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Based on observation and interview the facility fails to insure that the facility ' s automatic sprinkler system is installed in accordance with NFPA 13 and maintained in accordance with NFPA 25. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting 1 of 3 smoke zones. The facility has a capacity of 16 with a census of 8 at the time of survey.
Findings include:

During the survey on January 11, 2016 the following is observed:

1 At 1:35 pm is observed that the sprinkler head in the patient bathroom 16 room is loaded with lint and dust.
2 At 1:40 pm is observed that the sprinkler head in the patient bathroom 13 room is loaded with lint and dust.
3 At 1:50 pm is observed that the sprinkler head in the patient bathroom 4 room is loaded with lint and dust.
The Maintenance Director was present during the survey and acknowledged the findings.


Review of the following NFPA Standard revealed: Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall). 2011 NFPA 25, 5.2.1.1.1

Based on observation and staff interview the facility fails to maintain smoke barriers to at least one hour fire resistance. This deficient practice would prevent containment of fire and smoke, affecting patients and staff in 1 of 3 smoke zones. The facility has a capacity of 16 with a census of 8 at the time of survey.
Findings include:
During the survey on January 11, 2017 the following is observed:
1. At 2:40 PM it is observed that the corridor to the pre operation room 1 hour barrier wall, has a gap around conduit above the ceiling by double doors.

2. At 2:42 PM it is observed that the corridor to the pre operation room 1 hour barrier wall, has a gap around electrical flex wiring above the ceiling by double doors.

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 1/2-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

Review of the following NFPA Standard revealed: Penetrations. The provisions of 8.4.4 shall govern the materials and methods of construction used to protect through-penetrations and membrane penetrations of smoke partitions.
8.4.4.1 Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a smoke partition shall be protected by a system or material that is capable of limiting the transfer of smoke.
NFPA 101 2012, 8.4.4

Based on record review and staff interview the facilities the facility does not assure Fire Loss Prevention for operating rooms procedure are in place. Written policy is required for safety precautions and fire prevention procedures. This deficient practice may prevent the staff properly handling hazard emergency in operating rooms and implementing prevention measures. This practice affects all patients and staff. This facility has a capacity of 16 and a census of 8 patients at the time of the survey.

Findings include:

During the survey and records review on January 11, 2017 between 9:30 am and 12:00 am the following is observed:
1. No policy was provided for Fire Loss Prevention in Operating room procedures.

The Maintenance Director was present and acknowledged the findings

Review of the following NFPA Standard revealed: Fire Loss Prevention in Operating Rooms. 15.13.1 Hazard Assessment.
15.13.1.1 An evaluation shall be made of hazards that could be encountered during surgical procedures.
15.13.1.2 The evaluation shall include hazards associated with the properties of electricity, hazards associated with the operation of surgical equipment, and hazards associated with
The nature of the environment.
15.13.1.3 Periodic reviews of surgical operations and procedures shall be conducted with special attention given to any change in materials, operations, or personnel.
15.13.2 Fire Prevention Procedures. Fire prevention procedures shall be established.
NFPA 99 2012, 15.13*