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Based on observation and staff interview, the facility failed to provide separation of corridors from use areas. This deficient practice would allow smoke and fire products to travel from the use area into the exit corridor, affecting 10 patients in one of four smoke zones. The facility has a capacity of 24 and census of 4 at the time of the survey.

Findings include:

During the tour on November 20, 2013 at 10:45 AM the following is observed:

1. There has not been a hardware examination to determine if the fire rated rolling service counter door at the central supply window is operable.

2. The fusible link to release the fire rated rolling service counter door at the central supply window is located above the ceiling tile.

Director of Plant Engineering was present stated he had been employed at the facility for five years and does not believe this fire shutter have ever been tested.

Review of the following NFPA Standard revealed: Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, and shall have a fire resistance rating of not less than 1/2 hour.

Exception: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system, a corridor shall be permitted to be separated from all other areas by non-rated partitions and terminate at the ceiling if the ceiling is constructed to limit the transfer of smoke.

Exception: Existing corridor partitions shall be permitted to terminate at ceilings that are not an integral part of a floor construction if 5 ft. or more of space exists between the top of the ceiling subsystem and the bottom of the floor or roof above, provided that the ceiling is a fire-rated assembly tested to have a fire resistance rating of not less than 1 hour in compliance with the provisions of 8.2.3.1. 2000 NFPA 101, 19.3.6.2

Review of the following NFPA Standard revealed: A service counter door of the rolling type shall be automatic closing so that, upon activation or release of a fusible link or detector, the door shall close.
1999 NFPA 80, 12-3.2.2

Review of the following NFPA Standard revealed: Hardware shall be examined frequently and any parts found to be inoperative shall be replaced immediately. 1999 NFPA 80, 15-2.1.1

Based on observation and staff interview the facility fails to assure that combustion air for the natural gas fired dryers in the laundry room is taken from the outside. Failing to ensure combustion air is being properly supplied to this dryer may cause incomplete combustion and cause carbon monoxide to be present in the atmosphere, affecting all patients in one of four smoke zones. The facility has a capacity of 24 and census of 4 at the time of the survey.

Findings include:

During the tour on November 20, 2013 at 11:45 AM it is observed that no provision for outside combustion air is provided for the natural gas fired dryers in the laundry room.

Director of Plant Engineering was present and acknowledged the lack of outside combustion air for the natural gas fired dryers in the laundry room.

Review of the following NFPA Standard revealed: Ventilating or heat-producing equipment shall be in accordance with NFPA 91, Standard for Exhaust Systems for Air Conveying of Vapors, Gases, Mists, and Noncombustible Particulate Solids; NFPA 211,Standard for Chimneys, Fireplaces, Vents, and Solid Fuel-Burning Appliances; NFPA 31, Standard for the installation of Oil-Burning Equipment; NFPA 54, National Fuel Gas Code; or NFPA 70, National Electrical Code, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction. 2000 NFPA 101, 9.2.2

Review of the following NFPA Standard revealed: Provisions for Make-Up Air.
(b) Provision for makeup air shall be provided for Type 2 clothes dryers, with a minimum free area (see 5.3.5) of 1 in.2 (6.5 m2) for each 1000 Btu/hr. (2200 mm2/kW) total input rating of the dryer(s) installed. 1999 NFPA 54, 6.4.3

Review of the following NFPA Standard revealed: Any heating device other than a central heating plant shall be designed and installed so that combustible material will not be ignited by the device or its appurtenances. If fuel fired, such heating devices shall be chimney connected or vent connected, shall take air for combustion directly from the outside, and shall be designed and installed to provide for complete separation of the combustion system from the atmosphere of the occupied area. Any heating device shall have safety features to immediately stop the flow of fuel and shut down the equipment in case of either excessive temperature or ignition failure. 2000 NFPA 101, 19.5.2.2

Based on record review and staff interview, the facility is not providing automatic fire extinguishing system complying with UL 300 and servicing the system in compliance with NFPA 96. Failure to have a compliant automatic fire extinguishing system and serviced by a qualified person has the potential to affect all patients in one of four smoke zones including the main dining area. The facility has a capacity of 24 and census of 4 at the time of the survey.

Findings include:

During the record review November 20, 2013 at 12:10 PM it is noted on the automatic fire extinguishing system inspection report dated May 2nd, 2013 that the system does not comply with UL 300 Standards and the last date of hydrostatic testing was 2000.

Director of Plant Engineering was present during record review and acknowledged the findings.

Review of the following NFPA Standard revealed: Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction. 2000 NFPA 101, 9.2.3

Review of the following NFPA Standard revealed: Inspection. An inspection and servicing of the fire extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least 8-3.3 every 6 months by properly trained and qualified persons. 1998 NFPA 96, 8-2

Review of the following NFPA Standard revealed: All actuation components, including remote manual pull stations, mechanical or electrical devices, detectors, actuators, and fire-actuated dampers, shall be checked for proper operation during the inspection in accordance with the manufacturer ' s listed procedures. In addition to these requirements, the specific inspection requirements of the applicable NFPA standard shall also be followed. 1998 NFPA 96, 8-2.1

Review of the following NFPA Standard revealed: Automatic fire-extinguishing systems shall comply with standard UL 300, Fire Testing of Fire Extinguishing Systems for Protection of Restaurant Cooking Areas, or other equivalent standards and shall be installed in accordance with their listing.

Exception: Automatic fire-extinguishing equipment provided as part of listed recirculating systems complying with standard UL 197, Standard for Safety-Commercial Electric Cooking Appliances. 1998 NFPA 96, 7-2.2

Review of the following NFPA Standard revealed: Hydrostatic Testing. The following parts of wet chemical extinguishing systems shall be subjected to a hydrostatic pressure test at intervals not exceeding 12 years:

(a) Wet chemical containers
(b) Auxiliary pressure containers
(c) Hose assemblies

Exception No. 1: Auxiliary pressure containers not exceeding 2-in. (0.05-m) outside diameter and less than 2 ft. (0.6 m) in length.

Exception No. 2: Auxiliary pressure containers bearing the DOT " 3E " marking. 1998 NFPA, 17A, 5-5

Based on observation and staff interview the facility failed to ensure that oxygen storage locations greater than 3,000 cu ft. are vented to the outside. This deficient practice would prevent oxygen from being vented to the exterior of the facility and allow the oxygen vapors to enrich the compartment where the storage is located, affecting all patients in one of four smoke zones. The facility has a capacity of 24 and census of 4 at the time of the survey.

Findings include:

During the tour on November 20, 2013 at 11:45 AM it is observed that the basement level oxygen storage room containing 9 E size cylinders, 5H size cylinders and 2-180 liter liquid oxygen tanks is not vented to the outside.

Director of Plant Engineering was present and confirmed the oxygen storage room contents and that ventilation to the outside is not provided.

Review of the following NFPA Standard revealed: Medical gas storage and administration shall be protected in accordance with NFPA 99, Standard for Health Care Facilities. 2000 NFPA 101, 19.3.2.4

Review of the following NFPA Standard revealed: Indoor storage areas which contain liquid oxygen, or more than 3000 cubic feet of stored oxygen, must have continuous natural or dedicated power ventilation to the outdoors, as described in the Code. 1999 NFPA 99, 4-3.1.1.2(b)