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Based on visual observation the facility failed to assure that the building had a complete, supervised, automatic sprinkler system installed in accordance with NFPA 13. Activation of the sprinkler system shall trigger notification of the emergency to the fire alarm system within 90 seconds, which results in protection of life and property. This deficiency has the potential to affect 8 of 8 patients.

Findings:

During the facility tour on February 5, 2020, between the hours of 7:45 a.m. to 1:45 p.m. the housekeeping closet was observed lacking pendant sprinkler protection below the suspended ceiling and above the housekeeping closet suspended ceiling a sprinkler upright within twelve inches from the underside of the roof located over all the combustible wood locations was lacking.

NFPA 13:8.1.1* The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers shall be installed throughout the premises.
(2) Sprinklers shall be located so as not to exceed the maximum protection area per sprinkler.
(3) Sprinklers shall be positioned and located so as to provide satisfactory performance with respect to activation time and distribution.
(4) Sprinklers shall be permitted to be omitted from areas specifically allowed by this standard.
(5) When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.
(6) Clearance between sprinklers and ceilings exceeding the maximums specified in this standard shall be permitted, provided that tests or calculations demonstrate comparable sensitivity and performance of the sprinklers to those installed in conformance with these sections.
(7) Furniture, such as portable wardrobe units, cabinets, trophy cases, and similar features not intended for occupancy, does not require sprinklers to be installed in them. This type of feature shall be permitted to be attached to the finished structure.

NFPA 13: 8.6.4 Deflector Position (Standard Pendent and Upright Spray Sprinklers).

NFPA 13:8.6.4.1 Distance Below Ceilings. NFPA 13:8.6.4.1.1 Unobstructed Construction.
NFPA 13:8.6.4.1.1.1 Under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm) throughout the area of coverage of the sprinkler.

Interview with the Maintenance Manager revealed the facility was not aware that the housekeeping closet and the combustible attic area were lacking sprinkler protection..

Based on visual observation the facility failed to provide corridor doors that were not closing and latching in the frame. When the doors latch a smoke resistive seal is formed to protect the room's occupants. The deficient practice had the potential to affect 8 of 8 patients.
1 of 1 corridors had doors that were deficient.

Findings:

During the facility tour on February 5, 2020, between the hours of 7:45 a.m. to 1:45 p.m. it was observed the patient room corridor doors identified as patient room 3,5,7 and 11 were not latching.


NFPA 101: 19.3.6.3.5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply:
(1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.
(2) Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved

A.19.3.6.3.5 While it is recognized that closed doors serve to maintain tenable conditions in a corridor and adjacent patient rooms, such doors, which, under normal or fire conditions, are self-closing, might create a special hazard for the personal safety of a room occupant. Such closed doors might present a problem of delay in discovery, confining fire products beyond tenable conditions.

Because it is critical for responding staff members to be able to immediately identify the specific room involved, it is recommended that approved automatic smoke detection that is interconnected with the building fire alarm be considered for rooms having doors equipped with closing devices. Such detection is permitted to be located at any approved point within the room. When activated, the detector is required to provide a warning that indicates the specific room of involvement by activation of a fire alarm annunciator, nurse call system, or any other device acceptable to the authority having jurisdiction.

In existing buildings, use of the following options reasonably ensures that patient room doors will be closed and remain closed during a fire:
(1) Doors should have positive latches, and a suitable program that trains staff to close the doors in an emergency should be established.
(2) It is the intent of the Code that no new installations of roller latches be permitted; however, repair or replacement of roller latches is not considered a new installation.
(3) Doors protecting openings to patient sleeping or treatment rooms, or spaces having a similar combustible loading, might be held closed using a closer exerting a closing force of not less than 5 lbf (22 N) on the door latch stile.

Interview with the Maintenance Manager revealed the facility was aware of the non latching patient corridor doors and is awaiting the arrival of the locksmith to install latching hardware on all the non latching patient corridor doors.

Based on visual observation the facility failed to assure that the emergency generator was maintained and tested in accordance with NFPA 110. In cases of a power outage the emergency generator powers essential life safety equipment for the facility. The deficient practice had the potential to affect 0 of 8 patients.

Findings:

During the facility tour on February 5, 2020 between the hours of 7:45 a.m. to 1:45 p.m. the 225 KW outside generator had lacked a remote manual stop with signage.

(1) The generator was not provided with a remote manual stop and remote manual signage located outside the weatherproof enclosure.

NFPA 110:5.6.5.6 All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building.

NFPA 110:5.6.5.6.1 The remote manual stop station shall be labeled.

Interview with the Maintenance Manger revealed the facility was not aware that a remote manual stop with labeling signage for emergency generators was required.