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Based on observation and staff interview the facility fails to properly protect and maintain their hazardous areas in accordance with NFPA 101. The deficient practice would affect no patients, and all visitors and staff in 2 of 3 smoke zones. The facility has a capacity of 25 with a census of 3 at the time of the survey.

Findings include:

During the survey conducted on 5/26/17 the following deficiencies are noted:

1. During the survey at 11:27 AM it is observed that the rated door to the L wing laundry rooms did not fully close and latch when tested.
2. During the survey at 11:45 AM it is observed that the door to the laboratory is not equipped with a self-closing device.

Maintenance staff was present and acknowledged the door that did not completely close and latch, and the needed closing device to the laboratory.

NFPA Standard: NFPA 101 19.3.2.1.3 The doors shall be self-closing or automatic-closing. 19.3.2.1.5 Hazardous areas shall include, but shall not be restricted to, the following: (1) Boiler and fuel-fired heater rooms (2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops (4) Repair shops (5) Rooms with soiled linen in volume exceeding 64 gal (242 L) (6) Rooms with collected trash in volume exceeding 64 gal (242 L) (7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction (8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard 19.3.2.1.2* Where the sprinkler option of 19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4.

Based on staff interview and document review, the facility does not have a proper fire watch plan and procedure in accordance with NFPA 101. The deficient practice would affect all patients, visitors, and staff in 3 of 3 smoke zones. The facility has a capacity of 25 with a census of 3 at the time of the survey.

Findings include:

During the survey conducted on 5/26/17 the following deficiency is noted:

1. During document review at 10:05 AM it is observed that the facility does not have a complete fire watch policy regarding the procedures to be taken in the event that the fire alarm was out of service for more than 4 hours in a 24 hour period. The policy lacked the contact information for the state fire marshal office.

Maintenance staff was present and acknowledged the incomplete fire watch policy.

NFPA Standard: NFPA 101 2012 9.6.1.6* Where a required fire alarm system is out of service
for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated, or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

Based on staff interview and document review, the facility does not have a proper fire watch plan and procedure in accordance with NFPA 25. The deficient practice would affect all patients, visitors, and staff in 3 of 3 smoke zones. The facility has a capacity of 25 with a census of 3 at the time of the survey.

Findings include:

During the survey conducted on 5/26/17 the following deficiency is noted:

1. During document review at 10:05 AM, it is observed that the facility does not have a complete Fire Watch plan and procedure to be taken in the event sprinkler system was out of service for more than 10 hours in a 24 hour period. The policy lacked the contact information for the state fire marshal office, and did not state any contact information for the Insurance company or property owner in their policy.

Maintenance staff was present and acknowledged the incomplete Fire Watch Plan and Procedure.

NFPA Standard: 15.5.2 Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented: (1) The extent and expected duration of the impairment have been determined. (2) The areas or buildings involved have been inspected and the increased risks determined. (3) Recommendations have been submitted to management or the property owner/manager. Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following: (a) Evacuation of the building or portion of the building affected by the system out of service (b)*An approved fire watch (c)*Establishment of a temporary water supply (d)*Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire (4) The fire department has been notified. (5) The insurance carrier, the alarm company, property owner/ manager, and other authorities having jurisdiction have been notified. (6) The supervisors in the areas to be affected have been notified. (7) A tag impairment system has been implemented. (See Section 15.3.) (8) All necessary tools and materials have been assembled on the impairment site. NFPA 25 15.5.2

Based upon observation and staff interview, the facility fails to properly inspect and maintain their boilers in accordance with the state of Kansas. This deficient practice reduces the reliability of the boilers, affecting no patients or visitors, and all staff in 1 of 3 smoke zones. The facility has a capacity of 25 with a census of 3 at the time of the survey.

Findings Include:

During the survey conducted on 5/26/17 the following deficiencies are noted:

1. There is no boiler certificate or service paperwork available at the time of survey for boiler KS 64132 in the boiler room.

Staff A was present and acknowledged the needed certificate for the boiler.

Based upon document review and staff interview, the facility fails to properly maintain their gas and vacuum piped systems. The deficient practice reduces the reliability of the medical gas systems, affecting no patients, and all visitors and staff in 1 of 3 smoke zones. The facility has a capacity of 25 with a census of 3 at the time of this survey.

Findings include:

During the survey conducted on 5/26/17 the following deficiencies are noted:

-- 1. During document review at 10:53 AM it is observed that the last annual service report for the piped gas system stated the following deficiency: ER1, 2, OR 1: No alarm installed in this zone; need to install with sensors on patient side.

Maintenance Staff was present and acknowledged the deficiency stated on the service report.

NFPA Standard: Medical gas, vacuum, WAGD, or support gas systems have documented maintenance programs. The program includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets. Inspection and maintenance schedules are established through risk assessment considering manufacturer recommendations. Inspection procedures and testing methods are established through risk assessment. Persons maintaining systems are qualified as demonstrated by training and certification or credentialing to the requirements of AASE 6030 or 6040. 5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14, 5.3.13.4.2 (NFPA 99)