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Based on observation and staff interview the facility fails to properly protect and maintain their hazardous areas in accordance with NFPA 101. The deficient practice would affect no patients, and all visitors and staff in 2 of 7 smoke zones. The facility has a capacity of 24 with a census of 3 at the time of the survey.

Findings include:

During the survey conducted on 3/5/19 the following deficiencies are noted:

1. During the survey at 2:06 PM, it is observed that there is a 1" unsealed hole in the front wall of utility closet #2.
2. During the survey at 2:22 PM, it is observed that there is an unsealed penetration by an approximate 6" exhaust stack near the center of the ceiling in the laundry room.
3. During the survey at 2:30 PM, it is observed that there is an unsealed approximate 3" hole by conduit in the side wall of the water supplies storage room.
4. During the survey at 2:41 PM, it is observed that there 5 approximate 1" unsealed penetrations by conduit in the front wall of the pump room.

Staff A was present and acknowledged the findings.

NFPA Standard: NFPA 101 19.3.2.1.3 The doors shall be self-closing or automatic-closing.
19.3.2.1.5 Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms (2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops (4) Repair shops (5) Rooms with soiled linen in volume exceeding 64 gal (242 L)
(6) Rooms with collected trash in volume exceeding 64 gal (242 L) (7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction (8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard
19.3.2.1.2* Where the sprinkler option of 19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4.

Based on document review, and staff interview, this facility is not maintaining the sprinkler system in accordance with NFPA 25. By not maintaining the system with an acceptable clearance around sprinkler heads to prevent obstructions to spray patterns. This deficient practice could affect the operation of the heads by obstructing spray patterns, delaying the response time or preventing the operation of the heads that can compromise the effectiveness of the fire suppression system, affecting all patients, visitors, and staff in 7 of 7 smoke zones. The facility has a capacity of 24 with a census of 3 at the time of the survey.

Findings include:

During the survey conducted on 3/5/19 the following deficiency is noted:

1. During document review at 1:16 PM, it is observed that there is no documentation for a quarterly test of the sprinkler system in the 1st quarter of 2018.

Staff A was present and acknowledged the finding.

NFPA Standard: Automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25 per 2012 NFPA 101, 9.7.5.

NFPA Standard: Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. 2012 NFPA 101 4.6.12.1

NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 2012 NFPA 101, 4.6.12.1

Based on observation and staff interview, the facility fails to maintain their smoke barrier walls as required by Life Safety Code NFPA 101. This deficient practice would affect all patients, visitors, and staff in 4 of 7 smoke zones. The facility has a capacity of 24 and at the time of the survey the census was 3.

Findings Include:

During the survey on 3/5/19 the following deficiencies are noted:

1. During the survey at 2:14 PM, it is observed that there are two approximate 2" unsealed penetrations by data wires in the smoke barrier wall, above doors #141.
2. During the survey at 3:00 PM, it is observed that there is an approximate 2" unsealed penetration by data wires in the smoke barrier wall, above doors #198.
3. During the survey at 3:10 PM, it is observed that there is an approximate 2" unsealed penetration by data wires in the smoke barrier wall, above doors #262.

Staff A was present and acknowledged the findings.

NFPA Standard: NFPA 101 2012 19.3.7.3 Any required smoke barrier shall be constructed in
accordance with Section 8.5 and shall have a minimum 1?2-hour fire resistance rating, unless otherwise permitted by one of the following: (1) This requirement shall not apply where an atrium is used,
and both of the following criteria also shall apply: (a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c). (b) Not less than two separate smoke compartments shall be provided on each floor. (2)*Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier. 8.5.6.2 Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed
as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke.

Based on document review and staff interview, the facility fails to conduct fire drills as required by Life Safety Code NFPA 101. This deficient practice would affect all patients, visitors, and staff in 7 of 7 smoke zones. The facility has a capacity of 24 and at the time of the survey the census was 3.

Findings Include:

During the survey on 3/5/19 the following deficiency is noted:

1. During document review at 1:20 PM, it is observed that the fire drill held on 2nd shift in the 1st quarter of 2019 at 8:30 PM was held as a coded silent drill.

Staff A was present and acknowledged the findings.

NFPA Standard: NFPA 101 2012 19.7.1.4* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 19.7.1.5 Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 19.7.1.6 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. 19.7.1.7 When drills are conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

Based upon observation, document review, and staff interview the facility is not inspecting and maintaining their rated door assemblies in compliance with NFPA 80. This deficient practice could prevent the ability of the facility to properly confine smoke and prevent fire from spreading to other zones. This deficient practice would affect all patients, visitors, and staff in 7 of 7 smoke zones. The facility has a capacity of 24 with a census of 3 at the time of the survey.

Findings include:

During the survey conducted on 3/5/19 the following deficiency is noted:

1. During document review at 1:05 PM, it is observed that there is no documentation for any annual inspections or testing of the fire door assemblies by qualified personnel.


Staff A was present and acknowledged the findings.

NFPA Standard: NFPA 80 2010 5.2.1 Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ. 5.2.3.1 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. 5.2.4.2 As a minimum, the following items shall be verified: (1) No open holes or breaks exist in the 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 non combustible 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 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. 3.3.95 Qualified Person. A person who, by possession of a recognized degree, certificate, professional standing, or skill, and who by knowledge, training, and experience, has demonstrated the ability to deal with the subject matter, the work, or the project.