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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 in 2 of 8 smoke zones. The facility has a capacity of 25 with a census of 16 at the time of survey.

Findings include:

During the survey on December 27, 2017, the following is observed:

1.At 10:10 am, the kitchen door to the pantry did not self close and latch.

2.At 10:25 am, the soiled utility room in surgery did not self close and latch.

3. At 10:50 am, combustibles are found to be stored in room 205, this room is not properly rated for hazardous storage.

The Maintenance Director 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 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 all patients in all 8 smoke zones. The facility has a capacity of 25 and a census of 16 at the time of survey.

Findings include:


During record review on December 26, 2017, the following is observed: Between 12:30 pm and 3:30 pm it is revealed that the facility did not have in the written fire watch policy, all the procedures and contact information that is required to include contact of the insurance carrier by 2011 NFPA 25, 15.5.2


The Maintenance Director 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 observation and staff interview, the facility is not ensuring that corridor doors remain free of penetrations to resist the passage of smoke. This deficient practice of not ensuring that doors will resist the passage of smoke prevents the ability of the facility to properly confine fire and smoke products and to properly defend occupants in place, affecting patients in 1 of 8 smoke zones. The facility has a capacity of 25 patients with a census of 16 at the time of the survey.

Findings include:

During the survey on December 27, 2017 it is observed that:

1.At 9:20 am there are four ¼" hole penetration in the door to room 207.

The Maintenance Director was present and acknowledged the findings.


Review of the following NFPA Standard revealed: Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following:
(1) 13?4 in. (44 mm) thick, solid-bonded core wood
(2) Material that resists fire for a minimum of 20 minutes
NFPA 101 2012 19.3.6.3.1*

Based on observation and staff interviews, the facility fails to maintain smoke barriers to at least one hour fire resistance. This deficient practice would cause containment of fire and smoke, affecting patients and staff in 2 of 8 smoke zones. The facility has a capacity of 25 with a census of 16 at the time of survey.
Findings include:

During the survey on December 27, 2017, the following is observed:

1. At 11:35 AM, it is observed that the waiting room smoke barriers corridor wall, above double doors in the attic space, has gaps around cable run.

2 At 12:00 PM, it is observed that the outpatient smoke barrier corridor wall, above double doors in the attic space, has gaps around cable run.

The Maintenance Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1 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.
19.3.7.4 Reserved.
NFPA 101 2012 19.3.7.3, 19.3.7.5 Accumulation space shall be provided in accordance

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 patients in all 8 smoke zones. The facility has a capacity of 25 with a census of 16 at the time of survey

Findings include:

During record review on December 26, 2017 between 10:30 am and 12:15 pm it is noted that:

1.The facility's fire drill record for the previous 12 months revealed that 2 of the last 4 fire drills conducted on the 1st shift occurred within the 1:00 PM hour

2. The facility's fire drill record for the previous 12 months revealed that 2 of the last 4 fire drills conducted on the 1st shift occurred within the 10:00 AM hour

3. The facility's fire drill records for the previous 12 months revealed that no drills were conducted on the 3rd shift of the 3rd quarter.


The Maintenance Director 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, 19.7.1.6

Based on staff interview and document review the facility the facility fails to ensure that the facility's medical gas equipment is maintained and inspected in accordance with NFPA 99. This deficient practice could adversely affect all persons using or receiving medical gases from the bulk medical gas system in all 8 smoke zones. The facility has a capacity of 25 with a census of 16 at the time of the survey.

Findings include:

During record review on December 26, 2017 between 12:30 pm and 3:30 pm it is noted that:

The annual medical gas inspection and testing report on June, 2017 revealed that deficiencies were found and no documentation provided for corrections of the following:

1.Med gas Air compressor carbon monoxide monitor not working.

2.Med air source intake not located 10' or more from doors, exhaust and other intakes

3.Med gas Vacuum exhaust is not located 10' or more from any air intake into the facility

The Maintenance Director was present and acknowledged the findings.


Review of the following NFPA Standard Revealed: Compressor Intake.
(A) The medical air compressors shall draw their air from a source of clean air.
(B) The medical air intake shall be located a minimum of 7.6 m (25 ft) from ventilating system exhausts, fuel storage vents, combustion vents, plumbing vents, vacuum and WAGD discharges, or areas that can collect vehicular exhausts or other noxious fumes
2012 NFPA 99, 5.1.3.6.3.12