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Based on observations and interview, the facility failed to maintain its doors in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 7.2.1.5.10-7.2.1.5.10.6 by not ensuring doors in a means of egress shall be readily operable from the egress side. This has the ability to affect one of eight smoke compartments(Surgical Wing). The facility had a capacity of 25 with a census of 8 residents at the time of the survey.

Findings include:

Observations and interview on 4/11/19 at 12:48 p.m., revealed door to the Scope Room contained a dead-bolt lock installed with no positive latching device and in an emergency, someone could be inadvertently locked into this room and would not be able to get out of it.

Maintenance Staff verified this observation during the survey process.

Based on interview and record review, the facility did not assure that an adequate policy is in place regarding the procedures to be taken in the event that the fire alarm is out of service for more than four hours in any 24-hour period in accordance with National Fire Prevention Association (NFPA) 101, Life Safety Code, 2012 edition, 9.6.1.6. Lack of written policies and procedures could result in staff failing to implement interim measures in the event of an emergency. This deficient practice affected all occupants of the building in this facility with a capacity of 25 and a census of 8.

Findings include:

Interview with Maintenance Staff on 4/11/19, at 11:54 a.m., revealed the facility did not have a policy regarding the procedures to be taken in the event that the fire alarm was out of service for more than four hours in a 24-hour period.
Maintenance Staff confirmed the finding during the exit conference.

Based on interview and record review, this facility did not assure that a complete policy is in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than 10 hours in any 24-hour period in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, Chapter 15. Lack of complete written policies and procedures could result in staff failing to implement interim safety measures in the event of an emergency. This deficient practice affected all occupants of the building. This facility had a capacity of 25 and a census of 8 residents at the time of the survey.

Findings include:

Record review on 4/11/19, at 11:45 a.m., of the fire watch procedures revealed the facility did not have a policy regarding the procedures to be taken in the event that the sprinkler system was out of service for more than 10 hours in a 24-hour period. The policy is required to have the following information included in their policy as required by NFPA 25, 2011 Edition (Chapter 15):

15.2.1 The property owner or designated representative shall assign an impairment coordinator to comply with the requirements of this chapter.
15.2.2 In the absence of a specific designee, the property owner or designated representative shall be considered the impairment coordinator.
15.2.3 Where the lease, written use agreement, or management contract specifically grants the authority for inspection, testing, and maintenance of the fire protection system(s) to the tenant, management firm, or managing individual, the tenant, management firm, or managing individual shall assign a person as impairment coordinator.
15.3 Tag Impairment System.
15.3.1* A tag shall be used to indicate that a system, or part thereof, has been removed from service.
15.3.2* The tag shall be posted at each fire department connection and the system control valve, and other locations required by the authority having jurisdiction, indicating which system, or part thereof, has been removed from service.
15.4 Impaired Equipment.
15.4.1 The impaired equipment shall be considered to be the water-based fire protection system, or part thereof, that is removed from service.
15.4.2 The impaired equipment shall include, but shall not be limited to, the following:
(1) Sprinkler systems
(2) Standpipe systems
(3) Fire hose systems
(4) Underground fire service mains
(5) Fire pumps
(6) Water storage tanks
(7) Water spray fixed systems
(8) Foam-water systems
(9) Fire service control valves

15.5.1 All preplanned impairments shall be authorized by the impairment coordinator.

15.5.2 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.

15.6.1 Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure.

15.6.2 When emergency impairments occur, emergency action shall be taken to minimize potential injury and damage.

15.6.3 The coordinator shall implement the steps outlined in Section 15.5.

15.7 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.


Maintenance Staff confirmed the findings during the exit conference.

Based on interview and record review, the facility failed to provide a written plan for the use of the hood extinguishment system located in the Kitchen in the event of a fire in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.7.1/19.7.1 and 18.7.2/19.7.2. The deficient practice affected all smoke zones and all occupants. This facility had a capacity of 25 and a census of 8 residents at the time of the survey.

Findings include:

Record review on 4/11/19, at 11:47 a.m., revealed the facility did not have a written plan for the use of the hood extinguishment system in the event of a fire emergency.

Maintenance Staff confirmed this observation at the time of exit.

Based on record review and interview, the facility failed to maintain the emergency generator power supply as required by National Fire Protection Association (NFPA) 110, Standard for Emergency and Standby Power Systems, 2010 edition, 8.3.8, by not ensuring a fuel quality test was performed at least annually using tests approved by ASTM standards. This deficient practice affects all smoke compartments throughout the building and all occupants. The facility had a capacity of 25 and a census of 8 residents at the time of the survey.

Findings include:

Record review and interview on 4/11/19, at 10:22 a.m., revealed the facility could not provide documentation of an annual fuel quality test for the diesel fuel for the generator.

Maintenance Staff confirmed this finding at the time of the survey.