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Based on document review and staff interview, the facility fails to test and maintain their emergency light systems in accordance with NFPA 101. This deficient practice would affect all patients, visitors, and staff in 3 of 3 smoke zones. The facility has 25 certified beds and at the time of the survey the census was 8.

Findings include:

During the survey conducted on 1/14/19 the following deficiency is noted:

1. During document review at 2:39 PM, it is observed that there is the last documentation for an annual 90 minute test of the emergency lights was in November of 2017 and is past due.

Staff A was present and acknowledged the finding.

NFPA Standard: NFPA 101 2012 7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows: (1) Functional testing shall be conducted monthly, with a
minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2). (2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction. (3) Functional testing shall be conducted annually for a minimum of 11?2 hours if the emergency lighting system is battery powered. (4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3). (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

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 all patients, visitors, and staff in 3 of 3 smoke zones. The facility has 25 certified beds and at the time of the survey the census was 8.

Findings include:

During the survey conducted on 1/15/19 the following deficiencies are noted:

1. During the survey at 8:40 AM, it is observed that there is an approximate 1" unsealed penetration by conduit in the ceiling of the boiler room that would not resist the passage of smoke.
2. During the survey at 9:11 AM it is observed that there are three approximate 1" unsealed penetrations by conduit in the ceiling of the housekeeping storage room that would not resist the passage of smoke.
3. During the survey at 10:13 AM, it is observed that the door to the staff only storage room is obstructed from closing by equipment hanging on the door.
4. During the survey at 10:30 AM, it is observed that there are two approximate 3" unsealed penetrations by pipes in the front wall, above the doors, in the ambulance bay that would not resist the passage of smoke.

Staff A was present and acknowledged the findings.

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 observation and staff interview the facility fails to properly install and maintain the fire extinguishers as required by NFPA 10. The deficient practice would affect all patients, visitors, and staff in 2 of 3 smoke zones. The facility has 25 certified beds and at the time of the survey the census was 8.

Findings include:

During the survey conducted on 1/15/19 the following deficiencies are noted:

1. During the survey at 8:35 AM, it is observed that the fire extinguisher in the maintenance shop is obstructed by a welding machine.
2. During the survey at 8:43 AM, it is observed that the fire extinguisher in the boiler room is mounted higher than 5'.
3. During the survey at 9:58 AM, it is observed that the fire extinguisher in the technical closet is obstructed by equipment.

Staff A was present and acknowledged the findings.

NFPA Standard: NFPA 101 9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with
NFPA 10, Standard for Portable Fire Extinguishers. NFPA Standard: NFPA 10 2010 7.2.1.1 Fire extinguisher shall be manually inspected when initially placed in service. 7.2.1.2 Fire extinguishers and class D extinguishing agents shall be inspected either manually or by means of an electronic monitoring device / system at intervals not exceeding 31 days.
NFPA Standard: NFPA 101 9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with
NFPA 10, Standard for Portable Fire Extinguishers.

Based on observation and staff interview, the facility fails to maintain their smoke barrier walls as required by Life Safety Code NFPA 101. This deficient practice would affect approximately all patients, visitors, and staff in 2 of 3 smoke zones. The facility has 25 certified beds and at the time of the survey the census was 8.

Findings Include:

During the survey on 1/15/19 the following deficiencies are noted:

1. During the survey at 11:24 AM, it is observed that there is an unsealed penetration by IT data wire in the smoke barrier wall above the smoke barrier doors near the pharmacy.
2. During the survey at 11:40 AM, it is observed that there is an unsealed penetration by cell phone tower cable in the smoke barrier wall above the smoke barrier doors near room 101.

Staff A was present and acknowledged the findings.

NFPA Standard: NFPA 101 2012 19.3.7.3 Any required smoke barrier shall be constructed in
accordance with Section 8.5 and shall have a minimum 1?2-hour fire resistance rating, unless otherwise permitted by one of the following: (1) This requirement shall not apply where an atrium is used,
and both of the following criteria also shall apply: (a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c). (b) Not less than two separate smoke compartments shall be provided on each floor. (2)*Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier. 8.5.6.2 Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed
as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke.

Based on observation and staff interview the facility fails to properly maintain their electrical systems in accordance with NFPA 70. The deficient practice would affect no patients or visitors, and all staff in 1 of 3 smoke zones. The facility has 25 certified beds and at the time of the survey the census was 8.

Findings include:

During the survey conducted on 1/15/19 the following deficiency is noted:

1. During the survey at 9:29 AM, it is observed that the electrical panel is blocked by equipment in the rehabilitation storage closet.

Staff A was present and acknowledged the finding.

NFPA Standard: Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2

Based on document review and staff interview, the facility fails to conduct fire drills as required by Life Safety Code NFPA 101. This deficient practice would affect all patients, visitors, and staff in 3 of 3 smoke zones. The facility has 25 certified beds and at the time of the survey the census was 8.

Findings Include:

During the survey on 1/14/19 the following deficiency is noted:

1. During document review at 1:49 PM, it is observed that there is no documentation for testing the fire alarm within 24 hours of completing silent fire drills.

Staff A was present and acknowledged the finding.

NFPA Standard: NFPA 101 2012 19.7.1.4* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 19.7.1.5 Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 19.7.1.6 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. 19.7.1.7 When drills are conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

Based upon observation, document review, and staff interview the facility is not inspecting and maintaining their rated door assemblies in compliance with NFPA 80. This deficient practice could prevent the ability of the facility to properly confine smoke and prevent fire from spreading to other zones. This deficient practice would affect no patients, and all visitors and staff in 1 of 3 smoke zones. The facility has 25 certified beds and at the time of the survey the census was 8.


Findings include:

During the survey conducted on 1/15/19 the following deficiency is noted:

1. During the survey at 10:29 AM, it is observed that labels on the fire door and frame, to the ambulance bay, are painted over and cannot be read.


Staff A was present and acknowledged the finding.

NFPA Standard: NFPA 80 2010 5.2.1 Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ. 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing. 5.2.4.2 As a minimum, the following items shall be verified: (1) No open holes or breaks exist in the surfaces of either the door or frame. (2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped. (3) The door, frame, hinges, hardware, and non combustible threshold are secured, aligned, and in working order with no visible signs of damage. (4) No parts are missing or broken. (5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7 (6) The self-closing device is operational; that is, the active door completely closes when operated from the open position. (7) If a coordinator is installed, the inactive leaf closes before the active leaf. (8) Latching hardware operates and secures the door when it is in the closed position. (9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame. (10) No field modifications to the door assembly have been performed that void the label. (11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity. 3.3.95 Qualified Person. A person who, by possession of a recognized degree, certificate, professional standing, or skill, and who by knowledge, training, and experience, has demonstrated the ability to deal with the subject matter, the work, or the project.

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 all patients, visitors, and staff in 3 of 3 smoke zones. The facility has 25 certified beds and at the time of the survey the census was 8.


Findings include:

During the survey conducted on 1/14/19 the following deficiency is noted:

-- 1. During document review at 1:16 PM, it is observed that the last annual service of the piped in gas system on 5/3/18 stated the following deficiency: 1.25 need to replace reserve cylinder 6-200CF. There is no documentation that this has been corrected.

Staff A was present and acknowledged the finding.

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)

Based on staff interview and document review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice would affect all patients, visitors, and staff in 3 of 3 smoke zones. The facility has 25 certified beds and at the time of the survey the census was 8.

Findings include:

During the survey conducted on 1/14/19 the following deficiency is noted:

1. During document review at 3:47 PM, it is observed that the calculations provided show that the south generator did not exceed the 30% under load in the April and June monthly tests. The last annual load bank test on the south generator was completed in April of 2017.

Staff A was present and acknowledged the finding.

NFPA Standard: A permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available. The permanent record shall include the following: (1) The date of the maintenance report (2) Identification of the servicing personnel (3) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced (4) Testing of any repair for the time as recommended by the manufacturer. 2010 NFPA 110, 8.3.4, 8.3.4.1 NFPA 99 6.4.4.1.1.4 Inspection and Testing. Criteria, conditions, and personnel requirements shall be in accordance with 6.4.4.1.1.4(A) through 6.4.4.1.1.4(C). (A)* Test Criteria. Generator sets shall be tested 12 times a year, with testing intervals of not less than 20 days nor more than 40 days. Generator sets serving essential electrical systems shall be tested in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 8. (B) Test Conditions. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads. (C) Test Personnel. The scheduled tests shall be conducted by competent personnel to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures. NFPA 99 6.4.4.1.1.4

NFPA Standard: Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods: (1)Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer (2) Under Operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating NFPA 110 8.4.2
NFPA Standard: Diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads of not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours.