HospitalInspections.org

Based on observation and interview, this facility failed to provide a firewall with a two-hour fire rating between the nonsprinklered hospital and the sprinklered hospital portions of the facility. In addition the doors failed to close and latch between the Medical Clinic and the Hospital. This deficient practice affects all occupants including staff, visitors and residents. This facility has a capacity of 21 and a census of 5 patients.


Findings are:

1. Observation on 6/6/11 at 11:12 am revealed an unsealed hole in the two hour wall across from Room 6, leaving unfilled gaps that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone.

2. Observation on 6/6/11 at 11:24 am revealed the fire doors in the two hour wall between the Medical Clinic and the Hospital failed to close and latch.
All observations were confirmed by Maintenance A at the times of the observations.
NFPA Standard: Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition. Communicating openings in the fire barriers shall be permitted only in corridors and protected by approved self-closing fire doors. 2000 NFPA 101, 18/19.1.1.4.1 and 18/19.1.1.4.2

Based on observation and interview the facility failed to maintain all corridor walls to the roof deck above and to seal all penetrations above the suspended ceiling. This deficient practice affects all smoke compartments in the new building. The facility has a capacity of 21 and a census of 5.
Findings are:
During tour of the new building on 6/6/11 from approximately 11:30 am through 3:00 pm revealed:
The corridor walls were observed above the ceiling in a random area of the new building. The corridor walls were observed to have unsealed penetrations and holes throughout. Examination of the suspended ceiling revealed the installation of canned ceiling lights which failed to be smoke resisting eliminating the ceiling as a smoke resisting barrier. Light from canned lights in the area by the CT area could be seen from the exit corridor above the ceiling.

Maintenance A confirmed the failure of the corridor walls to be complete and the failure of the canned lights to be smoke resisting.
NFPA Standard: Corridor walls shall form a barrier to limit the transfer of smoke. Such walls shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke. No fire resistance rating is required for corridor walls. NFPA 101 18.3.6.2

Based on observation and staff interview, the facility failed to ensure that doors to patient rooms, offices and other ancillary areas are free of impediments that would prevent the doors from being closed or that the doors are provided with suitable hardware that keeps the doors shut tightly into their frames. This deficient practice affects occupants in two of two smoke zones, as the doors would not prevent the spread of fire and smoke. This facility has a capacity of 21 and a census of 5 patients.
Findings are:

1. Observation on 6/6/11 at 10:50 am revealed the failure of the corridor doors to room 7 and room 10 to close and latch when tested.

2. Observation on 6/6/11 at 11:25 am and again at 12:30 pm revealed the corridor door to Room 115 blocked in the open position by a scale.

3. Observation on 6/6/11 at 11:28 am revealed the failure of the corridor door to Room 108 to close and latch when tested.

4. Observation on 6/6/11 at 12:31 pm revealed a baby cart and equipment blocking open the corridor door to Room 111.

All observations were confirmed by Maintenance A at the times of the observations.
NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors shall be provided with positive latching hardware. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Based on observation and interview, this facility failed to ensure that all the smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone. This deficient practice affects all occupants of the building, including staff, visitors and patient. This facility has a capacity of 21 with a census of 5.

Findings are:

Observations throughout the walk though of the new building on 6/6/11 from approximately 11:30 through 3:00 pm revealed the failure of all the smoke separation walls to be complete without unsealed penetrations, holes or open ended conduits. This included unsealed holes in the smoke separation by the new nurses ' station and the smoke separation by the Laboratory.

Maintenance A confirmed the failure of the smoke separation walls to be complete and sealed at each of the observations.

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1

Based on observation and record review, the facility failed to ensure that hazardous areas are separated from other areas by partitions and self-closing doors to ensure a one-hour fire-resistance rating. This deficient practice affects all occupants in one smoke zone, where the ceiling would not stop the spread of fire and smoke, in the event of a fire. This facility has a capacity of 54 and a census of 39 residents.
Findings are:
1. Observation on 6/6/11 at 1:30 pm revealed unsealed penetrations around conduits and brackets in the walls of the Electrical panel room by Radiology.

2. Observation on 6/6/11 at 1:48 pm revealed the self-closure to the Housekeeping storage room door contained a manual hold open device. The hold open failed to be connected to the fire alarm for self-closing in and emergency.

All observations were confirmed by Maintenance A at the times of the observations.
NFPA Standard: Any hazardous area shall be protected in accordance with Section 8.4. The areas described in Table 18.3.2.1 shall be protected as indicated. NFPA 101 18.3.2.1

Based on observation, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected 4 of 5 patients and staff. This facility has a capacity of 21 and a census of 5 patients.
Findings are:

1. Observation on 6/6/11 at 10:47 am revealed the corridor door to the light bulb storage room contained a large louver. The louver could allow heated gases and fire to penetrate into the exiting corridor in a fire situation. This room contained combustible storage. In addition the door failed to have a self-closure installed.

2. Observation on 6/6/11 at 11:01 am revealed the Janitors Closet by Room 4 contained unsealed holes in the wall.

3. Observation on 6/6/11 at 11:05 am revealed the Vending Supply storage room failed to have a self-closure installed on the door. The door also contained an unsealed hole around the door knob. In addition this room contained a hole in the plaster wall of approximately 9 inches by 11 inches with abandoned copper tubing sticking out of the hole.

4. Observation on 6/6/11 at 11:22 am revealed the old Nursery being used for combustible storage. The corridor door to this room failed to have a self-closure installed on the door.

5. Observation on 6/6/11 at 11:37 am revealed the failure of the corridor door to the Soiled Utility to close and latch.
All observations were confirmed by Maintenance A at the times of the observations.
NFPA Standard: Hazardous areas without sprinkler protection require one-hour fire resistance rating construction and doors shall be 3/4 hour fire rated with self-closers and positive latches. 2000 NFPA 101, 19.3.2.1

Based on observation, the facility failed to provide exit access from an area without the use of a special tool or knowledge from the egress side. The deficient practice affected the Clinic and the basement area. The facility has a capacity of 21 and at the time of the survey the census was 5.
Findings are:

1. Observation on 6/6/11 at 11:15 am revealed slide bolt locks on the outside of the exit from the Clinic break room into the Hospital. In addition the exit door from the basement contained a slide bolt lock on the corridor side of the door. Interview with Maintenance A at this time confirmed the slide bolt lock and that no one would be able to exit should the slide bolt be engaged.

2. Observation on 6/6/11 at 2:21 pm revealed the door marked with an exit sign from the old Surgery corridor led into a garage used for storage. The way to the exit door failed to have a protected and separated corridor to the exit door to the exterior of the garage.

All observations were confirmed by Maintenance A at the times of the observations.
NFPA Standard: Exits and exit access shall be located and arranged so that exits are readily accessible at all times. 2000 NFPA 101, 7.5.1.1NFPA Standard: Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1
NFPA Standard: A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 inches and not more than 48 inches above the finished floor. Doors shall be operable with not more than one releasing operation. 2000 NFPA 101, 7.2.1.5.4

Based on observation, documentation review and interview, the facility failed to provide emergency lighting of at least 1?-hour duration at the nurse ' s medication preparation area, as required by NFPA 99. In addition the facility failed to provide documentation of 1 ? hour testing of any battery emergency lighting in the facility. The deficient practice could affect all 5 patients, staff and visitors of the facility. The facility has a capacity of 21 with a census of 5 patients.
Findings are:

1. Documentation review on 5/31/11 revealed the lack of documentation for the 1 ? hour testing of any battery emergency lights installed in the facility. Interview with Maintenance A on 5/31/11 at 3:16 pm confirmed the lack of any documentation.

2. Interview with Maintenance A on 6/6/11 at 3:00 pm revealed Maintenance A was unaware if any emergency lighting was installed on the exterior of the building or if lighting on the exterior to a public way was connected to the emergency generators.

3. Observation on 6/6/11 at 1:04 pm revealed the lights in the new nurses ' station medication room were switchable leaving the entire room in darkness. Interview with Maintenance A at this time revealed he/she was unaware if the lights in the new nurses ' station medication room were on the emergency generator for task illumination in the event of a power failure.
NFPA Standard: Emergency illumination shall be provided for not less than 11/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 foot-candle. 2000 NFPA 101, 7.9.2.
NFPA Standard: The emergency lighting system shall be arranged to provide the required illumination automatically in the event of the interruption of normal lighting, opening of a circuit breaker, or a manual act, including accidental opening of a switch controlling normal lighting facilities. 2000 NFPA 101, 7.9.2.2
NFPA Standard: Task illumination required at medication preparation areas. 1999 NFPA 99, 3-4.2.1, 3-5.2.1, 3-6.2.1

Based upon observation, record review and interview, the facility failed to hold fire drills under varied conditions at different times of the day for five of five quarters reviewed. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This facility has a capacity of 21 and a census of 5 patients.
Findings are:
1. Review of fire drill documentation on 5/31/11 revealed all Evening shift fire drills were conducted within 8 minutes of 3:00 pm. Interview with Maintenance A on 5/31/11 at 3:48 pm confirmed more than one shift of employees were participating in the Evening shift fire drills.

2. Review of fire drill documentation on 5/31/11 revealed three Day shift fire drills were conducted within 10 minutes of 2:15 pm. Two reviewed Day shift fire drills were conducted within three minutes of 10:55 am.

3. Interview with Maintenance A, and record review on 6/6/11 at 3:48pm revealed the fire drills were planned in the safety committee and assigned to a department of the hospital for conducting the fire drill. The drill failed to be an unannounced for the department involved in the fire drill with it being assigned to that department. No one individual was responsible for all the fire drills.

4. Review of the fire alarm activation report on 6/8/11 failed to verify the fire alarm being sounded on the day before or the day after a Night shift drill. Interview with Maintenance A on 5/31/11 at 3:48 pm revealed Maintenance A was unaware of the requirement for the sounding of the fire alarm the day after or the day before when a coded announcement is used for the Night shift fire drills.

NFPA Standard: The proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy ' s fire safety plan. 2000 NFPA 101, 19.7.2.1

Based on interview and record review, the facility failed to maintain and test a complete automatic sprinkler system with quarterly testing of water flow, supervisory and pressure switch devices. In addition the facility failed to install a ceiling for the type of sprinkler coverage in the old Nursery. The deficient practice would affect all sprinklered smoke compartments in the building, staff and all patients. The facility has the capacity for 21 beds with a census of 5 the day of survey.

Findings are:

1. Record review on 5/31/11 of the facility's sprinkler testing reports for the last 24 month period indicated that the testing for the sprinkler system had been tested annually with testing completed on 2/10/10 and 02/2/28/11. The facility had no water flow, supervisory and pressure switch devices documented as tested quarterly. Interview with the facility Maintenance Supervisor on 6/6/11 at 2:00 pm revealed the facility was not aware of the requirements for quarterly testing procedures and documentation for the sprinkler system.

2. Observation on 6/6/11 at 11:19 am revealed quick response pendant sprinkler heads installed in the Old nursery room. The rooms failed to have a thermal barrier ceiling installed for this type of sprinkler system. The sprinkler head activation could be delayed without the ceiling to retain the heat at the sprinkler head location in these rooms without the intended ceiling. Interview with Maintenance A at this time confirmed the area was to receive a suspended ceiling when the area is remodeled.

The findings were acknowledged by the Administrator and verified by the Maintenance A at the exit interview on 6/6/11.

NFPA Standard: Every required sprinkler system shall be continuously maintained in proper operating condition. NFPA 101, 4.6.12.1
NFPA Standard:. Water flow alarm devices including, but not limited to, mechanical water motor gongs, vane-type water-flow devices, and pressure switches that provide audible or visual signals shall be tested quarterly. NFPA 25, 2-3.3

Based on interview the facility failed to provide training for the staff in the kitchen of the procedures in the event of a kitchen cook stove fire. This deficient practice could affect all 5 patients using the dining room. The facility has a capacity of 21 and a census of 5.

Findings are:

During tour of the kitchen on 6/6/11 at 2:36 pm the two Cooks A and Cook B were interviewed about what to do if a fire broke out on the stove. Neither Cook A nor Cook B had the knowledge of the procedure to determine what should be done to either activate the range hood extinguishing system at the pull station and/or to activate just the fire alarm system in the building.


NFPA Standard: Employees of health care occupancies shall be instructed in life safety procedures and devices. 2000 NFPA 101 19.7.1.3

Based on observation and staff interview, the facility failed to use electrical wiring and equipment in accordance with the National Fire Protection Association, 70 in 1 of 2 smoke compartments. This condition increased the probability of electrical equipment and wiring causing an electrical shock or fire, which would affect all patients and staff in the smoke compartment. Facility census was 5 of 21.

Findings are:

1. Observations on 6/6/11 from approximately 10:51 am through 11:12 am of a random sample of rooms in the existing portion of the building revealed that a light fixture with an outlet above the sink was installed and failed to be GFCI protected. Observed Rooms were 2, Conference Room, 3, 4, 6, 8, 9, 10, and CEO office.

2. Observation on 6/6/11 at 2:38 pm revealed a wire molding plugged into an outlet in the old Laboratory.


All observations were confirmed by Maintenance A at the times of the observations.


NFPA Standard: All 125-volt, single-phase, 15- and 20-ampere receptacles installed in the locations specified in (1) through (8) shall have ground-fault circuit-interrupter protection for personnel.
(1) Bathrooms 2002 NFPA 70, 210.8
NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8

Based on observation and interview, this facility failed to provide a firewall with a two-hour fire rating between the nonsprinklered hospital and the sprinklered hospital portions of the facility. In addition the doors failed to close and latch between the Medical Clinic and the Hospital. This deficient practice affects all occupants including staff, visitors and residents. This facility has a capacity of 21 and a census of 5 patients.


Findings are:

1. Observation on 6/6/11 at 11:12 am revealed an unsealed hole in the two hour wall across from Room 6, leaving unfilled gaps that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone.

2. Observation on 6/6/11 at 11:24 am revealed the fire doors in the two hour wall between the Medical Clinic and the Hospital failed to close and latch.
All observations were confirmed by Maintenance A at the times of the observations.
NFPA Standard: Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition. Communicating openings in the fire barriers shall be permitted only in corridors and protected by approved self-closing fire doors. 2000 NFPA 101, 18/19.1.1.4.1 and 18/19.1.1.4.2

Based on observation and interview the facility failed to maintain all corridor walls to the roof deck above and to seal all penetrations above the suspended ceiling. This deficient practice affects all smoke compartments in the new building. The facility has a capacity of 21 and a census of 5.
Findings are:
During tour of the new building on 6/6/11 from approximately 11:30 am through 3:00 pm revealed:
The corridor walls were observed above the ceiling in a random area of the new building. The corridor walls were observed to have unsealed penetrations and holes throughout. Examination of the suspended ceiling revealed the installation of canned ceiling lights which failed to be smoke resisting eliminating the ceiling as a smoke resisting barrier. Light from canned lights in the area by the CT area could be seen from the exit corridor above the ceiling.

Maintenance A confirmed the failure of the corridor walls to be complete and the failure of the canned lights to be smoke resisting.
NFPA Standard: Corridor walls shall form a barrier to limit the transfer of smoke. Such walls shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke. No fire resistance rating is required for corridor walls. NFPA 101 18.3.6.2

Based on observation and staff interview, the facility failed to ensure that doors to patient rooms, offices and other ancillary areas are free of impediments that would prevent the doors from being closed or that the doors are provided with suitable hardware that keeps the doors shut tightly into their frames. This deficient practice affects occupants in two of two smoke zones, as the doors would not prevent the spread of fire and smoke. This facility has a capacity of 21 and a census of 5 patients.
Findings are:

1. Observation on 6/6/11 at 10:50 am revealed the failure of the corridor doors to room 7 and room 10 to close and latch when tested.

2. Observation on 6/6/11 at 11:25 am and again at 12:30 pm revealed the corridor door to Room 115 blocked in the open position by a scale.

3. Observation on 6/6/11 at 11:28 am revealed the failure of the corridor door to Room 108 to close and latch when tested.

4. Observation on 6/6/11 at 12:31 pm revealed a baby cart and equipment blocking open the corridor door to Room 111.

All observations were confirmed by Maintenance A at the times of the observations.
NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors shall be provided with positive latching hardware. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Based on observation and interview, this facility failed to ensure that all the smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone. This deficient practice affects all occupants of the building, including staff, visitors and patient. This facility has a capacity of 21 with a census of 5.

Findings are:

Observations throughout the walk though of the new building on 6/6/11 from approximately 11:30 through 3:00 pm revealed the failure of all the smoke separation walls to be complete without unsealed penetrations, holes or open ended conduits. This included unsealed holes in the smoke separation by the new nurses ' station and the smoke separation by the Laboratory.

Maintenance A confirmed the failure of the smoke separation walls to be complete and sealed at each of the observations.

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1

Based on observation and record review, the facility failed to ensure that hazardous areas are separated from other areas by partitions and self-closing doors to ensure a one-hour fire-resistance rating. This deficient practice affects all occupants in one smoke zone, where the ceiling would not stop the spread of fire and smoke, in the event of a fire. This facility has a capacity of 54 and a census of 39 residents.
Findings are:
1. Observation on 6/6/11 at 1:30 pm revealed unsealed penetrations around conduits and brackets in the walls of the Electrical panel room by Radiology.

2. Observation on 6/6/11 at 1:48 pm revealed the self-closure to the Housekeeping storage room door contained a manual hold open device. The hold open failed to be connected to the fire alarm for self-closing in and emergency.

All observations were confirmed by Maintenance A at the times of the observations.
NFPA Standard: Any hazardous area shall be protected in accordance with Section 8.4. The areas described in Table 18.3.2.1 shall be protected as indicated. NFPA 101 18.3.2.1

Based on observation, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected 4 of 5 patients and staff. This facility has a capacity of 21 and a census of 5 patients.
Findings are:

1. Observation on 6/6/11 at 10:47 am revealed the corridor door to the light bulb storage room contained a large louver. The louver could allow heated gases and fire to penetrate into the exiting corridor in a fire situation. This room contained combustible storage. In addition the door failed to have a self-closure installed.

2. Observation on 6/6/11 at 11:01 am revealed the Janitors Closet by Room 4 contained unsealed holes in the wall.

3. Observation on 6/6/11 at 11:05 am revealed the Vending Supply storage room failed to have a self-closure installed on the door. The door also contained an unsealed hole around the door knob. In addition this room contained a hole in the plaster wall of approximately 9 inches by 11 inches with abandoned copper tubing sticking out of the hole.

4. Observation on 6/6/11 at 11:22 am revealed the old Nursery being used for combustible storage. The corridor door to this room failed to have a self-closure installed on the door.

5. Observation on 6/6/11 at 11:37 am revealed the failure of the corridor door to the Soiled Utility to close and latch.
All observations were confirmed by Maintenance A at the times of the observations.
NFPA Standard: Hazardous areas without sprinkler protection require one-hour fire resistance rating construction and doors shall be 3/4 hour fire rated with self-closers and positive latches. 2000 NFPA 101, 19.3.2.1

Based on observation, the facility failed to provide exit access from an area without the use of a special tool or knowledge from the egress side. The deficient practice affected the Clinic and the basement area. The facility has a capacity of 21 and at the time of the survey the census was 5.
Findings are:

1. Observation on 6/6/11 at 11:15 am revealed slide bolt locks on the outside of the exit from the Clinic break room into the Hospital. In addition the exit door from the basement contained a slide bolt lock on the corridor side of the door. Interview with Maintenance A at this time confirmed the slide bolt lock and that no one would be able to exit should the slide bolt be engaged.

2. Observation on 6/6/11 at 2:21 pm revealed the door marked with an exit sign from the old Surgery corridor led into a garage used for storage. The way to the exit door failed to have a protected and separated corridor to the exit door to the exterior of the garage.

All observations were confirmed by Maintenance A at the times of the observations.
NFPA Standard: Exits and exit access shall be located and arranged so that exits are readily accessible at all times. 2000 NFPA 101, 7.5.1.1NFPA Standard: Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1
NFPA Standard: A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 inches and not more than 48 inches above the finished floor. Doors shall be operable with not more than one releasing operation. 2000 NFPA 101, 7.2.1.5.4

Based on observation, documentation review and interview, the facility failed to provide emergency lighting of at least 1?-hour duration at the nurse ' s medication preparation area, as required by NFPA 99. In addition the facility failed to provide documentation of 1 ? hour testing of any battery emergency lighting in the facility. The deficient practice could affect all 5 patients, staff and visitors of the facility. The facility has a capacity of 21 with a census of 5 patients.
Findings are:

1. Documentation review on 5/31/11 revealed the lack of documentation for the 1 ? hour testing of any battery emergency lights installed in the facility. Interview with Maintenance A on 5/31/11 at 3:16 pm confirmed the lack of any documentation.

2. Interview with Maintenance A on 6/6/11 at 3:00 pm revealed Maintenance A was unaware if any emergency lighting was installed on the exterior of the building or if lighting on the exterior to a public way was connected to the emergency generators.

3. Observation on 6/6/11 at 1:04 pm revealed the lights in the new nurses ' station medication room were switchable leaving the entire room in darkness. Interview with Maintenance A at this time revealed he/she was unaware if the lights in the new nurses ' station medication room were on the emergency generator for task illumination in the event of a power failure.
NFPA Standard: Emergency illumination shall be provided for not less than 11/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 foot-candle. 2000 NFPA 101, 7.9.2.
NFPA Standard: The emergency lighting system shall be arranged to provide the required illumination automatically in the event of the interruption of normal lighting, opening of a circuit breaker, or a manual act, including accidental opening of a switch controlling normal lighting facilities. 2000 NFPA 101, 7.9.2.2
NFPA Standard: Task illumination required at medication preparation areas. 1999 NFPA 99, 3-4.2.1, 3-5.2.1, 3-6.2.1

Based upon observation, record review and interview, the facility failed to hold fire drills under varied conditions at different times of the day for five of five quarters reviewed. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This facility has a capacity of 21 and a census of 5 patients.
Findings are:
1. Review of fire drill documentation on 5/31/11 revealed all Evening shift fire drills were conducted within 8 minutes of 3:00 pm. Interview with Maintenance A on 5/31/11 at 3:48 pm confirmed more than one shift of employees were participating in the Evening shift fire drills.

2. Review of fire drill documentation on 5/31/11 revealed three Day shift fire drills were conducted within 10 minutes of 2:15 pm. Two reviewed Day shift fire drills were conducted within three minutes of 10:55 am.

3. Interview with Maintenance A, and record review on 6/6/11 at 3:48pm revealed the fire drills were planned in the safety committee and assigned to a department of the hospital for conducting the fire drill. The drill failed to be an unannounced for the department involved in the fire drill with it being assigned to that department. No one individual was responsible for all the fire drills.

4. Review of the fire alarm activation report on 6/8/11 failed to verify the fire alarm being sounded on the day before or the day after a Night shift drill. Interview with Maintenance A on 5/31/11 at 3:48 pm revealed Maintenance A was unaware of the requirement for the sounding of the fire alarm the day after or the day before when a coded announcement is used for the Night shift fire drills.

NFPA Standard: The proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy ' s fire safety plan. 2000 NFPA 101, 19.7.2.1

Based on interview and record review, the facility failed to maintain and test a complete automatic sprinkler system with quarterly testing of water flow, supervisory and pressure switch devices. In addition the facility failed to install a ceiling for the type of sprinkler coverage in the old Nursery. The deficient practice would affect all sprinklered smoke compartments in the building, staff and all patients. The facility has the capacity for 21 beds with a census of 5 the day of survey.

Findings are:

1. Record review on 5/31/11 of the facility's sprinkler testing reports for the last 24 month period indicated that the testing for the sprinkler system had been tested annually with testing completed on 2/10/10 and 02/2/28/11. The facility had no water flow, supervisory and pressure switch devices documented as tested quarterly. Interview with the facility Maintenance Supervisor on 6/6/11 at 2:00 pm revealed the facility was not aware of the requirements for quarterly testing procedures and documentation for the sprinkler system.

2. Observation on 6/6/11 at 11:19 am revealed quick response pendant sprinkler heads installed in the Old nursery room. The rooms failed to have a thermal barrier ceiling installed for this type of sprinkler system. The sprinkler head activation could be delayed without the ceiling to retain the heat at the sprinkler head location in these rooms without the intended ceiling. Interview with Maintenance A at this time confirmed the area was to receive a suspended ceiling when the area is remodeled.

The findings were acknowledged by the Administrator and verified by the Maintenance A at the exit interview on 6/6/11.

NFPA Standard: Every required sprinkler system shall be continuously maintained in proper operating condition. NFPA 101, 4.6.12.1
NFPA Standard:. Water flow alarm devices including, but not limited to, mechanical water motor gongs, vane-type water-flow devices, and pressure switches that provide audible or visual signals shall be tested quarterly. NFPA 25, 2-3.3

Based on interview the facility failed to provide training for the staff in the kitchen of the procedures in the event of a kitchen cook stove fire. This deficient practice could affect all 5 patients using the dining room. The facility has a capacity of 21 and a census of 5.

Findings are:

During tour of the kitchen on 6/6/11 at 2:36 pm the two Cooks A and Cook B were interviewed about what to do if a fire broke out on the stove. Neither Cook A nor Cook B had the knowledge of the procedure to determine what should be done to either activate the range hood extinguishing system at the pull station and/or to activate just the fire alarm system in the building.


NFPA Standard: Employees of health care occupancies shall be instructed in life safety procedures and devices. 2000 NFPA 101 19.7.1.3

Based on observation and staff interview, the facility failed to use electrical wiring and equipment in accordance with the National Fire Protection Association, 70 in 1 of 2 smoke compartments. This condition increased the probability of electrical equipment and wiring causing an electrical shock or fire, which would affect all patients and staff in the smoke compartment. Facility census was 5 of 21.

Findings are:

1. Observations on 6/6/11 from approximately 10:51 am through 11:12 am of a random sample of rooms in the existing portion of the building revealed that a light fixture with an outlet above the sink was installed and failed to be GFCI protected. Observed Rooms were 2, Conference Room, 3, 4, 6, 8, 9, 10, and CEO office.

2. Observation on 6/6/11 at 2:38 pm revealed a wire molding plugged into an outlet in the old Laboratory.


All observations were confirmed by Maintenance A at the times of the observations.


NFPA Standard: All 125-volt, single-phase, 15- and 20-ampere receptacles installed in the locations specified in (1) through (8) shall have ground-fault circuit-interrupter protection for personnel.
(1) Bathrooms 2002 NFPA 70, 210.8
NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8