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Based on observations and interview, the facility failed to maintain fire doors in operational condition. Fire doors help to contain hazardous conditions, and the failure of these doors endanger all persons within the facility by allowing the passage of smoke, flames, noxious gases, etc. into adjoining compartments.


The findings include:


During the facility tour with the Director of Facilities from 1:30 PM through 3:30 PM on 10/25/2018, it was found that the fire rated doors in the following locations contained deficiencies:

1) Double fire doors in hallway by Conference Room - missing hardware;
2) Exit door in main electrical room - could not fully close or latch;
3) Patient Room Door 8 to corridor- latch not lined up with strikeplate - would not close.


During interview with the Director of Facilities at the time of the findings, it was acknowledged that the fire doors noted were not in proper operating condition. It was also stated that he would make the required corrections to the doors immediately.


NFPA 101, 19 and 7.2.1

Based on record review and staff interview, the facility failed to maintain their fire alarm system in accordance with NFPA 72, maintaining the integrity of the system to alarm in the event of a fire, to allow for the emergency egress and relocation of patients, staff, or other building occupants which could result in injury or loss.


The findings include:


During record review on 10/25/2018 at 10:30 AM with the Director of Facilities, the Fire Alarm testing records showed that according to the documentation, not all devices had been tested, inspected, and maintained to ensure the integrity of the fire alarm system in accordance with NFPA 72. Duct Detector devices were missed, and not marked on inspection documents as being verified for sensitivity and verified utilizing sampling tubes for the correct pressure differential (within the manufacturer's published ranges) between the inlet and exhaust tubes using a method acceptable to the manufacturer to ensure that the device will properly sample the airstream.


During interview with the Director of Facilities at 10:40 AM on 10/25/2018, it was acknowledged, there were no records to show that the duct detector devices of the facility had been verified as within the sensitivity manufacture range and for differential pressure.


NFPA 72 (2010) 14.1, 14.1.1, 14.2.1.1, 14.2.1.2, 14.2.6.2, 14.4.2.2, Table 14.4.2.2(14)(g)(6), 14.4.5, Table 14.4.5.

NFPA 101 (2012) 9.6, 9.6.1.5, 19.3.4.1

NFPA 72 (2013) 14.1, 14.1.1, 14.2.1.1, 14.2.1.2, 14.2.6.2, 14.4.2.2, Table 14.4.2.2(14)(g)(6), 14.4.5, Table 14.4.5.

NFPA 101 (2015) 9.6, 9.6.1.5, 19.3.4.1

Based on documentation review and interview, the facility failed to conduct the annual inspection of fire doors according to NFPA 80. Fire doors help to contain hazardous conditions and the failure of these doors endangers all persons within the facility by allowing the passage of smoke, flames, noxious gases, etc. into adjoining compartments.


The findings include:


During the document review with the Director of Facilities on 10/25/2018 at 11:15 AM, it was found that there was a lack of documentation for the annual 11 point annual inspection for rated fire doors.


During interview with the Director of Maintenance on 10/25/2018 at 11:17 AM, it was stated that he was unsure of what was included in the new regulation. It was also stated that now that he knew what needs to be done that it would be done immediately.

NFPA 80 - 5.2.4.2
CMS S & C 17-38
NFPA 101 4.5.7, 4.5.8, 4.6.12.1, 4.6.12.3, 4.6.12.4, 8.3, 8.3.3, 8.5.4.5, 19.3.6.3.16, 19.3.7.6, 19.7.6