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Based upon observation and interview the facility failed to ensure hazardous areas doors were maintained self closing. This deficient practice could allow smoke and gases to enter an exit access corridor affecting egress. The facility is licensed for 40 and had a census of 35 on the day of the survey.

Findings include:

During the facility tour on October 15 & 16, 2012 observation revealed the door between the corridor and the central storage-supply room was not self-closing or automatic closing, the door closing device had been removed. Interview with the Director of Plant Operations revealed the closer was broken and the facility was awaiting parts to correct the situation. This finding was acknowledged by the Director of Plant Operations and the Administrator during the exit interview.

Actual NFPA standard:

18.3.2.1* Hazardous Areas.
Any hazardous area shall be protected in accordance with Section 8.4. The areas described in Table 18.3.2.1 shall be protected as indicated.

8.4.1.1*
Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42.

8.4.1.3
Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.

Based upon record review and interview conducted on October 15 2012 the facility failed to ensure fire drills were conducted at least once per shift per quarter during the last 12 months. Failure to train personnel in emergency procedures could result in panic and confusion in a true emergency. The facility is licensed for 40 beds and had a census of 35 on the day of the survey.

Findings include:

During the record review conducted on October 15, 2012 records were not available to demonstrate that drills were conducted at least once per shift, per quarter. No records could be located to document a second shift drill was conducted during the third quarter of 2012. This deficient practice was acknowledged by the Director of Plant Operations and the Administrator during the exit conference.

Actual NFPA standard:

18.7.1.2*
Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Based upon record review and interview on October 15, 2012 the facility failed to test and maintain the automatic sprinkler system in a reliable operating condition in accordance with NFPA 25. This deficient practice could result in the system not being fully functional during an emergency, this practice affected all residents, patients and staff present on the day of the survey. The hospital is licensed for 40 beds and had a census of 35 on the day of the survey.

Findings include:

Review of facility sprinkler testing records revealed the five year internal investigation and maintenance was due in 2011 and has not been conducted. No record of a five year internal investigation was available for review. This deficient practice was acknowledged by the Director of Plant Operations and the Administrator during the exit interview.

Actual NFPA standard:

NFPA 25 10-2.2* Obstruction Prevention.
Systems shall be examined internally for obstructions where conditions exist that could cause obstructed piping. If the condition has not been corrected or the condition is one that could result in obstruction of piping despite any previous flushing procedures that have been performed, the system shall be examined internally for obstructions every 5 years. This investigation shall be accomplished by examining the interior of a dry valve or preaction valve and by removing two cross main flushing connections.