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Based upon a review of records and staff interview, the facility fails to assure that emergency lighting of at least 1-1/2-hour duration is automatically provided in accordance with 7.9. The deficient practice could result in a failure to provide illumination in the event of a power failure. This deficient practice can affect all patients, visitors and staff in 2 of 4 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 02/12/2019, the following deficiency is noted:


1.) At approximately 03:14 PM, In the Nurse's station medication prep area you can switch off the lights preventing the room from being illuminated during an emergency.

2.) At approximately 03:26 PM, In the ER medication prep area you can switch off the lights preventing the room from being illuminated during an emergency.


Staff A was present and acknowledged the finding.


NFPA 99 2012 edition:
NFPA Standard: 6.4.2.2.4.2 The critical branch shall supply power for task illumination,
fixed equipment, select receptacles, and select power
circuits serving the following areas and functions related to patient
care:
(1) Critical care areas that utilize anesthetizing gases, task illumination,
select receptacles, and fixed equipment
(2) Isolated power systems in special environments
(3) Task illumination and select receptacles in the following:
(a) Patient care rooms, including infant nurseries, selected
acute nursing areas, psychiatric bed areas (omit receptacles),
and ward treatment rooms
(b) Medication preparation areas
(c) Pharmacy dispensing areas
(d) Nurses' stations (unless adequately lighted by corridor
luminaires)
(4) Additional specialized patient care task illumination and
receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7)*Telephone equipment rooms and closets
(8) Task illumination, select receptacles, and select power circuits
for the following areas:
(a) General care beds with at least one duplex receptacle
per patient bedroom, and task illumination as required
by the governing body of the health care facility
(b) Angiographic labs
(c) Cardiac catheterization labs
(d) Coronary care units
(e) Hemodialysis rooms or areas
(f) Emergency room treatment areas (select)
(g) Human physiology labs
(h) Intensive care units
(i) Postoperative recovery rooms (select)

Based upon observation and staff interview, the facility fails to assure that Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10. The deficient practice could result in the inability to reach a fire extinguisher and extinguish a fire, affecting no residents and any visitors or staff in 2 of 4 smoke zones. The facility has a capacity of 25 with a census of 3 at the time of this survey.

Findings include:

During the tour conducted on 2/12/2019, the following is observed:

1.) At approximately 2:52 PM, In the lab the fire extinguisher is blocked by multiple boxes.

2.) At approximately 3:03 PM, In the business office the fire extinguisher next to the copy machine is blocked by a box.

Staff A was present and acknowledged the finding.


NFPA Standard: Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. In no case shall the clearance between the bottom of the hand portable fire extinguisher and the floor be less than 4 in. (102 mm). 2010 NFPA 10 6.1.3.8

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 can affect all patients, visitors and staff in 1 of 4 smoke zones. The facility has a capacity of 25 with a census of 3 at the time of this survey.

Findings Include:

During the tour conducted on 2/12/2019, the following is observed:

1.) At approximately 2:59 PM, in the west hall mechanical room there are multiple penetrations.

Staff A was present and acknowledged the finding.

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.