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Based on observation and interview the facility failed to maintain doors in smoke barriers to prevent gaps in excess of 1/8th of an inch between the doors when closed. This deficient practice affects all occupants on either side of the smoke barriers. The facility census was two.

Findings included:

Observations, during a tour of the facility conducted on the afternoon of 03/29/16 showed the following:
-A gap of at least 1/4th inch was observed between the edges of the smoke barrier doors, located in the corridor adjacent to the nurses station, when the doors closed after being released from the wall mounted automatic hold-open device.
-A gap of at least 1/4th inch was observed between the edges of the smoke barrier doors, located in the corridor adjacent to patient room 102, when the doors closed after being released from the wall mounted automatic hold-open device.

During an interview on 03/29/16 at 2:12 AM, Staff R, Director of Facility Services, stated there were gaps of greater than 1/8th inch between both sets of smoke barrier doors when closed.

Section 8.3.4.1 of the National Fire Protection Association (NFPA 101) states doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

Based on record review and interview the facility failed to conduct fire drills at various times during the day for the 7:00 AM to 7:00 PM shift. This deficient practice has the potential to affect all occupants in the facility during an emergency situation. The facility census was two.

Findings included:

Review of the fire drill records for the previous 12 months, conducted on the morning of 03/30/16, showed fire drills for the first shift, 7:00 AM to 7:00 PM, were conducted at the following times:

-05/28/15 at 9:15 AM
-08/28/15 the time of the drill was not recorded
-12/14/15 at 9:00 AM
-03/26/16 at 9:05 AM

During an interview on 03/30/16 at 12:30 PM, Staff R, Director of Facility Services, stated three fire drills had been conducted within the same time frame and the time of day for a fourth fire drill had not been recorded.

Section 19.7.1.2 of the National Fire Protection Association (NFPA 101) states 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.

Section 4.7.5 of the National Fire Protection Association (NFPA 101) states drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.

Based on interview and document review the facility failed to ensure the fire alarm smoke detectors were individually tested for smoke sensitivity. This deficient practice affects all occupants in the facility. The facility census was two.

Findings included:

Review of the facility fire alarm inspection documents, conducted on the morning of 03/30/16, showed an outside contractor had conducted an annual certification of the fire alarm system on 03/02/16. This certification document did not show the sensitivity range of any of the facility smoke detectors nor did it indicate when the detectors were last tested for sensitivity range.

During an interview on 03/30/16 at 8:45 AM, Staff R, Director of Facility Services, stated the smoke detector sensitivity testing had not been conducted since the installation of the fire alarm system approximately five years ago.

Section 10.4.3.2 of the National Fire Protection Association (NFPA 72) states sensitivity of smoke detectors and single-and multiple-station alarms in other than one-and two-family dwellings shall be tested in accordance with 10.4.3.2.1 through 10.4.3.2.6.

Based on observation and interview the facility failed to have sufficient numbers of quick response sprinkler heads available in the facility. This deficient practice has the potential to affect the prompt repair of the sprinkler system if needed. The facility census was two.

Findings included:

Observation on 03/29/16 at 2:40 PM of the wall mounted spare sprinkler head box, located in the main sprinkler system room, showed only 4 spare sprinkler heads to be on hand and ready for use if the sprinkler system required immediate repair.

During an interview on 03/29/16 at 2:41 PM, Staff R, Director of Facility Services, stated there were only 4 spare sprinkler heads available for use.

Section 5.4.1.4 of the National Fire Protection Association (NFPA 25) states a supply of spare sprinklers (never fewer than six) shall be maintained on the premises so that any sprinklers that have operated or been damaged in any way can be promptly replaced.