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Based on observation and interview, the facility failed to provide a smoke resistant enclosure around hazardous areas to separate them from the rest of the building. The deficient practice would allow smoke, gasses and fire to spread into the exit corridors. The facility census was 44 patients.

Findings are:
Observation on 12-4-17 between 1:42 pm and 2:11 pm revealed:
1. There was an unsealed penetration in the ceiling of IT Room 2314.
2. The door to the Clean DME Room 2322, which was equipped with a self-closing device, was obstructed by a crash cart. The crash cart prevented the door from self-closing.
3. The double doors to Mechanical Room 0158, which were equipped with self-closing devices, failed to close and latch within the door frame.

During an interview on 12-4-17 between 1:42 pm and 2:11 pm, Maintenance Manager A confirmed the findings.

Based on observation and interview, the facility failed to ensure the audible / visual fire alarm devices were not obstructed. This deficient practice did not provide visual fire alarm notification to occupants. The facility census was 44 patients.

Findings are:
Observations on 12-4-17 at 12:25 pm revealed, the audible / visual device in Room 2290B was obstructed by boxes.

During an interview on 12-4-17 at 12:25 pm, Maintenance Manager A confirmed the items obstructing the audible / visual device.

Based on observation and interview, the facility failed to maintain sprinkler components free of obstructions, failed to provide required sprinkler components, and allowed non-sprinkler components to be attached to on sprinkler piping in the basement level. This deficient practice increased the potential for damage to the sprinkler piping and could obstruct the spray pattern of sprinkler heads resulting in a larger fire that could spread outside of the room of origin. The deficient practice had the potential to affect all residents. The facility census was 44 patients.

Findings are:
Observation on 12-4-17 at 12:08 pm and 2:40 pm revealed:
1. There was an obstruction to the sprinkler head in Storage Room 2290B.
2. There was a missing escutcheon or the sprinkler head in the Housekeeping Room across from the Employee Break Room.
3. A communication wire was attached to the sprinkler pipe in the basement trash/soiled linen discharge room.

During an interview on 12-4-17 at 12:08 pm and 2:40 pm, Maintenance Manager A confirmed the findings.

Based on observation and interview, the facility failed to ensure that the corridor room doors would resist the passage of smoke. This deficient practice would not prevent the spread of fire and smoke within the exit corridors. The facility census was 44 patients.

Findings are:
Observation on 12-4-17 at 1:35 pm revealed, the door to Patient Room 230 was held open with a trash can. When the trash can was removed, the door closed.

During an interview on 12-4-17 at 1:35 pm, Maintenance Manager A confirmed the trash can held open the door.

NFPA Standards:
2012 NFPA 101, 19.3.6.3.1*
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) 1 3/4 in. (44 mm) thick, solid-bonded core wood
(2) Material that resists fire for a minimum of 20 minutes
19.3.6.3.2
The requirements of 19.3.6.3.1 shall not apply where otherwise permitted by either of the following:
(1) Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials shall not be required to comply with 19.3.6.3.1.

Based on observation and staff interviews, the facility did not ensure that corridor smoke separation doors would resist the passage of smoke from one smoke compartment to another. This deficient practice would not prevent the spread of fire and smoke between smoke compartments. This facility census was 44 patients.

Findings are:
Observation on 12-4-17 at 12:38 pm revealed, the north smoke door next to the Education Room was equipped with latching device. When the doors closed, the latch did not operate resulting is a gap between the doors. The gap would allow smoke to pass between smoke compartments.

During interview on 12-4-17 at 12:38 pm, Maintenance Manager A confirmed the smoke separation doors were not smoke tight.

Based on observation and interview, the facility allowed storage to obstruct access to the electrical panels. This deficient practice could cause a delay and injury when turning off the power during an electrical issue emergency. The facility census was 44 patients.

Findings are:
Observations on 12-4-17 at 12:18 pm revealed, a three foot by two foot mobile maintenance work cart was stored in front of three electrical panels in Electrical Room 2272. The work cart encroached into the required 3 foot minimum clearance in front of electrical panels.

During an interview on 12-4-17 at 12:18 pm, Maintenance Manager A confirmed the cart stored in front of the electrical panel boxes.

NFPA Standard:
2011 NFPA 70, 110.26
Sufficient access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment.

Based on observation and interview the facility failed to assure that the fire-rated door for the trash chute was not obstructed. This deficient practice had the potential to spread smoke, gasses and fire outside the room. The facility census was 44 patients.

Findings are:
Observations on 12-4-17 at 12:03 pm revealed a trash bag was obstructing the fire-rated trash chute door and keeping it from closing.

During an interview on 12-4-17 at 12:03 pm, Maintenance Manager A confirmed the rated trash chute door was obstructed by a plastic trash bag.

Based on observation and staff interview, the facility failed to segregate full oxygen cylinders from empty oxygen cylinders. The deficient practice could cause confusion when choosing tanks in an emergency resulting in an empty cylinder being chosen when a full one was required. The facility census was 44 patients.

Findings are:
Observation on 12-4-17 at 11:12 am revealed, the Oxygen storage rooms contained multiple size "E" oxygen cylinders were not physically separated from the full ones.

During an interview on 12-4-17 at 11:12 am, Maintenance Manager A confirmed the findings.