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Based on observation and interview the facility failed to ensure the building was fully sprinkled as required. This deficient practice affected one (1) of ten (10) smoke compartments, staff, and other occupants of the building.

The findings include:

During the Life Safety Code Survey on 01/29/19 at 9:40 AM with the Director of Maintenance (DOM), the walk in freezer and cooler in the kitchen was observed not to be sprinkler protected as required. These areas must be sprinkler protected for a building to be considered fully sprinkled.

Interview with the DOM on 01/29/19 at 9:40 AM revealed he was not aware the freezer and cooler needed to be sprinkler protected.

The findings were revealed to the Administrator on exit.

Based on observation and interview, the facility failed to ensure rooms open to the corridor were protected with smoke detection according to National Fire Protection Agency (NFPA) requirements. This deficient practice affected one (1) of ten (10) smoke compartments, staff and other occupants of the building.

The findings include:

During the Life Safety Code tour on 01/29/19 at 11:10 AM with the Director of Maintenance (DOM), the surgical waiting room was observed to be open to the corridor without a smoke detector within the room area.

Interview with the DOM on 01/29/19 at 11:10 AM revealed he was not aware rooms open to the corridor required smoke detector protection.

The findings were revealed to the Administrator on exit.


Reference: NFPA 101 2012 edition

19.3.6.1 Corridor Separation. Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5 (see also 19.2.5.4), unless otherwise permitted by one of the following:
(1) Smoke compartments protected throughout by an approved supervised automatic sprinkler system in accordance with 19.3.5.8 shall be permitted to have spaces that are unlimited in size and open to the corridor, provided that all of the following criteria are met:
(a)*The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas.
(b) The corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the smoke compartment in which the space is located is protected throughout by quick-response sprinklers.
(c) The open space is protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the entire space is arranged and located to allow direct supervision by the facility staff from a nurses ' station or similar space.
(d) The space does not obstruct access to required exits.
(2) In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.8, waiting areas shall be permitted to be open to the corridor, provided that all of the following criteria are met:
(a) The aggregate waiting area in each smoke compartment does not exceed 600 ft2 (55.7 m2).
(b) Each area is protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or each area is arranged and located to allow direct supervision by the facility staff from a nursing station or similar space.
(c) The area does not obstruct access to required exits.
(3)*This requirement shall not apply to spaces for nurses ' stations.

Based on observation and interview, it was determined the facility failed to ensure the safety of residents, staff and other occupants of the building by allowing unapproved portable space heating units in office areas. This deficient practice affected two (2) of ten (10) smoke compartments.

The findings include:

During the Life Safety Code tour on 01/29/19 at 10:50 AM with the Director of Maintenance (DOM), a portable space heater was observed in the Emergency Room front office area. Facilities must provide factory documentation that portable space heaters are approved for use in these areas. In addition, an unapproved portable space heating device was observed in the Lab Director office area

Interview with the DOM on 01/29/19 at 10:50 AM revealed he was not aware of the requirements for the proper use of portable space heaters.

The findings were revealed to the Administrator on exit.