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Based on observations and interview, it was determined the facility failed to maintain smoke barriers that would resist the passage of smoke between smoke compartments in accordance with NFPA standards. The deficiency had the potential to affect eleven (11) of eleven (11) smoke compartments, residents, staff, and visitors. The facility is licensed for eighty (80) beds with a census of twenty-six (26) on the day of the survey.

The findings include:

Observations, on 03/01/12 between 10:00 AM and 12:30 PM, with the Maintenance Director revealed the smoke partitions extending above the ceiling throughout the entire facility have penetrations by wires and piping. The spaces around the penetrations were not filled with a material rated equal to the partition and could not resist the passage of smoke.

Interview, on 03/01/12 between 10:00 AM and 12:30 PM, with the Maintenance Director revealed he was not aware of the penetrations in smoke barriers.

Reference: NFPA 101 (2000 Edition).

8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(a) The space between the penetrating item and the smoke barrier shall
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(b) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(c) Where designs take transmission of vibration into consideration, any vibration isolation shall
1. Be made on either side of the smoke barrier, or
2. Be made by an approved device designed for the specific purpose.

Based on observation and interview, it was determined the facility failed to ensure the exits were maintained in accordance with NFPA standards. The deficiency had the potential to affect three (3) of eleven (11) smoke compartments, residents, staff, and visitors. The facility is licensed for eighty (80) beds with a census of twenty-six (26) on the day of the survey.

The findings include:

Observation, on 03/01/12 between 10:00 AM and 12:30 PM, with the Maintenance Director revealed the Dining Room exit does not have a durable surface to a public way. Further observation showed the two exits on the back of the hospital do not have a durable surface to a public way also.

Interview, on 03/01/12 between 10:00 AM and 12:30 PM, with the Maintenance Director revealed he was unaware the exits needed a durable surface to the public way and that 4 feet is required.

Exits must terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge must be of required width and size to provide all occupants with safe access to a public way. 7.7.1

Reference:

NFPA 101 (2000 edition)

7.2.1.6.1 Delayed-Egress Locks. Approved, listed, delayed egress
locks shall be permitted to be installed on doors serving
low and ordinary hazard contents in buildings protected
throughout by an approved, supervised automatic fire detection
system in accordance with Section 9.6, or an approved,
supervised automatic sprinkler system in accordance with Section
9.7, and where permitted in Chapters 12 through 42, provided
that the following criteria are met.

(a) The doors shall unlock upon actuation of an
approved, supervised automatic sprinkler system in accordance
with Section 9.7 or upon the actuation of any heat
detector or activation of not more than two smoke detectors
of an approved, supervised automatic fire detection system in
accordance with Section 9.6.

(b) The doors shall unlock upon loss of power controlling
the lock or locking mechanism.

(c) An irreversible process shall release the lock within 15
seconds upon application of a force to the release device
required in 7.2.1.5.4 that shall not be required to exceed 15 lbf
(67 N) nor be required to be continuously applied for more
than 3 seconds. The initiation of the release process shall activate
an audible signal in the vicinity of the door. Once the
door lock has been released by the application of force to the
releasing device, relocking shall be by manual means only.
Exception: Where approved by the authority having jurisdiction, a delay
not exceeding 30 seconds shall be permitted.

(d) *On the door adjacent to the release device, there
shall be a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high and not less than 1/8 in. (0.3 cm) in stroke width on a contrasting background that reads as follows:
PUSH UNTIL ALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS

7.10.8.1* No Exit. Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows:
NO
EXIT
Such sign shall have the word NO in letters 2 in. (5 cm) high with a stroke width of 3/8 in. (1 cm) and the word EXIT in letters 1 in. (2.5 cm) high, with the word EXIT below the word NO.


7.5.2.2* Exit access and exit doors shall be designed and
arranged to be clearly recognizable. Hangings or draperies
shall not be placed over exit doors or located to conceal or
obscure any exit. Mirrors shall not be placed on exit doors.
Mirrors shall not be placed in or adjacent to any exit in such a
manner as to confuse the direction of exit.
Exception: Curtains shall be permitted across means of egress openings
in tent walls if the following criteria are met:
(a) They are distinctly marked in contrast to the tent wall so as to
be recognizable as means of egress.
(b) They are installed across an opening that is at least 6 ft (1.8 m)
in width.
(c) They are hung from slide rings or equivalent hardware so as to
be readily moved to the side to create an unobstructed opening in the
tent wall of the minimum width required for door openings.

Based on observation and interview, it was determined the facility failed to ensure exit discharge doors opened in the direction of egress. The deficiency had the potential to affect one (1) of eleven (11) smoke compartments, residents, staff, and visitors. The facility is licensed for eighty (80) beds with a census of twenty-six (26) on the day of the survey.

The findings include:

Observation, on 03/01/12 at 12:03 PM, with the Maintenance Director revealed the exit gate from the dining room did not swing outward. The gate would have to be pulled against egress travel in the event of an evacuation.

Interview, on 03/01/12 at 12:03 PM, with the Maintenance Director revealed he was not aware the exit discharge gate needed to open in the direction of egress.

NFPA 2000
7.2.1.4.3
A door shall swing in the direction of egress travel where used in an exit enclosure or where serving a high hazard contents area, unless it is a door from an individual living unit that opens directly into an exit enclosure.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted quarterly on each shift at random times, in accordance with NFPA standards. The deficiency had the potential to affect eleven (11) of eleven (11) smoke compartments, residents, staff, and visitors. The facility is licensed for eighty (80) beds with a census of twenty-six (26) on the day of the survey.

The findings include:

Fire Drill review, on 03/01/12 at 10:20 AM, with the Maintenance Director revealed the fire drills were not being conducted at unexpected times under varied conditions. First shift fire drills were being conducted predictably between 9:25 AM and 10:35 AM, second shift at 3:30 PM, and third shift around 12:05 AM.

Interview, on 03/01/12 at 10:20 AM, with the Maintenance Director revealed he was unaware the fire drills were not being conducted as required.

Reference: NFPA Standard NFPA 101 19.7.1.2.
Fire drills shall be conducted at least quarterly on each shift and at unexpected times under varied conditions on all shifts.

Based on record review and interview, it was determined the facility failed to have quarterly inspections performed of the fire sprinkler system in accordance with NFPA standards. The deficiency had the potential to affect eleven (11) of eleven (11) smoke compartments, residents, staff, and visitors. The facility is licensed for eighty (80) beds with a census of twenty-six (26) on the day of the survey.

The findings include:

Record review, on 03/01/12 at 10:00 AM, with the Maintenance Director revealed the facility did not have documentation for quarterly inspections of the fire sprinkler system. Components located in the fire sprinkler system must be inspected monthly and quarterly accordingly to NFPA requirements and the records for the inspection made available for the authority having jurisdiction.

Interview, on 03/01/12 at 10:00 AM, with the Maintenance Director revealed he was unaware the sprinkler system had to be inspected. He said the sprinklers had never been tested since he had been in his position.

Reference: NFPA 25 (1998 Edition).

2-1 General. This chapter provides the minimum requirements
for the routine inspection, testing, and maintenance of
sprinkler systems. Table 2-1 shall be used to determine the
minimum required frequencies for inspection, testing, and
maintenance.
Exception: Valves and fire department connections shall be inspected,
tested, and maintained in accordance with Chapter 9.

Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance
Item Activity Frequency Reference
Gauges (dry, preaction deluge systems) Inspection Weekly/monthly 2-2.4.2
Control valves Inspection Weekly/monthly Table 9-1
Alarm devices Inspection Quarterly 2-2.6
Gauges (wet pipe systems) Inspection Monthly 2-2.4.1
Hydraulic nameplate Inspection Quarterly 2-2.7
Buildings Inspection Annually (prior to freezing
weather)
2-2.5
Hanger/seismic bracing Inspection Annually 2-2.3
Pipe and fittings Inspection Annually 2-2.2
Sprinklers Inspection Annually 2-2.1.1
Spare sprinklers Inspection Annually 2-2.1.3
Fire department connections Inspection Table 9-1
Valves (all types) Inspection Table 9-1
Alarm devices Test Quarterly 2-3.3
Main drain Test Annually Table 9-1
Antifreeze solution Test Annually 2-3.4
Gauges Test 5 years 2-3.2
Sprinklers - extra-high temp. Test 5 years 2-3.1.1 Exception No. 3
Sprinklers - fast response Test At 20 years and every 10 years
thereafter
2-3.1.1 Exception No. 2
Sprinklers Test At 50 years and every 10 years
thereafter
2-3.1.1
Valves (all types) Maintenance Annually or as needed Table 9-1
Obstruction investigation Maintenance 5 years or as needed Chapter 10

Based on observation and interview, it was determined the facility failed to maintain doors within a required means of egress in accordance with NFPA standards. The deficiency had the potential to affect eleven (11) of eleven (11) smoke compartments, residents, staff, and visitors. The facility is licensed for eighty (80) beds with a census of twenty- six (26) on the day of the survey.

The findings include:

Observation, on 03/01/12 between 10:00 AM and 12:30 PM, with the Maintenance Director revealed an unapproved lock (slide bolt type) was installed on the cross-corridor doors throughout the facility.

Interview, on 03/01/12 between 10:00 AM and 12:30 PM, with the Maintenance Director revealed he was aware of the locks installed on the door; however, he was not aware that slide bolt locks were prohibited.


Reference: NFPA 101 (2000 Edition)

19.2.2.2.4
Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.

Based on interview and facility policy and procedure review, the facility failed to develop a fire watch policy in accordance with NFPA standards. The deficiency had the potential to affect eleven (11) of eleven (11) smoke compartments, residents, staff, and visitors. The facility is licensed for eighty (80) beds with a census of twenty-six (26) on the day of the survey.

The findings include:

Policy and Procedure review, on 03/01/12 at 10:10 AM, with the Maintenance Director revealed the facility had no written fire watch policy.

Interview, on 03/01/12 at 10:10 AM, with the Maintenance Director revealed he was unaware there needed to be a policy if the sprinkler system or fire alarm system would be non-functioning for 4 or more hours in a 24 hour period.

Reference; NFPA 101 (2000 edition)
9.7.6* Sprinkler System Shutdown.
9.7.6.1
Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.

Based on observation and interview, it was determined the facility failed to ensure that Alcohol Based Hand Rub dispensers were not installed over or adjacent to an ignition source in accordance with NFPA standards. The deficiency had the potential to affect two (2) of eleven (11) smoke compartments, residents, staff, and visitors. The facility is licensed for eighty (80) beds with a census of twenty-six (26) on the day of the survey.

The findings include:

Observation, on 03/01/12 at 11:15 AM, with the Maintenance Director revealed an Alcohol Based Hand Rub dispenser was installed over a carpeted area next to the maintenance room on the eastern hall.

Interview, on 03/01/12 at 11:15 AM, with the Maintenance Director revealed he was not aware the dispensers were not allowed to be mounted above carpet if the building is not fully sprinklered.

Reference:

Where Alcohol Based Hand Rub (ABHR) dispensers are installed in a corridor:
o The corridor is at least 6 feet wide
o The maximum individual fluid dispenser capacity shall be 1.2 liters (2 liters in suites of rooms)
o The dispensers have a minimum spacing of 4 ft from each other
o Not more than 10 gallons are used in a single smoke compartment outside a storage cabinet.
o Dispensers are not installed over or adjacent to an ignition source.
o If the floor is carpeted, the building is fully sprinklered. 19.3.2.7, CFR 403.744, 418.100, 460.72, 482.41, 483.70, 483.623, 485.623