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Based on observation, operational testing and interview, the facility failed to ensure that smoke barrier doors would fully self-close. Failure of smoke barrier doors to close could allow by-products of combustion to pass between smoke compartments, hindering the ability to defend in place during a fire or other emergency. This deficient practice affected all patients, staff and visitors on the date of the survey. The facility is licensed for 8 hospital beds and had a census of 3 on the day of the survey.

Findings include:

During the facility tour conducted on October 12, 2016 from approximately 10:00 AM to 11:00 AM, observation and operational testing of the cross-corridor doors in the smoke barrier revealed that 1 of 2 would not fully self-close and latch. Interview of the Maintenance Supervisor revealed he was not aware the door was not fully closing as designed.

Actual NFPA standard:

18.3.7.6*
Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 18.2.2.2.6.

8.3.4 Doors.
8.3.4.1*
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 observation and operational testing, the facility failed to ensure hazardous areas which open to the corridor were protected with self-closing doors. Failure to protect hazardous areas with self-closing doors could allow byproducts of combustion to pass into corridors, affecting egress of patients during a fire. This deficient practice affected all patients, staff and visitors on the day of the survey. The facility is licensed for 8 hospital beds and had a census of 3 on the day of the survey.

Findings include:

During the facility tour conducted on October 12, 2016 from approximately 10:00 AM to 11:00 AM, observation and operational testing of the Laundry Room door revealed it would not fully self-close when activated.

Actual NFPA standard:

3.3.13.2 Area, Hazardous.
An area of a structure or building that poses a degree of hazard greater than that normal to the general occupancy of the building or structure, such as areas used for the storage or use of combustibles or flammables; toxic, noxious, or corrosive materials; or heat-producing appliances.

7.2.1.8 Self-Closing Devices.
7.2.1.8.1*
A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

Based on record review, observation and interview, the facility failed to ensure fire suppression systems were maintained in accordance with NFPA 25. Failure to conduct required testing and ensure adequate number of replacement sprinkler pendants are available could result in a lack of system performance during a fire. This deficient practice affected all patients, staff and visitors on the date of the survey. The facility is licensed for 8 hospital beds and had a census of 3 on the day of the survey.

Findings include:

1) During review of provided facility fire suppression system inspection records conducted on October 12, 2016 from approximately 8:30 AM to 9:00 AM, no record was provided indicating a quarterly inspection was performed during the third quarter of 2016. Interview of the Maintenance Supervisor revealed he was not aware the third quarter inspection had been missed.

2) During the facility tour conducted on October 12, 2016 from approximately 1:00 PM to 2:00 PM, observation of the spare sprinkler pendant box revealed only five (5) spare sprinklers.

Actual NFPA standard:

Finding 1
NFPA 25

2-3 Testing.
2-3.1 Sprinklers.
2-3.3* Alarm Devices.
Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

Finding 2
NFPA 25

2-4 Maintenance.
2-4.1 Sprinklers.
2-4.1.4
A supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. The cabinet shall be so located that it will not be exposed to moisture, dust, corrosion, or a temperature exceeding 100°F (38°C).
Exception: Where dry sprinklers of different lengths are installed, spare dry sprinklers shall not be required, provided that a means of returning the system to service is furnished.

2-4.1.5
The stock of spare sprinklers shall be as follows:
(a) For protected facilities having under 300 sprinklers -no fewer than 6 sprinklers
(b) For protected facilities having 300 to 1000 sprinklers -no fewer than 12 sprinklers
(c) For protected facilities having over 1000 sprinklers -no fewer than 24 sprinklers

Based on observation, the facility failed to maintain safe electrical installations by eliminating exposure to energized conductors. Failure to provide protection against accidental contact with exposed wiring could result in electrocution or fires by arcing. This deficient practice affected all patients, staff and visitors on the date of the survey. The facility is licensed for 8 beds and had a census of 3 on the day of the survey.

Findings include:

1) During the facility tour conducted on October 12, 2016 from approximately 10:00 AM to 12:00 PM, observation of the upper floor mechanical space revealed four (4) electrical junction boxes with exposed wiring, approximately four inches square in size. In addition, further observation of the fire suppression riser room revealed one (1) junction box with exposed wiring approximately four inches square.

2) During the facility tour conducted on October 12, 2016 from approximately 2:00 PM to 3:00 PM, an above the ceiling inspection outside room 136 revealed two (2) electrical junction boxes with exposed wiring, approximately four inches square.

Actual NFPA standard:

NFPA 70
110.12 Mechanical Execution of Work.
Electrical equipment shall be installed in a neat and workmanlike manner.
(A) Unused Openings. Unused cable or raceway openings in boxes, raceways, auxiliary gutters, cabinets, cutout boxes, meter socket enclosures, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment. Where metallic plugs or plates are used with nonmetallic enclosures, they shall be recessed at least 6 mm (¼ in.) from the outer surface of the enclosure.
(B) Subsurface Enclosures. Conductors shall be racked to provide ready and safe access in underground and subsurface enclosures into which persons enter for installation and maintenance.
(C) Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasives, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating.

314.17 Conductors Entering Boxes, Conduit Bodies, or Fittings.
Conductors entering boxes, conduit bodies, or fittings shall be protected from abrasion and shall comply with 314.17(A) through (D).
(A) Openings to Be Closed. Openings through which conductors enter shall be adequately closed......