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Based upon observation, a review of records and staff interview, the facility fails to assure that a building undergoing, repair, renovation, modification, or reconstructions complies with the requirements of Chapter 18 and 19. The deficient practice increases the risk of fire or smoke spreading to other areas of the building, affecting all patients, visitors and staff in 3 of 3 smoke zones. The facility has a capacity of 18 with a census of 2 at the time of the survey.

Findings include: During the 50% construction inspection beginning at 11:00 a.m. on November 6, 2017, it is observed:

-- 1. At 11:10 a.m., a temporary corridor separating the construction zone into two spaces, leading from the emergency department to the clinic is not included in the approved plans and does not meet the requirements for one-hour separation for a construction zone.

-- 2. At 11:50 a.m., near the clinic door leading to the surgical corridor, there were three doors taped to their frames. Two doors were constructed of 1/2 inch Masonite board and one was constructed of 5/8 inch gypsum board.

-- 3. At 12:20 p.m., in the surgical corridor near x-ray, inspection of the sprinkler branch lines revealed that there are no sprinkler heads installed on any of the branch lines and that there is no smoke detection installed throughout the construction zone.

-- 4. At 12:25 p.m., in the physical therapy corridor the door connecting the clinic to the physical corridor was a 5/8 inch piece of gypsum board held up by gorilla tape to the door frame.

Construction Foreman was present and acknowledged the findings at the time of construction.

A 50-percent construction inspection conducted on November 7, 2017, identified immediate jeopardy related to the 18 bed Critical Access Hospital's failure to follow the approved plan review for the construction of the new addition. The facility failed to submit a plan for temporary egress prior to beginning the current phase of construction; failed to build proper one-hour separation between the construction and occupied areas of the facility; and were also allowing patients and visitors into the construction zone for x-rays. The construction zone was not provided with sprinkler coverage, smoke detection, suitable means of egress, or proper separation. Hot work, including welding, was occurring in the construction zone. Immediate jeopardy was identified on November 7, 2017 and although a cease and desist order was given to the construction company, the facility continued the deficient practices until November 8, 2017. At 12:30 p.m., on November 8, 2017, the facility's CEO was made aware of the potential for immediate jeopardy in a meeting with the with the construction company's Construction Manager, construction company's Superintendent, and the State Agency's Fire Protection Specialist. At that 12:30 p.m. meeting on November 8, 2017, the parties discussed various options to create a solution. On November 8, 2017, at 1:09 p.m. the facility was placed in immediate jeopardy status and placed on fire watch at the request of the Fire Marshal's Office as a result of the State Agency's Fire Protection Specialist's findings during a review where patients, visitors and employees in the building were allowed to enter a construction area without a 1-hr separation. On November 8, 2017, at approximately 4:45 p.m., the State Agency's Surveyor observed that although no patients or visitors were in the construction area, hospital employees were still in the construction areas. The employees were immediately instructed by the CEO to stop any entry into the construction zone until construction of temporary walls is complete. The immediate jeopardy was abated at 5:10 p.m. on November 8, 2017, upon receipt by the State Agency's Surveyor of a written statement from the facility's CEO assuring that use of the north hallway for any reason would not be permitted until the temporary wall is completed. At 8:29 p.m. on November 8, 2017, the Office of the State Fire Marshal received notification from the construction company's Project Manager that construction of rated separation walls had been completed. On November 9, 2017, in the afternoon, a Supervisor from the Office of the State Fire Marshal conducted a site visit at Minneola District Hospital and visually verified that all walls meet the separation requirements.

NFPA Standard: Buildings shall be permitted to be occupied during construction, repair, alterations, or additions only when required means of egress and required fire protection features are in place and continuously maintained for the portion occupied or where alternative life safety measures acceptable to the AHJ are in place. 2012 NFPA 101, 4.6.10.1

NFPA Standard: Protection shall be provided to separate an occupied portion of the structure from the area undergoing alteration, construction, or demolition operations when such operations are considered as having a higher level of hazard than the occupied portion of the building. Walls shall have at least a 1-hour fire resistance rating and openings shall have at least a 45-minute fire protection rating. Non-rated walls and openings shall be permitted when an approved automatic sprinkler system is installed. 2012 NFPA 241, 8.6.2

Based on observation and staff interview, the facility fails assure that all means of egress are protected in accordance with Chapter 7 and that all means of egress are continuously maintained free of all obstructions to full use in case of emergency. This deficient reduces the exiting capacity of the facility and increases the risk of injury, affecting all patients and any visitors or staff in 3 of 3 smoke zones. The facility has a capacity of 18 and a census of 2 at the time of the survey.

Findings include:

During a 50% construction inspection beginning at 11:00 a.m. on November 6, 2017, it is observed:

-- 1. At 11:10 a.m., a temporary corridor separating the construction zone into two spaces, leading from the emergency department to the clinic, is not included in the approved plans and does not meet the requirements for one-hour separation for a construction zone.

-- 2. At 11:25 a.m., patients and facility staff were traversing through the surgical corridor that was under construction.

-- 3. At 11:30 a.m., in the surgical corridor, the were no exit signs provided.

-- 4. At 11:50 a.m., near the clinic door leading to the surgical corridor, there were three doors taped to their frames. Two doors were constructed of 1/2 inch Masonite board and one was constructed of 5/8 inch gypsum board.

-- 5. At 12:00 p.m., in the surgical corridor, a torch was being used to solder copper pipe by a construction. Inquiry of the Construction Foreman revealed that there was no permit for hot work.

-- 6. At 12:05 p.m., in the surgical corridor, inquiry of the x-ray tech revealed that the facility was admitting patients into the x ray room.

-- 7. At 12:20 p.m., in the surgical corridor near x-ray, inspection of the sprinkler branch lines revealed that there are no sprinkler heads installed on any of the branch lines and that there is no smoke detection installed throughout the construction zone.

-- 8. At 12:25 p.m., in the physical therapy corridor, the door connecting the clinic to the physical therapy corridor was a 5/8 inch piece of gypsum board held up by gorilla tape to the door frame.

Construction Foreman was present and acknowledged the findings at the time of discovery.

A 50-percent construction inspection conducted on November 7, 2017, identified immediate jeopardy related to the 18 bed Critical Access Hospital's failure to follow the approved plan review for the construction of the new addition. The facility failed to submit a plan for temporary egress prior to beginning the current phase of construction; failed to build proper one-hour separation between the construction and occupied areas of the facility; and were also allowing patients and visitors into the construction zone for x-rays. The construction zone was not provided with sprinkler coverage, smoke detection, suitable means of egress, or proper separation. Hot work, including welding, was occurring in the construction zone. Immediate jeopardy was identified on November 7, 2017 and although a cease and desist order was given to the construction company, the facility continued the deficient practices until November 8, 2017. At 12:30 p.m., on November 8, 2017, the facility's CEO was made aware of the potential for immediate jeopardy in a meeting with the with the construction company's Construction Manager, construction company's Superintendent, and the State Agency's Fire Protection Specialist. At that 12:30 p.m. meeting on November 8, 2017, the parties discussed various options to create a solution. On November 8, 2017, at 1:09 p.m. the facility was placed in immediate jeopardy status and placed on fire watch at the request of the Fire Marshal's Office as a result of the State Agency's Fire Protection Specialist's findings during a review where patients, visitors and employees in the building were allowed to enter a construction area without a 1-hr separation. On November 8, 2017, at approximately 4:45 p.m., the State Agency's Surveyor observed that although no patients or visitors were in the construction area, hospital employees were still in the construction areas. The employees were immediately instructed by the CEO to stop any entry into the construction zone until construction of temporary walls is complete. The immediate jeopardy was abated at 5:10 p.m. on November 8, 2017, upon receipt by the State Agency's Surveyor of a written statement from the facility's CEO assuring that use of the north hallway for any reason would not be permitted until the temporary wall is completed. At 8:29 p.m. on November 8, 2017, the Office of the State Fire Marshal received notification from the construction company's Project Manager that construction of rated separation walls had been completed. On November 9, 2017, in the afternoon, a Supervisor from the Office of the State Fire Marshal conducted a site visit at Minneola District Hospital and visually verified that all walls meet the separation requirements.

NFPA Standard: Buildings shall be permitted to be occupied during construction, repair, alterations, or additions only when required means of egress and required fire protection features are in place and continuously maintained for the portion occupied or where alternative life safety measures acceptable to the AHJ are in place. 2012 NFPA 101, 4.6.10.1

NFPA Standard: Protection shall be provided to separate an occupied portion of the structure from the area undergoing alteration, construction, or demolition operations when such operations are considered as having a higher level of hazard than the occupied portion of the building. Walls shall have at least a 1-hour fire resistance rating and openings shall have at least a 45-minute fire protection rating. Non-rated walls and openings shall be permitted when an approved automatic sprinkler system is installed. 2012 NFPA 241, 8.6.2

Based on observation and staff interview the facility fails to assure that hazardous areas are protected in accordance with 8.7.1. This deficient practice increases the risk of fire or smoke spreading to other areas of the building would allow for the spread of smoke and fire to travel into the adjacent area, affecting all patients, visitors and staff in 3 of 3 smoke zones. The facility has a capacity of 18 and a census of 2 at the time of this survey.

Findings include:

During the 50% construction project inspection for phase 3 beginning at 11:00 a.m. on November 6, 2017, it is observed:

-- 1. At 11:10 a.m., a temporary corridor separating the construction zone into two spaces, leading from the emergency department to the clinic, does not meet the requirements for one-hour separation for a construction zone.

-- 2. At 11:25 a.m., patients and facility staff were traversing through the surgical corridor that was under construction.

-- 3. At 11:50 a.m., near the clinic door leading to the surgical corridor, there were three doors taped to their frames. Two doors were constructed of 1/2 in Masonite board and one was constructed of 5/8 in gypsum board.

-- 4. At 12:00 p.m., in the surgical corridor, a torch was being used to solder copper pipe by a construction. Inquiry of the Construction Foreman revealed that there was no permit for hot work.

-- 5. At 12:05 p.m., in the surgical corridor, inquiry of the x-ray tech revealed that the facility was admitting patients into the x ray room.

-- 6. At 12:20 p.m., in the surgical corridor, inspection of the sprinkler branch lines revealed that the there are no sprinkler heads installed on any of the branch lines and that there is no smoke detection installed throughout the construction zone.

Construction Foreman was present and acknowledged the findings at the time of discovery.

A 50-percent construction inspection conducted on November 7, 2017, identified immediate jeopardy related to the 18 bed Critical Access Hospital's failure to follow the approved plan review for the construction of the new addition. The facility failed to submit a plan for temporary egress prior to beginning the current phase of construction; failed to build proper one-hour separation between the construction and occupied areas of the facility; and were also allowing patients and visitors into the construction zone for x-rays. The construction zone was not provided with sprinkler coverage, smoke detection, suitable means of egress, or proper separation. Hot work, including welding, was occurring in the construction zone. Immediate jeopardy was identified on November 7, 2017 and although a cease and desist order was given to the construction company, the facility continued the deficient practices until November 8, 2017. At 12:30 p.m., on November 8, 2017, the facility's CEO was made aware of the potential for immediate jeopardy in a meeting with the with the construction company's Construction Manager, construction company's Superintendent, and the State Agency's Fire Protection Specialist. At that 12:30 p.m. meeting on November 8, 2017, the parties discussed various options to create a solution. On November 8, 2017, at 1:09 p.m. the facility was placed in immediate jeopardy status and placed on fire watch at the request of the Fire Marshal's Office as a result of the State Agency's Fire Protection Specialist's findings during a review where patients, visitors and employees in the building were allowed to enter a construction area without a 1-hr separation. On November 8, 2017, at approximately 4:45 p.m., the State Agency's Surveyor observed that although no patients or visitors were in the construction area, hospital employees were still in the construction areas. The employees were immediately instructed by the CEO to stop any entry into the construction zone until construction of temporary walls is complete. The immediate jeopardy was abated at 5:10 p.m. on November 8, 2017, upon receipt by the State Agency's Surveyor of a written statement from the facility's CEO assuring that use of the north hallway for any reason would not be permitted until the temporary wall is completed. At 8:29 p.m. on November 8, 2017, the Office of the State Fire Marshal received notification from the construction company's Project Manager that construction of rated separation walls had been completed. On November 9, 2017, in the afternoon, a Supervisor from the Office of the State Fire Marshal conducted a site visit at Minneola District Hospital and visually verified that all walls meet the separation requirements.

NFPA Standard: Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. 2012 NFPA 101, 19.3.2.1