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Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other spaces. The area of deficient practice would provide a path for smoke and fire to travel into the adjacent area, affecting 1 of 3 smoke zones. The facility has a capacity of 13 with a census of 6 at the time of survey.

Findings include:

During the survey on January 3, 2017 the following is observed:

1. At 9:23 AM the Storage room has a penetration from a 2 " x 3 " hole in the sheet rock near ceiling deck above door of west wall.
2. At 9:25 AM the Storage room has penetration from 1 "x 4 " gap around 2 " pipe near ceiling deck by Janitors storage.
3. At 9:33 AM the New Electrical room has a penetration from IT cables on east wall.
4. At 9:40 AM the Mechanical room has fire caulk pulling away from wall from perversely sealed 3 " hole.
5. At 9:57 AM the Multi-Purpose room is being used for storage , both doors a not equipped with self-closing devices.
6. At 11:10 AM it is observed that fire stop foam to fill gaps around cables in Business office server room that provides a barrier between large storage area was not approved for use as applied.

The Maintenance Director was present during the survey and acknowledged the findings.


Review of the following NFPA Standard revealed: Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. 2012 NFPA 101, 19.3.2.1

Review of the following NFPA Standard revealed: An automatic extinguishing system, where used in hazardous areas, shall be permitted to be in accordance with 19.3.5.9. 2012 NFPA 101, 19.3.2.1.1

Review of the following NFPA Standard revealed: Where the sprinkler option of19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4. 2012

Review of the following NFPA Standard revealed: Doors in barriers required to have a fire resistance rating shall have a minimum 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with, 19.3.2.1, 2012 NFPA 101 7.2.1.8.

Based on observation and staff interview, the facility failed to assure that all of the required areas are provided with sprinkler protection, failing to meet the building construction requirements would affect patients and staff in 1 of 3 smoke zones. The facility has a capacity of 13 with a census of 6 at the time of survey.


Findings include:

During the survey on January 4 2017 at 1:40 PM it is observed that Mechanical / Backflow room in OR is not provided with sprinkler protection.

The Maintenance Director was present and acknowledged the findings

Review of the following NFPA Standard revealed: Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. 19.3.5.4* The sprinkler system required by 19.3.5.1 or 19.3.5.3 shall be installed in accordance with 9.7.1.1(1). 19.3.5.5 In Type I and Type II construction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered
NFPA 101 1012, 19.3.5.

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 patients and staff in 1 of 3 smoke zones. The facility has a capacity of 13 with a census of 6 at the time of survey.
Findings include:

During the survey the following is observed:

1. On January 3, 2017 at 10:15 AM it is observed that 3 sprinkler heads in the Men ' s Locker room are 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 is not ensuring that corridor doors fit tightly within the door frame to resist the passage of smoke. This deficient practice of not ensuring that doors will resist the passage of smoke prevents the ability of the facility to properly confine fire and smoke products and to properly defend occupants in place affecting patients and staff in 1 of 3 smoke zones. The facility has a capacity of 13 with a census of 6 at the time of survey.
Findings include:

1. On January 3, 2017 at 10:15 AM it is observed that there is a gap greater then a ½ inch between the door and the door Jam around the top and leading edge of the door on Endoscopy room door to corridor.

The Maintenance Director was present and acknowledged the findings

Review of the following NFPA Standard revealed: Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following:
(1) 13/4 in. (44 mm) thick, solid-bonded core wood
(2) Material that resists fire for a minimum of 20 minutes
NFPA 101 2012 19.3.6.3.1*

S/S E
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 2 of 3 smoke zones. The facility has a capacity of 13 with a census of 6 at the time of survey.
Findings include:
During the survey on January 3, 2017 the following is observed:
1. At 12:20 PM it is observed that Water softener room to the corridor smoke barrier wall has 2 " x4 " hole around conduct in west wall

2. At 1:35 PM it is observed that Mechanical /backflow room to the OR hallway has a 3 ' x4 ' piece of drywall cut out from the barrier wall.

3. At 1:38 PM it is observed that OR hall smoke barrier has a gap around a pipe and a cable sleeve ranging in size from a 3/4 inch to 2 inch. Above suspended ceiling.

4. At 1:42 PM it is observed that OR hall by OR supply smoke barrier has a gap of 2 " by 13 ' long that runs the length of conduct pipe above suspended ceiling.

5. At 2:05 PM it is observed that OR hallway by OR room #3 has a 3 ' x 5 ' piece of drywall cut out from the barrier wall for Pipes, cables and duct work above suspended ceiling.

6. At 2:10 PM it is observed that OR hall smoke barrier has a gap around duct by supply room above suspended ceiling.

7. At 2:15 PM it is observed that OR hall smoke barrier north end of corridor has a 1 " gap around conduct above suspended ceiling.

8. At 2:32 PM it is observed that the end of the corridor by Medical Gas storage has a gap around 1/2: " flex cable above suspended ceiling.

9. At 2:47 PM it is observed that Lobby Lounge to the corridor has a 1 " gap around conduct above suspended ceiling.


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

Based on observation and staff interview, the facility did not ensure that electrical wiring and equipment is installed and maintained in accordance with NFPA 70, National Electrical Code. This deficient practice does not ensure prevention of an electrical fire or electric shock hazard, , affecting patients and staff in 1 of 3 smoke zones. The facility has a capacity of 13with a census of 6 at the time of survey.
Findings Include:

During the survey the following is observed:

On January 3, 2017 at 10:50 AM the following is observed: A protected power strip was hanging by plugins and not secured in any manner.

The Maintenance Director was present and acknowledged the findings

Review of the following NFPA Standard revealed: Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. 2012 NFPA 101, 9.1.2