor doors at the gym had a gap that was approximately ? of an inch.

Interview, on 10/24/12 between 2:30 PM and 5:00 PM with the Plant Operation Supervisor, revealed he was unaware the doors would not close all the way leaving a gap between the doors in the closed position.


Reference: NFPA 101 (2000 edition)

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.

Reference: NFPA 80 (1999 Edition)
Standard for Fire Doors 2-3.1.7
The clearance between the edge of the door on the pull side shall be 1/8 in. (+/-) 1/16 in. (3.18 mm (+/-) 1.59 mm) for steel doors and shall not exceed 1/8 in. (3.18mm) for wood doors.

Based on observation and interview, it was determined the facility failed to meet the requirements of Protection of Hazards in accordance with NFPA Standards. The deficiency had the potential to affect two (2) of six (6) smoke compartments, no residents, staff and visitors. The facility is certified for ninety-seven (97) beds with a census of fifty-nine (59) on the day of the survey. The facility failed to ensure eight (8) rooms were properly protected due to the storage in the rooms.


The findings include:

Observation, on 10/24/12 between 2:30 PM and 5:00 PM with the Plant Operation Supervisor, revealed:
1) The business development office with combustible storage did not have a 45 minute rated door with closer installed.
2) The controller office with combustible storage did not have a 45 minute rated door with closer installed.
3) The business office with combustible storage did not have a 45 minute rated door with closer installed.
4) The human resources director office with combustible storage did not have a 45 minute rated door with closer installed.
5) The reception mailroom area with combustible storage did not have a 45 minute rated door with closer installed.
6) The clinical service director office with combustible storage did not have a 45 minute rated door with closer installed.
7) The consult 17 office with combustible storage did not have a 45 minute rated door with closer installed.
8) The dietary director office with combustible storage did not have a 45 minute rated door with closer installed.


Interview, on 10/24/12 between 2:30 PM and 5:00 PM with the Plant Operation Supervisor, revealed he was not aware the areas listed above were considered hazardous storage thus requiring a 45 minute rated door, a self-closer, and separation.

Reference:

NFPA 101 (2000 Edition).

18.3.2 Protection from Hazards.
18.3.2.1* Hazardous Areas.
Any hazardous area shall be protected in accordance with Section 8.4. The areas described in Table 18.3.2.1 shall be protected as indicated.

Table 18.3.2.1 Hazardous Area Protection

Hazardous Area Description Separation/Protection
Boiler and fuel-fired heater rooms 1 hour
Central/bulk laundries larger than 100 ft2 (9.3 m2) 1 hour
Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe
hazard See 18.3.6.3.4
Laboratories that use hazardous materials that would be classified as a severe hazard in accordance with NFPA 99, Standard for Health Care Facilities 1 hour
Paint shops employing hazardous substances and materials in quantities less than those that would be classified as a severe hazard 1 hour
Physical plant maintenance shops 1 hour
Soiled linen rooms 1 hour
Storage rooms larger than 50 ft2 (4.6 m2) but not exceeding
100 ft2 (9.3 m2) storing
combustible material See 18.3.6.3.4
Storage rooms larger than 100 ft2 (9.3 m2) storing combustible
material 1 hour
Trash collection rooms 1 hour

18.3.6.3.4
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, it was determined the facility failed to ensure exits were equipped with lighting in accordance with NFPA standards. The deficiency had the potential to affect four (4) of six (6) smoke compartments, sixty-six (66) residents, staff and visitors. The facility is certified for ninety-seven (97) beds with a census of fifty-nine (59) on the day of the survey. The facility failed to ensure the emergency lights had two (2) bulbs at six (6) exits.

The findings include:

Observation, on 10/24/12 at 1:55 PM with the Plant Operation Supervisor, revealed the exterior exits at the risk management office, the adolescent unit, the adult civilian unit, the director of nursing office, gym front, and the gym back only had a single light for illumination of the outside of the exit.

Interview, on 10/24/12 at 1:55 PM with the Plant Operation Supervisor, revealed he was unaware the lighting fixtures serving the exterior exits must include more than one bulb for illumination of the egress path.

Reference: NFPA 101 (2000 edition)
7.8.1.4* Required illumination shall be arranged so that the
failure of any single lighting unit does not result in an illumination
level of less than 0.2 ft-candle (2 lux) in any designated
area.

Based on observation and interview, it was determined the facility failed to ensure no exit signs were maintained in accordance with NFPA standards. The deficiency had the potential to affect three (3) of six (6) smoke compartments, sixty-six (66) residents, staff and visitors. The facility is certified for ninety-seven (97) beds with a census of fifty-nine (59) on the day of the survey. The facility failed to ensure eight (8) doors leading to courtyards were marked with proper no exit signs.


The findings include:

Observation, on 10/24/12 between 2:30 PM and 5:00 PM with the Plant Operation Supervisor, revealed doors leading to the outside of the facility that where not exits. The following areas were affected: activity room a, b, c, and d; quiet room a, b, c, and d; and the main courtyard entrance.

Interview, on 10/24/12 between 2:30 PM and 5:00 PM with the Plant Operation Supervisor, revealed he was unaware doors must be marked with no exit signage if they are not being used as an exit.



Reference: NFPA 101 (2000 edition)

7.10.8 Special Signs.
7.10.8.1* No Exit.
Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows:
NO
EXIT
Such sign shall have the word NO in letters 2 in. (5 cm) high with a stroke width of 3/8 in. (1 cm) and the word EXIT in letters 1 in. (2.5 cm) high, with the word EXIT below the word NO.
Exception: This requirement shall not apply to approved existing signs.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted quarterly on each shift at random times, in accordance with NFPA standards. The deficiency had the potential to affect six (6) of six (6) smoke compartments, all residents, staff and visitors. The facility is certified for ninety-seven (97) beds with a census of fifty-nine (59) on the day of the survey. The facility failed to ensure fire drills were being conducted each quarter on third shift and at varied times on all shifts.

The findings include:

Fire Drill review, on 10/24/12 at 1:55 PM with the Plant Operation Supervisor and the Chief Executive Officer, revealed the fire drills were not being conducted at unexpected times under varied conditions. First shift fire drills were being conducted predictably between 1:15 PM and 1:30 PM, second shift predictably between 4:00 PM and 4:30 PM, and third shift predictably between 11:00 PM and 11:15 PM. Further review revealed there was no drill performed on third shift during the second quarter of 2012.

Facility Fire Drill Policy review, at 2:00 PM with the Plant Operation Supervisor and the Chief Executive Officer, revealed number four of the policy stated time of day that fire drills are performed should be staggered throughout the year.

Interview, on 10/24/12 at 1:55 PM with the Plant Operation Supervisor, revealed he was unaware the fire drills were not being conducted as required. He stated he was more focused on getting it done on each shift per quarter than monitoring the time separation. He reports the fire drills directly to the Chief Executive Officer.

Interview, on 10/24/12 at 1:55 PM with the Plant Operation Supervisor, revealed once the fire drills are reported to him they are reviewed at monthly safety meetings and at quarterly governing board meetings.

Reference: NFPA 101 Life Safety Code (2000 Edition).
18.7.1.2*
Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Based on observation and interview it was determined the facility failed to ensure the building had a complete sprinkler system, in accordance with NFPA Standards. The deficiency had the potential to affect three (3) of six (6) smoke compartments, all residents, staff and visitors. The facility is certified for ninety-seven (97) beds with a census of fifty-nine (59) on the day of the survey. The facility failed to ensure six (6) electrical rooms and two (2) mechanical rooms of the building had proper sprinkler coverage.

The findings include:

Observation, on 10/24/12 between 2:30 PM and 5:00 PM with the Plant Operation Supervisor, revealed electrical rooms C1, C2, B1, B2, B3, and B4 did not have a ceiling to provide proper spacing for the sprinkler head. Further observation revealed the Mechanical Rooms B and C did not have a ceiling to provide proper spacing for the sprinkler head.

Interview, on 10/24/12 between 2:30 PM and 5:00 PM with the Plant Operation Supervisor, revealed he was not aware that the areas listed did not have proper sprinkler protection.


Reference: NFPA 13 (1999 Edition)

5-6.4.1.2 Under obstructed construction, the sprinkler
deflector shall be located within the horizontal planes of
1 in. to 6 in. (25.4 mm to 152 mm) below the structural
members and a maximum distance of 22 in. (559 mm)
below the ceiling/roof deck.
Exception No. 1: Sprinklers shall be permitted to be installed with the
deflector at or above the bottom of the structural member to a maximum
of 22 in. (559 mm) below the ceiling/roof deck where the sprinkler is
installed in conformance with 5-6.5.1.2.
Exception No. 2: Where sprinklers are installed in each bay of obstructed
construction, deflectors shall be permitted to be a minimum
of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm) below the
ceiling.
Exception No. 3: Sprinkler deflectors shall be permitted to be 1 in. to
6 in. below composite wood joists to a maximum distance of 22 in.
below the ceiling/roof deck only where joist channels are fire-stopped
to the full depth of the joists with material equivalent to the web construction
so that individual channel areas do not exceed 300 ft2
(27.9 m2).
Exception No. 4: *Deflectors of sprinklers under concrete tee construction
with stems spaced less than 71/2 ft (2.3 m) but more than
3 ft (0.9 m) on centers shall, regardless of the depth of the tee, be permitted
to be located at or above a horizontal plane 1 in. (25.4 mm)
below the bottom of the stems of the tees and shall comply with Table
5-6.5.1.2.
5-6.4.1.3* Sprinklers

Based on record review and interview, it was determined the facility failed to have quarterly inspections performed of the fire sprinkler system in accordance with NFPA standards. The deficiency had the potential to affect six (6) of six (6) smoke compartments, all residents, staff and visitors. The facility is certified for ninety-seven (97) beds with a census of fifty-nine (59) on the day of the survey. The facility failed to ensure the sprinkler system was tested quarterly throughout the year.

The findings include:

Record review, on 10/24/12 at 2:15 PM with the Plant Operation Supervisor and the Chief Executive Officer, revealed the facility did not have documentation for a first quarter inspection during 2012 for the fire sprinkler system. Components located in the fire sprinkler system must be inspected monthly and quarterly accordingly to NFPA requirements and the records for the inspection made available for the authority having jurisdiction.

Interview, on 10/24/12 at 1:55 PM with the Plant Operation Supervisor and the Chief Executive Officer, revealed they believe the sprinkler system was inspected during the first quarter and they are working getting the paperwork.

Reference: NFPA 25 (1998 Edition).

2-1 General. This chapter provides the minimum requirements
for the routine inspection, testing, and maintenance of
sprinkler systems. Table 2-1 shall be used to determine the
minimum required frequencies for inspection, testing, and
maintenance.
Exception: Valves and fire department connections shall be inspected,
tested, and maintained in accordance with Chapter 9.

Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance
Item Activity Frequency Reference
Gauges (dry, preaction deluge systems) Inspection Weekly/monthly 2-2.4.2
Control valves Inspection Weekly/monthly Table 9-1
Alarm devices Inspection Quarterly 2-2.6
Gauges (wet pipe systems) Inspection Monthly 2-2.4.1
Hydraulic nameplate Inspection Quarterly 2-2.7
Buildings Inspection Annually (prior to freezing
weather)
2-2.5
Hanger/seismic bracing Inspection Annually 2-2.3
Pipe and fittings Inspection Annually 2-2.2
Sprinklers Inspection Annually 2-2.1.1
Spare sprinklers Inspection Annually 2-2.1.3
Fire department connections Inspection Table 9-1
Valves (all types) Inspection Table 9-1
Alarm devices Test Quarterly 2-3.3
Main drain Test Annually Table 9-1
Antifreeze solution Test Annually 2-3.4
Gauges Test 5 years 2-3.2
Sprinklers - extra-high temp. Test 5 years 2-3.1.1 Exception No. 3
Sprinklers - fast response Test At 20 years and every 10 years
thereafter
2-3.1.1 Exception No. 2
Sprinklers Test At 50 years and every 10 years
thereafter
2-3.1.1
Valves (all types) Maintenance Annually or as needed Table 9-1
Obstruction investigation Maintenance 5 years or as needed Chapter 10

Based on observation and interview, it was determined the facility failed to ensure there was proper fire protection in the designated smoking area, in accordance with NFPA standards. The deficiency had the potential to affect five (5) of six (6) smoke compartments, all residents, staff and visitors. The facility is certified for ninety-seven (97) beds with a census of fifty-nine (59) on the day of the survey. The facility failed to ensure there was a fire blanket or fire extinguisher at the employee smoking area.

The findings include:

Observation, on 10/24/12 at 3:25 PM with the Plant Operation Supervisor, revealed the employee smoking area did not have a fire blanket or a fire extinguisher located at the smoking area.

Interview, on 10/24/12 at 3:25 PM with the Plant Operation Supervisor, revealed he was not aware of the requirement for fire extinguisher or fire blanket at smoking areas.

Reference: S & C Letter: 12-04-NH;
Date: November 10, 2011
Subject: Alert: Smoking Safety in Long Term Care Facilities

Based on observation and interview it was determined the facility failed to ensure, portable space heaters used in the facility were in accordance with NFPA standards. The deficiency had the potential to affect one (1) of six (6) smoke compartments, no residents, staff and visitors. The facility is certified for ninety-seven (97) beds with a census of fifty-nine (59) on the day of the survey. The facility failed to ensure two (2) space heaters in employee areas did not exceed 212 degrees Fahrenheit.

The findings include:

Observation, on 10/24/12 between 2:30 PM and 5:00 PM with the Plant Operation Supervisor, revealed a portable space heater located in the Business Office.

Interview, on 10/24/12 between 2:30 PM and 5:00 PM with the Plant Operation Supervisor, revealed he was not aware the heaters could not exceed 212?F in non-sleeping, staff, and employee areas.


Reference: NFPA 101 (2000 edition)
18.7.8 Portable Space-Heating Devices.
Portable space-heating devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212?F (100?C).

Based on observation and interview, it was determined the facility failed to ensure electrical wiring was maintained in accordance with NFPA standards. The deficiency had the potential to affect six (6) of six (6) smoke compartments, all residents, staff and visitors. The facility is certified for ninety-seven (97) beds with a census of fifty-nine (59) on the day of the survey. The facility failed to ensure power strips and multi-plug adapters were being used correctly.

The findings include:

Observations, on 10/24/12 between 2:30 PM and 5:00 PM with the Plant Operation Supervisor, revealed:

1) Soap dispensing pumps to the washing machines in all the Laundry Room were plugged into a multi-plug adapter.
2) A medical bar was plugged into a multi-plug adapter located in exam room #2 and #1.
3) A refrigerator was plugged into a power multi-plug adapter in exam room #2 and #1.
4) A bed was plugged into a multi-plug adapter in exam room #1.
5) A power strip was plugged into another power strip in the Nursing Directors ' office.
6) A refrigerator in the Chief Executive Officers ' office was plugged into a power strip.
7) A refrigerator in the Human Resource Directors ' office was plugged into a power strip.
8) A refrigerator in the Admission Directors ' office was plugged into a power strip.

Interview, on 10/24/12 between 2:30 PM and 5:00 PM with the Plant Operation Supervisor, revealed he was not aware the power strips were being misused. He was also not aware high draw devices could not be plugged into a power strip.


Reference: NFPA 99 (1999 edition)
3-3.2.1.2 D
Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Based on observation and interview, it was determined the facility failed to properly prop open doors in accordance with NFPA standards. The deficiency had the potential to affect three (3) of six (6) smoke compartments, thirty-eight (38) residents, staff and visitors. The facility is certified for ninety-seven (97) beds with a census of fifty-nine (59) on the day of the survey. The facility failed to ensure three (3) doors in the facility were being properly propped open.

The findings include:

Observation, on 10/24/12 between 2:30 PM and 5:00 PM with the Plant Operation Supervisor, revealed a door wedge propping the door open of the Director of Nursing Office, a table propping the door of the Medical Records file room, and a wire screwed to the wall of the IT room.

Interview, on 10/24/12 between 2:30 PM and 5:00 PM with the Plant Operation Supervisor, revealed he was unaware the items were being used to prop open doors in then facility. He was aware doors could not be propped open with items that do not release when the door is pushed or pulled.


Reference: NFPA 101 (2000 Edition)

18.3.6.3.3*
Hold-open devices that release when the door is pushed or pulled shall be permitted.

Based on observation and interview, it was determined the facility failed to ensure cross -corridor doors located in a smoke barrier would resist the passage of smoke in accordance with NFPA standards. The deficiency had the potential to affect five (5) of six (6) smoke compartments, all residents, staff and visitors. The facility is certified for ninety-seven (97) beds with a census of fifty-nine (59) on the day of the survey. The facility failed to ensure the cross corridor doors throughout the facility had a gap of less than 1/8 of an inch on the pull side of the door.

The findings include:

Observation, on 10/24/12 between 2:30 PM and 5:00 PM with the Plant Operation Supervisor, revealed the cross-corridor doors located next to room # 206 and next to the education administration office would not close completely when tested due to a rubber stripping placed on the doors. The cross corridor doors at the gym had a gap that was approximately ? of an inch.

Interview, on 10/24/12 between 2:30 PM and 5:00 PM with the Plant Operation Supervisor, revealed he was unaware the doors would not close all the way leaving a gap between the doors in the closed position.


Reference: NFPA 101 (2000 edition)

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.

Reference: NFPA 80 (1999 Edition)
Standard for Fire Doors 2-3.1.7
The clearance between the edge of the door on the pull side shall be 1/8 in. (+/-) 1/16 in. (3.18 mm (+/-) 1.59 mm) for steel doors and shall not exceed 1/8 in. (3.18mm) for wood doors.

Based on observation and interview, it was determined the facility failed to meet the requirements of Protection of Hazards in accordance with NFPA Standards. The deficiency had the potential to affect two (2) of six (6) smoke compartments, no residents, staff and visitors. The facility is certified for ninety-seven (97) beds with a census of fifty-nine (59) on the day of the survey. The facility failed to ensure eight (8) rooms were properly protected due to the storage in the rooms.


The findings include:

Observation, on 10/24/12 between 2:30 PM and 5:00 PM with the Plant Operation Supervisor, revealed:
1) The business development office with combustible storage did not have a 45 minute rated door with closer installed.
2) The controller office with combustible storage did not have a 45 minute rated door with closer installed.
3) The business office with combustible storage did not have a 45 minute rated door with closer installed.
4) The human resources director office with combustible storage did not have a 45 minute rated door with closer installed.
5) The reception mailroom area with combustible storage did not have a 45 minute rated door with closer installed.
6) The clinical service director office with combustible storage did not have a 45 minute rated door with closer installed.
7) The consult 17 office with combustible storage did not have a 45 minute rated door with closer installed.
8) The dietary director office with combustible storage did not have a 45 minute rated door with closer installed.


Interview, on 10/24/12 between 2:30 PM and 5:00 PM with the Plant Operation Supervisor, revealed he was not aware the areas listed above were considered hazardous storage thus requiring a 45 minute rated door, a self-closer, and separation.

Reference:

NFPA 101 (2000 Edition).

18.3.2 Protection from Hazards.
18.3.2.1* Hazardous Areas.
Any hazardous area shall be protected in accordance with Section 8.4. The areas described in Table 18.3.2.1 shall be protected as indicated.

Table 18.3.2.1 Hazardous Area Protection

Hazardous Area Description Separation/Protection
Boiler and fuel-fired heater rooms 1 hour
Central/bulk laundries larger than 100 ft2 (9.3 m2) 1 hour
Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe
hazard See 18.3.6.3.4
Laboratories that use hazardous materials that would be classified as a severe hazard in accordance with NFPA 99, Standard for Health Care Facilities 1 hour
Paint shops employing hazardous substances and materials in quantities less than those that would be classified as a severe hazard 1 hour
Physical plant maintenance shops 1 hour
Soiled linen rooms 1 hour
Storage rooms larger than 50 ft2 (4.6 m2) but not exceeding
100 ft2 (9.3 m2) storing
combustible material See 18.3.6.3.4
Storage rooms larger than 100 ft2 (9.3 m2) storing combustible
material 1 hour
Trash collection rooms 1 hour

18.3.6.3.4
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, it was determined the facility failed to ensure exits were equipped with lighting in accordance with NFPA standards. The deficiency had the potential to affect four (4) of six (6) smoke compartments, sixty-six (66) residents, staff and visitors. The facility is certified for ninety-seven (97) beds with a census of fifty-nine (59) on the day of the survey. The facility failed to ensure the emergency lights had two (2) bulbs at six (6) exits.

The findings include:

Observation, on 10/24/12 at 1:55 PM with the Plant Operation Supervisor, revealed the exterior exits at the risk management office, the adolescent unit, the adult civilian unit, the director of nursing office, gym front, and the gym back only had a single light for illumination of the outside of the exit.

Interview, on 10/24/12 at 1:55 PM with the Plant Operation Supervisor, revealed he was unaware the lighting fixtures serving the exterior exits must include more than one bulb for illumination of the egress path.

Reference: NFPA 101 (2000 edition)
7.8.1.4* Required illumination shall be arranged so that the
failure of any single lighting unit does not result in an illumination
level of less than 0.2 ft-candle (2 lux) in any designated
area.

Based on observation and interview, it was determined the facility failed to ensure no exit signs were maintained in accordance with NFPA standards. The deficiency had the potential to affect three (3) of six (6) smoke compartments, sixty-six (66) residents, staff and visitors. The facility is certified for ninety-seven (97) beds with a census of fifty-nine (59) on the day of the survey. The facility failed to ensure eight (8) doors leading to courtyards were marked with proper no exit signs.


The findings include:

Observation, on 10/24/12 between 2:30 PM and 5:00 PM with the Plant Operation Supervisor, revealed doors leading to the outside of the facility that where not exits. The following areas were affected: activity room a, b, c, and d; quiet room a, b, c, and d; and the main courtyard entrance.

Interview, on 10/24/12 between 2:30 PM and 5:00 PM with the Plant Operation Supervisor, revealed he was unaware doors must be marked with no exit signage if they are not being used as an exit.



Reference: NFPA 101 (2000 edition)

7.10.8 Special Signs.
7.10.8.1* No Exit.
Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows:
NO
EXIT
Such sign shall have the word NO in letters 2 in. (5 cm) high with a stroke width of 3/8 in. (1 cm) and the word EXIT in letters 1 in. (2.5 cm) high, with the word EXIT below the word NO.
Exception: This requirement shall not apply to approved existing signs.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted quarterly on each shift at random times, in accordance with NFPA standards. The deficiency had the potential to affect six (6) of six (6) smoke compartments, all residents, staff and visitors. The facility is certified for ninety-seven (97) beds with a census of fifty-nine (59) on the day of the survey. The facility failed to ensure fire drills were being conducted each quarter on third shift and at varied times on all shifts.

The findings include:

Fire Drill review, on 10/24/12 at 1:55 PM with the Plant Operation Supervisor and the Chief Executive Officer, revealed the fire drills were not being conducted at unexpected times under varied conditions. First shift fire drills were being conducted predictably between 1:15 PM and 1:30 PM, second shift predictably between 4:00 PM and 4:30 PM, and third shift predictably between 11:00 PM and 11:15 PM. Further review revealed there was no drill performed on third shift during the second quarter of 2012.

Facility Fire Drill Policy review, at 2:00 PM with the Plant Operation Supervisor and the Chief Executive Officer, revealed number four of the policy stated time of day that fire drills are performed should be staggered throughout the year.

Interview, on 10/24/12 at 1:55 PM with the Plant Operation Supervisor, revealed he was unaware the fire drills were not being conducted as required. He stated he was more focused on getting it done on each shift per quarter than monitoring the time separation. He reports the fire drills directly to the Chief Executive Officer.

Interview, on 10/24/12 at 1:55 PM with the Plant Operation Supervisor, revealed once the fire drills are reported to him they are reviewed at monthly safety meetings and at quarterly governing board meetings.

Reference: NFPA 101 Life Safety Code (2000 Edition).
18.7.1.2*
Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Based on observation and interview it was determined the facility failed to ensure the building had a complete sprinkler system, in accordance with NFPA Standards. The deficiency had the potential to affect three (3) of six (6) smoke compartments, all residents, staff and visitors. The facility is certified for ninety-seven (97) beds with a census of fifty-nine (59) on the day of the survey. The facility failed to ensure six (6) electrical rooms and two (2) mechanical rooms of the building had proper sprinkler coverage.

The findings include:

Observation, on 10/24/12 between 2:30 PM and 5:00 PM with the Plant Operation Supervisor, revealed electrical rooms C1, C2, B1, B2, B3, and B4 did not have a ceiling to provide proper spacing for the sprinkler head. Further observation revealed the Mechanical Rooms B and C did not have a ceiling to provide proper spacing for the sprinkler head.

Interview, on 10/24/12 between 2:30 PM and 5:00 PM with the Plant Operation Supervisor, revealed he was not aware that the areas listed did not have proper sprinkler protection.


Reference: NFPA 13 (1999 Edition)

5-6.4.1.2 Under obstructed construction, the sprinkler
deflector shall be located within the horizontal planes of
1 in. to 6 in. (25.4 mm to 152 mm) below the structural
members and a maximum distance of 22 in. (559 mm)
below the ceiling/roof deck.
Exception No. 1: Sprinklers shall be permitted to be installed with the
deflector at or above the bottom of the structural member to a maximum
of 22 in. (559 mm) below the ceiling/roof deck where the sprinkler is
installed in conformance with 5-6.5.1.2.
Exception No. 2: Where sprinklers are installed in each bay of obstructed
construction, deflectors shall be permitted to be a minimum
of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm) below the
ceiling.
Exception No. 3: Sprinkler deflectors shall be permitted to be 1 in. to
6 in. below composite wood joists to a maximum distance of 22 in.
below the ceiling/roof deck only where joist channels are fire-stopped
to the full depth of the joists with material equivalent to the web construction
so that individual channel areas do not exceed 300 ft2
(27.9 m2).
Exception No. 4: *Deflectors of sprinklers under concrete tee construction
with stems spaced less than 71/2 ft (2.3 m) but more than
3 ft (0.9 m) on centers shall, regardless of the depth of the tee, be permitted
to be located at or above a horizontal plane 1 in. (25.4 mm)
below the bottom of the stems of the tees and shall comply with Table
5-6.5.1.2.
5-6.4.1.3* Sprinklers

Based on record review and interview, it was determined the facility failed to have quarterly inspections performed of the fire sprinkler system in accordance with NFPA standards. The deficiency had the potential to affect six (6) of six (6) smoke compartments, all residents, staff and visitors. The facility is certified for ninety-seven (97) beds with a census of fifty-nine (59) on the day of the survey. The facility failed to ensure the sprinkler system was tested quarterly throughout the year.

The findings include:

Record review, on 10/24/12 at 2:15 PM with the Plant Operation Supervisor and the Chief Executive Officer, revealed the facility did not have documentation for a first quarter inspection during 2012 for the fire sprinkler system. Components located in the fire sprinkler system must be inspected monthly and quarterly accordingly to NFPA requirements and the records for the inspection made available for the authority having jurisdiction.

Interview, on 10/24/12 at 1:55 PM with the Plant Operation Supervisor and the Chief Executive Officer, revealed they believe the sprinkler system was inspected during the first quarter and they are working getting the paperwork.

Reference: NFPA 25 (1998 Edition).

2-1 General. This chapter provides the minimum requirements
for the routine inspection, testing, and maintenance of
sprinkler systems. Table 2-1 shall be used to determine the
minimum required frequencies for inspection, testing, and
maintenance.
Exception: Valves and fire department connections shall be inspected,
tested, and maintained in accordance with Chapter 9.

Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance
Item Activity Frequency Reference
Gauges (dry, preaction deluge systems) Inspection Weekly/monthly 2-2.4.2
Control valves Inspection Weekly/monthly Table 9-1
Alarm devices Inspection Quarterly 2-2.6
Gauges (wet pipe systems) Inspection Monthly 2-2.4.1
Hydraulic nameplate Inspection Quarterly 2-2.7
Buildings Inspection Annually (prior to freezing
weather)
2-2.5
Hanger/seismic bracing Inspection Annually 2-2.3
Pipe and fittings Inspection Annually 2-2.2
Sprinklers Inspection Annually 2-2.1.1
Spare sprinklers Inspection Annually 2-2.1.3
Fire department connections Inspection Table 9-1
Valves (all types) Inspection Table 9-1
Alarm devices Test Quarterly 2-3.3
Main drain Test Annually Table 9-1
Antifreeze solution Test Annually 2-3.4
Gauges Test 5 years 2-3.2
Sprinklers - extra-high temp. Test 5 years 2-3.1.1 Exception No. 3
Sprinklers - fast response Test At 20 years and every 10 years
thereafter
2-3.1.1 Exception No. 2
Sprinklers Test At 50 years and every 10 years
thereafter
2-3.1.1
Valves (all types) Maintenance Annually or as needed Table 9-1
Obstruction investigation Maintenance 5 years or as needed Chapter 10

Based on observation and interview, it was determined the facility failed to ensure there was proper fire protection in the designated smoking area, in accordance with NFPA standards. The deficiency had the potential to affect five (5) of six (6) smoke compartments, all residents, staff and visitors. The facility is certified for ninety-seven (97) beds with a census of fifty-nine (59) on the day of the survey. The facility failed to ensure there was a fire blanket or fire extinguisher at the employee smoking area.

The findings include:

Observation, on 10/24/12 at 3:25 PM with the Plant Operation Supervisor, revealed the employee smoking area did not have a fire blanket or a fire extinguisher located at the smoking area.

Interview, on 10/24/12 at 3:25 PM with the Plant Operation Supervisor, revealed he was not aware of the requirement for fire extinguisher or fire blanket at smoking areas.

Reference: S & C Letter: 12-04-NH;
Date: November 10, 2011
Subject: Alert: Smoking Safety in Long Term Care Facilities

Based on observation and interview it was determined the facility failed to ensure, portable space heaters used in the facility were in accordance with NFPA standards. The deficiency had the potential to affect one (1) of six (6) smoke compartments, no residents, staff and visitors. The facility is certified for ninety-seven (97) beds with a census of fifty-nine (59) on the day of the survey. The facility failed to ensure two (2) space heaters in employee areas did not exceed 212 degrees Fahrenheit.

The findings include:

Observation, on 10/24/12 between 2:30 PM and 5:00 PM with the Plant Operation Supervisor, revealed a portable space heater located in the Business Office.

Interview, on 10/24/12 between 2:30 PM and 5:00 PM with the Plant Operation Supervisor, revealed he was not aware the heaters could not exceed 212?F in non-sleeping, staff, and employee areas.


Reference: NFPA 101 (2000 edition)
18.7.8 Portable Space-Heating Devices.
Portable space-heating devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212?F (100?C).

Based on observation and interview, it was determined the facility failed to ensure electrical wiring was maintained in accordance with NFPA standards. The deficiency had the potential to affect six (6) of six (6) smoke compartments, all residents, staff and visitors. The facility is certified for ninety-seven (97) beds with a census of fifty-nine (59) on the day of the survey. The facility failed to ensure power strips and multi-plug adapters were being used correctly.

The findings include:

Observations, on 10/24/12 between 2:30 PM and 5:00 PM with the Plant Operation Supervisor, revealed:

1) Soap dispensing pumps to the washing machines in all the Laundry Room were plugged into a multi-plug adapter.
2) A medical bar was plugged into a multi-plug adapter located in exam room #2 and #1.
3) A refrigerator was plugged into a power multi-plug adapter in exam room #2 and #1.
4) A bed was plugged into a multi-plug adapter in exam room #1.
5) A power strip was plugged into another power strip in the Nursing Directors ' office.
6) A refrigerator in the Chief Executive Officers ' office was plugged into a power strip.
7) A refrigerator in the Human Resource Directors ' office was plugged into a power strip.
8) A refrigerator in the Admission Directors ' office was plugged into a power strip.

Interview, on 10/24/12 between 2:30 PM and 5:00 PM with the Plant Operation Supervisor, revealed he was not aware the power strips were being misused. He was also not aware high draw devices could not be plugged into a power strip.


Reference: NFPA 99 (1999 edition)
3-3.2.1.2 D
Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.