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Based on observation and staff interview, the facility failed to assure that the 2 hour wall separating the nursing facility from the independent living facility is properly sealed, failing to provide the proper fire resistance rating. This deficient practice of allowing improperly sealed penetrations in a 2 hour separation wall affects patients in 1 of 3 smoke zones. The facility has a capacity of 25 and a census of 7 at the time of survey.

Findings include:

During the survey on June 20, 2018, the following is observed:

1. At 11:00 am, it is observed that the corridor from the main lobby wall above the 2 Hour fire curtain to Radiology in attic space has gaps around ¾ "conduit and a ½ "x 8" slit in the drywall.

2. At 11:00 am, it is observed that the corridor from the main lobby wall above the 2 Hour fire curtain to Radiology in attic space has penetration inside the 3" conduit

Staff B was present and acknowledged the findings.


Review of the following NFPA Standard revealed: Sections of health care facilities shall be permitted to
be classified as other occupancies, provided that they meet all
of the following conditions:

(1) They are not intended to provide services simultaneously
for four or more inpatients for purposes of housing, treatment,
or customary access by inpatients incapable of self preservation.

(2) They are separated from areas of health care occupancies
by construction having a minimum 2 hour fire resistance
rating in accordance with Chapter 8.

(3) For other than previously approved occupancy separation
arrangements, the entire building is protected throughout
by an approved, supervised automatic sprinkler system
in accordance with Section 9.7.
2012 NFPA 101, 18.1.3.3

Based on observation and interview, the facility failed to provide approved, readily visible signs to mark all exit access paths. The deficient practice of not providing exit signs to direct occupants of the building to the exits may delay occupants from reaching the exit. The deficient practice affects patients 1 of 3 smoke zones. This facility has a capacity of 25 and a census of 7 residents.

Findings include:

During the survey on June 20, 2018 the following is observed:

At 10:40 am There is no readily visible exit sign marking the exit path through the corridor from the birthing center to the west exit

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

Review of the following NFPA Standard revealed: Illumination of means of egress shall be provided in accordance with Section 7.8 for every building and structure where required in Chapters 11 through 43. For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, aisles, corridors, ramps, escalators, walkways, and exit passageways leading to a public way. 2012 NFPA 101, 7.8.1.1

Review of the following NFPA Standard revealed: Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use, unless otherwise provided
in 7.8.1.2.2.
2012 NFPA 101, 7.8.1.2

Based on observation, staff interview and record review, the facility failed to clean the kitchen range hood, grease removal devices, fans, ducts, and other appurtenances at intervals prior to surfaces becoming heavily contaminated with grease or oily sludge in compliance with NFPA 96. The deficient practice provides fuel for cooking equipment to ignite, affecting all patients in 1 of 3 smoke zones, including the main dining room. The facility has a capacity of 25 residents with a census of 7 at the time of the survey.

Findings include:

During the survey on June 20, 2018, the following is observed:

At 11:35 am, no record of the kitchen exhaust hood system cleaning since May 16, 2016.

Staff B were present and acknowledged the findings.


Review of the following NFPA Standard revealed: Inspection for Grease Buildup. The entire exhaust system
shall be inspected for grease buildup by a properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction and in accordance with Table 11.4
2011 NFPA 96,11.4

Based on observation and staff interview, the facility failed to maintain smoke detectors in accordance with the requirements found in NFPA 72. This deficient practice may prevent the prompt initiating of smoke detectors and delay alerting the residents and staff to smoke products, affecting patients in 1 of 3 smoke zones.The facility has a capacity of 25 with a census of 7 at the time of survey.

Findings include:

During the tour on June 20, 2018 at 10:52 AM it is observed that no detectors were place within the required distance of the fire barrier doors in the west corridor

Review of the following NFPA Standard revealed: For the purposes of this Code, a complete fire alarm system shall provide functions for initiation, notification, and control, which shall perform as follows:

(1) The initiation function provides the input signal to the System

(2) The notification function is the means by which the system advises that human action is required in response to a particular condition.

(3) The control function provides outputs to control building equipment to enhance protection of life
2012 NFPA 101, 9.6.1.7

Review of the following NFPA Standard revealed: Location of Controls. Operator controls, alarm indicators, and manual communications capability shall be installed at a convenient location acceptable to the authority having jurisdiction. 2012 NFPA 101, 9.6.6


Review of the following NFPA Standard revealed: Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Supervisory signals shall
sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility. 2012 NFPA 101, 9.7.2.1*

Review of the following NFPA Standard revealed: The performance objective statement should describe the purpose of the detector placement and the intended response of the fire alarm control unit to the detector activation. This statement can include a narrative description of the required response time of the detectors, a narrative of the sequence of operations, a tabular list of programming requirements or some other method.
The performance objective of a fire detection system is usually expressed in terms of time and the size fire the system is intended to detect, measured in British thermal units per second (Btu/ sec) or kilowatts (kW). Typically, the fire alarm system designer does not establish this criterion. It is usually obtained from the
design documentation prepared by the designer responsible for the strategy of the structure as a whole. Where a prescriptive design is being provided, this requirement is fulfilled by stating in the design documentation that the design conforms to the prescriptive provisions of this Code.
2010 NFPA 72, A.17.6.1.1

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 and fire alarm more than 4 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 Staff and patients in all 3 smoke zones. The facility has a capacity of 26 and a census of at the time of survey.

Findings include:

During the survey on June 19, 2018, the following is observed: Between 9:00 am and 2:00 pm it is revealed that the facility did not have a written policy for implementing a fire watch for sprinkler system.

Staff B was present during the survey 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 record review and staff interviews, the facility does not have a written evacuation and relocation plan that addresses smoke zone in the event of an actual emergency, affecting all Staff and patients in all 3 smoke zones. The facility has a capacity of 25 with a census of 7 at the time of survey.

Findings include:

The record review on June 19, 2018, between 9:00 am and 2:00 am, revealed that the facility's written policy for the evacuation of residents, does not contain how smoke zones will relocate and or evacuate staff and patients

The Director was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: Fire Safety Plan. A written health care occupancy fire safety plan shall provide for all of the following:

(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire

NFPA 101 2012, 18.7.2.2

Based on record review and staff interview, the facility is not conducting fire drills as required and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency, affecting Staff and patients in all 3 smoke zones. The facility has a capacity of 26 with a census of at the time of survey.

Findings include:

1.It is observed during record review of the facility's fire drill documentation on June 19, 2018, between 9:00 am and 2:00 pm. revealed that the facility did not list the times when alarms were tested on the following day of a silent drill for the 2nd shift of the 2nd quarter, no documentation was provided of the times the central station received alarm times

2.The facility's fire drill record for the previous 12 months revealed that 2 of the last 4 fire drills conducted on the 2st shift of the 3rd and 4th quarters occurred within an hour of each other
3. The facility's fire drill record for the previous 12 months revealed that 3 of the last 4 fire drills conducted on the 1st shift of the 1st, 3rd and 4th quarters did not list the times when the central station received the alarms at the times drills were conducted.

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


Review of the following NFPA Standard revealed: 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
Review of the following NFPA Standard revealed: 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. 2012 NFPA 101, 18.7.1.6

Review of the following NFPA Standard revealed: Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency. 2012 NFPA 101, 4.7.4*

Based on staff interview and document review the facility fails to properly train and document their staff on the proper handling of gas equipment in accordance with NFPA 99. The deficient practice would affect all patients, and staff in all 3 smoke zones. The facility has a capacity of 25 with a census of 7 at the time of the survey.

Findings include:

The record review on June 19, 2018, between 9:00 am and 2:00 am, revealed that there is no documentation available for the education or training of facility staff on the risk, safety guidelines, and usage requirements of medical gas equipment at the time of survey.

Staff B was present and acknowledged there was no documentation available for the training or education of staff on handling medical gas equipment.

Review of the following NFPA Standard Revealed Gases in Cylinders and Liquefied Gases in Containers.2012 NFPA 99 11.5.2

Review of the following NFPA Standard Revealed Qualification and Training of Personnel.2012 NFPA 99 11.5.2.1

Review of the following NFPA Standard Revealed Personnel concerned with the application and maintenance of medical gases and others who handle medical gases and the cylinders that contain the medical gases shall be trained on the risks associated with their handling and use. 2012 NFPA 99 11.5.2.1.1*

Review of the following NFPA Standard Revealed Health care facilities shall provide programs of continuing education for their personnel. 2012 NFPA 99 11.5.2.1.2

Review of the following NFPA Standard revealed Continuing education programs shall include periodic review of safety guidelines and usage requirements for medical gases and their cylinders. 2012 NFPA 99 11.5.2.1.3

Review of the following NFPA Standard Revealed Equipment shall be serviced only by personnel trained in the maintenance and operation of the equipment. 2012 NFPA 99 11.5.2.1.4

Review of the following NFPA Standard revealed If a bulk cryogenic system is present, the supplier shall provide annual training on its operation. 2012 NFPA 99 11.5.2.1.5