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Based on observation and staff interview the facility fails to properly protect and maintain their hazardous areas in accordance with NFPA 101. The deficient practice would affect no patients and all visitors and staff in 2 of 8 smoke zones. The facility has a capacity of 25 with a census of 7 at the time of the survey.

Findings include:

During the survey conducted on 5/4/17 the following deficiencies are noted:

1. During the survey at 11:30 AM it is observed that main entrance door to the laboratory is not equipped with a self-closing device.
2. During the survey at 12:25 PM it is observed that there is a metal rod going through the wall of the boiler room next too the nuclear medicine room. The metal rod also has wires going through the wall, and this rod was square in shape and passed completely through the wall. There was no sealant around this rod, so it would not resist the passage of smoke.

Maintenance staff was present and acknowledged the unsealed penetration in the boiler room wall.

NFPA Standard: NFPA 101 19.3.2.1.3 The doors shall be self-closing or automatic-closing. 19.3.2.1.5 Hazardous areas shall include, but shall not be restricted to, the following: (1) Boiler and fuel-fired heater rooms (2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops (4) Repair shops (5) Rooms with soiled linen in volume exceeding 64 gal (242 L) (6) Rooms with collected trash in volume exceeding 64 gal (242 L) (7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction (8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard 19.3.2.1.2* Where the sprinkler option of 19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4.

Based on staff interview and document review, the facility does not have a proper fire watch plan and procedure in accordance with NFPA 25. The deficient practice would affect all patients, visitors, and staff in 8 of 8 smoke zones. The facility has a capacity of 25 with a census of 7 at the time of the survey.

Findings include:

During the survey conducted on 5/4/17 the following deficiency is noted:

1. During document review at 9:37 AM, it is observed that the facility does not have a complete Fire Watch plan and procedure to be taken in the event sprinkler system was out of service for more than 10 hours in a 24 hour period. The policy lacked the contact information for the Insurance company and property owner in their policy.

Maintenance staff was present and acknowledged the incomplete Fire Watch Plan and Procedure.

NFPA Standard: 15.5.2 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/manager. 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 (4) The fire department has been notified. (5) The insurance carrier, the alarm company, property owner/ manager, and other authorities having jurisdiction have been notified. (6) The supervisors in the areas to be affected have been notified. (7) A tag impairment system has been implemented. (See Section 15.3.) (8) All necessary tools and materials have been assembled on the impairment site. NFPA 25 15.5.2

Based upon observation and staff interview the facility is not maintaining their corridor doors in compliance with NFPA 101. This deficient practice could prevent the ability of the facility to properly confine smoke and prevent fire from spreading. This deficient practice would affect approximately 1 patient and all visitors or staff in 2 of 8 smoke zones. The facility has a capacity of 25 with a census of 7 at the time of this survey.

Findings include:

During the tour conducted on 5/4/17 the following deficiencies are observed:

-- 1. During the survey at 11:42 AM it is observed that in the Pharmacy there is 20 minute rated door held open by a wood door wedge.

-- 2. During the survey at 12:12 PM it is observed that the corridor door to the patient changing area, near radiology, was blocked open with a trashcan.

Maintenance staff was present and acknowledged the corridor doors that were obstructed from being closed.

NFPA Standard: Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1-3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Doors shall be provided with a means suitable for keeping the door closed.

Based upon observation and staff interview the facility is not maintaining their smoke barrier doors in compliance with NFPA 101. This deficient practice could prevent the ability of the facility to properly confine smoke and prevent fire from spreading to other zones. This deficient practice would affect no patients and all visitors or staff in 2 of 8 smoke zones. The facility has a capacity of 25 with a census of 7 at the time of this survey.

Findings include:

During the tour conducted on 5/4/17 the following deficiency is noted:

-- 1. During the survey at 11:21 AM it is observed that smoke barrier doors near administration were blocked from completely closing by a chair. This was corrected on site.


Maintenance staff was present and acknowledged the smoke barrier doors were obstructed by the chair and did not completely close.

NFPA Standard: Life Safety Code 2012 19.3.7.8* Doors in smoke barriers shall comply with 8.5.4 and
all of the following: (1) The doors shall be self-closing or automatic-closing in accordance with 19.2.2.2.7.
(2) Latching hardware shall not be required (3) The doors shall not be required to swing in the direction
of egress travel.

Based on observation and staff interview, the facility failed to install and maintain their emergency generator power supply as required by NFPA 101. The deficient practice would affect all patients, visitors, and staff in 8 of 8 smoke zones. The facility has a capacity of 25 with a census of 7 at the time of the survey.

Findings include:

During the survey conducted on 5/4/17 the following deficiency is noted:

1. During the survey at 10:58 AM it is observed that there is no remote shut off present for the generator.

Maintenance staff was present and acknowledged the needed remote shutoff for the generator.

NFPA Standard: All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.
NFPA Standard: For Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.