HospitalInspections.org

Based on observation and staff interview, the facility fails to prevent doors within a means of egress to assure that non-egress doors are identified and are not mistaken for an exit. These deficient practices affecting all residents and any visitors and staff in 2 of 2 smoke zones. The facility has a capacity of 25 and a census of 6 at the time of the survey.

Findings include:

During the tour conducted on , June 12, 2017 it is observed:

At 12:55 p.m.,two interior door from the facility's leads to a enclosed courtyard. A review of the facility's code footprint reveals that the two door are not a required exit. The door is likely to be mistaken for an exit and is not identified by proper signage reflecting "NO EXIT".

The Maintenance Director was present at the time of the observation and acknowledged the findings.

NFPA Standard: 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. The NO EXIT sign shall have the word NO in letters 2 in. (51 mm) high, with a stroke width of 3.8 in. (9.5 mm), and the word EXIT in letters 1 in. (25 mm) high, with the word EXIT below the word NO, unless such sign is an approved existing sign. 2012 NFPA 101, 7.10.8.3.1 7.10.8.3.2.

Based on observation, record review and interview the facility does not assure a fire watch procedure and policy is written as required for implementation when the fire sprinkler system is out of service for more than 10 hours in a 24 hour period. This deficient practice would prevent proper notification of insurance carrier, the alarm company, property owner or designated representative, and authorities having jurisdiction as required, affecting all residents in two smoke zones. The facility has a capacity of 25 and census of 6 at the time of the survey,

Findings include:

During record review on June 12, 2017 at 11:25 a.m., it is revealed that the facility's policy for implementing a fire watch for a sprinkler system impairment does not include the items found in NFPA 21, 15.5.1

1.) Notification of the insurance carrier,
2,) The alarm company,
3.) Property owner or designated representative,
4.) Local fire department,
5.) Office of the State Fire Marshal and the Department for Aging and Disability Services.
6.) Phone numbers for these entities are not listed in the policy.
7.) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period,
8.) The impairment coordinator.

The Maintenance Director was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Sprinkler System Impairments. Sprinkler impairment procedures shall comply with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2012 NFPA 101, 9.7.6

Review of the following NFPA Standard revealed: All preplanned impairments shall be authorized by the impairment coordinator. 2011 NFPA 25, 15.5.1

Based on observation, record review and interview the facility does not assure a the fire evacuation procedure and policy is written This deficient practice would prevent proper notification of insurance carrier, the alarm company, property owner or designated representative, and authorities having jurisdiction as required, affecting all residents in all smoke zones. The facility has a capacity of 25 and census of 6 at the time of the survey.


findings include:

During record review on June 12, 2017 at 11:25 a.m., revealed the following:

1.) Fail to address evacuation of the triangle or rooms surrounding the room of origin
2.) The rooms on either side and directly across the hall.
3.) Systematically remove the remaining occupants within the smoke compartment beyond (fire doors or fire doors next to the exit.)
4.) Never cross the line of fire or smoke!.
5.) Fails to indicate preperations of the floor and removal of items.
6.) Fail to address bariatic residents and evacuation.

Review of the following NFPA Standard revealed: For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. 2012 NFPA 101, 19.7.2.1.1

Review of the following NFPA Standard revealed: The basic response required of staff shall include the following:(1) Removal of all occupants directly involved with the fire emergency (2) Transmission of an appropriate fire alarm signal to warn other building occupants and summon staff (3) Confinement of the effects of the fire by closing doors to isolate the fire area (4) Relocation of patients as detailed in the health care occupancy's fire safety plan. 2012 NFPA 101, 19.7.2.1.2

Review of the following NFPA Standard revealed: Fire Safety Plan. A written health care occupancy fire safety plan shall provide for all of the following:

(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation

Based on record review and staff interview, the facility is not conducting fire drills as required and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency, affecting all residents in all smoke zones. The facility has two 12 hour shifts in use. Shift one is 05:00 AM until 5; 00 PM and shift two is 5:00 PM to 050:00 AM, The facility has a capacity of 25 with a census of 6 at the time of survey.


Findings include:

During record review of fire drill records for the last 6 quarters on June 12, 2017 at 9:45 p.m., revealed the following:

1.)Drills conducted on the night shift from 5 PM - to 5 AM were coded silent drills and the alarm did not transmit an alarm to the monitoring company when compared to the monitoring company's receiving log the following morning.
2.)First shift, first quarter and 2nd quarter fire drills were held within the same time between the hours of 11:00 AM and 11:45 AM.
3.)Second shift second quarter and 3rd quarter drills were held within the same time between the hours of 11:23 PM, and 11:00 PM.


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


NFPA Standard Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 18.7.1.4 through 18.7.1.7, 19.7.1.4 through 19.7.1.7