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Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other spaces. The area of deficient practice would provide a path for smoke and fire to travel into the adjacent area, affecting patients and staff in 1 of 4 smoke zones. The facility has a capacity of 25 with a census of 25 at the time of survey.

Findings include:

During the survey on February 12, 2019, the following is observed:

At 9:55 am ,that the door to the elevator mechanical room did not have a self closing device.

At 9:58 am, a penetration from electrical conduit is found in the elevator mechanical room wall to the kitchen.

Staff B was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: 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 8.7.1. 2012 NFPA 101, 19.3.2.1

Review of the following NFPA Standard revealed: An automatic extinguishing system, where used in hazardous areas, shall be permitted to be in accordance with 19.3.5.9. 2012 NFPA 101, 19.3.2.1.1

Review of the following NFPA Standard revealed: Where the sprinkler option of19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4. 2012 NFPA 101,19.3.2.1.2

Review of the following NFPA Standard revealed: The doors shall be self-closing or automatic-closing. 2012 NFPA 101, 19.3.2.1.3

Based on observation, record review and interview the facility does not assure a fire watch procedure and policy is written as required for implementation when the fire sprinkler system is out of service for more than 10 hours in a 24 hour period. This deficient practice would prevent proper notification of insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction as required, affecting patients and staff in all 4 smoke zones. The facility has a capacity of 25 and a census of 25 at the time of survey.


Findings include:

During record review on February 11, 2019, between 2:00 pm and 4:00 pm, the following is observed:

1.The facility did not have in the written fire watch policy 10 hour implementation of sprinkler impairments and all the procedures and contact information that is required to included insurance carrier by 2011 NFPA 25, 15.5.2

Staff B was present during the survey and record review and acknowledged the findings.

Review of the following NFPA Standard revealed: Sprinkler System Impairments. Sprinkler impairment procedures shall comply with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water Based Fire Protection Systems. 2012 NFPA 101, 9.7.6

Review of the following NFPA Standard revealed: All preplanned impairments shall be authorized by the impairment coordinator. 2011 NFPA 25, 15.5.1

Review of the following NFPA Standard revealed: 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. 2011 NFPA 25, 15.5.2

Review of the following NFPA Standard revealed: Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure. When emergency impairments occur, emergency action shall be taken to minimize potential injury and damage.

The coordinator shall implement the steps outlined in Section 15.5. 2011 NFPA 25, 15.6.1, 15.6.2 & 15.6.3

Review of the following NFPA Standard revealed: 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 2011 NFPA 25, 15.7

Based on observation and staff interviews, the facility fails to maintain fire door assemblies by inspection and testing not less than annually, and a written record of the inspection shall be signed and kept by the facility. This deficient practice may prevent fire doors from operating properly upon there activation. affecting patients and staff in all 4 smoke zones. The facility has a capacity of 25 with a census of 25 at the time of survey.

Findings include:

During a record review on February 11, 2019, between 2:00 pm and 4:00 pm, revealed that:

1.The facility did not have a fire door inspection program to include a listing of fire doors and their location, inspection check list and operating components and how they function.

2.The facility staff did not have all the qualifications required to perform its own door inspection program.

Staff B was present during the survey and record review and acknowledged the findings.

Review of the following NFPA Standard revealed: Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing.
2010 NFPA 80,5.2.3.1

Review of the following NFPA Standard revealed: A person who, by possession of a recognized degree, certificate, professional standing, or sill, and who, by knowledge, training, and experience, has demonstrated the ability to deal with the subject matter, the work, or the project.
2010 NFPA 80,3.3.95
Review of the following NFPA Standard revealed: Before testing, a visual inspection shall be performed to identify any damaged or missing parts that can create a hazard during testing or affect operation or resetting
2010 NFPA 80, 5.2.3.2
Review of the following NFPA Standard revealed: Fire door assemblies shall be visually inspected from
both sides to assess the overall condition of door assembly. 2010 NFPA 80, 5.2.4.1

As a minimum, the following items shall be verified:
(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self-closing device is operational; that is, the active door completely closes when operated from the full
open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.
2010 NFPA 80, 2.4.2

Review of the following NFPA Standard revealed: Listed items shall be identified by a label.
2010 NFPA 80, 4.2.1*

Review of the following NFPA Standard revealed: Labels shall be applied in locations that are readily visible
and convenient for identification by the AHJ after installation of the assembly.
2010 NFPA 80, 4.2.2

Based on observation and staff interviews, the facility did not ensure that portable space heaters and portable fire place simulators with heat are not to be used in health care facilities where the heating elements exceed 212-degree Fahrenheit. This deficient practice does not ensure prevention of fires from personal portable heaters. affecting patients and staff 1 of 4 smoke zones. The facility has a capacity of 25 with a census of 25 at the time of survey.

Findings Include:

During the survey on February 12,2019 the following is observed:

1.At 11:15 am a portable electrical fire place containing a heating device is found in the lounge of the south corridor

Staff B was present during the survey and acknowledged the findings

Review of the following NFPA Standard revealed: Portable Space-Heating Devices. Portable space heating devices shall be prohibited in all health care occupancies, unless both of the following criteria are met:

(1) Such devices are used only in nonsleeping staff and employee
areas.
(2) The heating elements of such devices do not exceed 212°F (100°C).

2012 NFPA 101, 19.7.8