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Based on observation and staff interview the facility failed to install manual fire alarm boxes near each required exit. The facility census was 8.

1. Observation on 10/4/22, during the facility tour, showed the exit that serves the South hall did not have a manual fire alarm box at or in the path of egress of the exit. Observation showed the exit could possibly serve patient's, staff and visitors in an emergency.

During an interview on 10/4/22 at 10:52 A.M., the Director of Environmental Services said that the exit did not have a pull station.

The National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, section 9.6.2.3 states,

"A manual fire alarm box shall be provided as follows, unless modified by another section of this code:

(1) For new alarm system installations, the manual fire alarm box shall be located within 60 in. (1525 mm) of exit doorways.

(2) For existing alarm system installations, the manual fire alarm box either shall be provided in the natural access path near each required exit or within 60 in. (1525 mm) of exit doorways."

Based on observation and facility staff interview, facility staff failed to ensure the building sprinkler system met NFPA 13, Standard For The Installation Of Sprinkler Systems, 2010 edition installation requirements. The facility census was 8.

Observation on 10/4/22, during the facility tour, showed the following:

1. Observation of sterilizer room showed a sprinkler sprig extending five feet, seven inches, without lateral support bracing.


During an interview on 10/4/22 at 10:00 A.M., the Director of Environmental Services confirmed the observation.

NFPA 13, 2010 edition, section 9.2.3.7

9.2.3.7 Sprigs. Sprigs 4 ft (1.2 m) or longer shall be restrained
against lateral movement.

Based on observation and facility staff interview, the facility staff failed to vent heating equipment according to NFPA 90B, Standard for the Installation of Warm Heating and Air-Conditioning and Ventilating Systems, 2012 edition and NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems, 2012 edition. The census was 8.

Observation on 10/4/22, during the building tour, showed an electric dryer in the sleep lab laundry room. Observation showed the dryer vented to a lint trap installed on the floor of the room. Observation showed the dryer vent did not vent to the exterior of the building.

During an interview on 10/4/22 at 10:24 A.M., the Director of Environmental Services confirmed the observation.

NFPA 101, 2012 edition, Section 19.5.2 states:

"19.5.2 Heating, Ventilating, and Air-Conditioning.
19.5.2.1 Heating, ventilating, and air-conditioning shall comply
with the provisions of Section 9.2 and shall be installed in
accordance with the manufacturer ' s specifications, unless otherwise
modified by 19.5.2.2."

9.2 Heating, Ventilating, and Air-Conditioning.
9.2.1 Air-Conditioning, Heating, Ventilating Ductwork, and
Related Equipment. Air-conditioning, heating, ventilating
ductwork, and related equipment shall be in accordance with
NFPA 90A, Standard for the Installation of Air-Conditioning and
Ventilating Systems, or NFPA 90B, Standard for the Installation of
Warm Air Heating and Air-Conditioning Systems, as applicable, unless
such installations are approved existing installations,
which shall be permitted to be continued in service.

Refer to NFPA 90A, Standard for the Installation of Air-Conditioning and
Ventilating Systems, 2012 edition, Section 4.2.4 thru 4.2.4.2 and Section 4.3.3.1 for additional information.

Based on staff interview and record review, facility staff failed to conduct fire drills for the night shift. This deficient practice has the potential to effect all facility residents. Failure to hold drills could effect facility staff response in a fire or other emergency. The facility census was 8..

1. Record review on 10/4/22 of the facility fire drill records, showed the following fire drills were not conducted:

- the last four quarterly night shift fire drills.

During an interview on 10/4/22 at 12:08 P.M., the Director if Environmental Services said facility staff did not conduct night shift fire drills.

The National Fire Protection Association 101 Life Safety Code, 2012 edition, Section 19.7.1 states:

19.7.1 Evacuation and Relocation Plan and Fire Drills.

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.