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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 2 of 6 smoke zones. The facility has a capacity of 24 patients and a census of 4 at the time of survey.

Findings include:

During the survey on December 5, 2017, the following is observed:

1. At 3:40 pm, it is observed that the corridor from the main lobby wall to the public area in attic space has penetration in the end of a cable conduit.

The Maintenance Director 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, 19.1.3.3

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 patients in 1 of 6 smoke zones, including the main dining room. The facility has a capacity of 24 patients with a census of 4 at the time of the survey.

Findings include:

During record review on December 5, 2017 between 10:30 am and 12:15 pm it is noted that: records indicated the kitchen exhaust hood system cleaning has only been performed once in the last 12 Months the

Maintenance Director was 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, 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 6 smoke zones. The facility has a capacity of 24 and a census of 4 at the time of survey.

Findings include:


During record review on December 5, 2017, the following is observed: Between 10:00 am and 12:15 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 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 6 smoke zones. The facility has a capacity of 24 with a census of 4 at the time of survey

Findings include:

During record review on December 5, 2017 between 10:30 am and 12:15 pm it is noted that:

1 The facility's fire drill records for the previous 12 months revealed that fire drills conducted on the 1st shift during the last 4 quarters, revealed that 3 of the 4 occurred within the 4:00 PM hour of each other.

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