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Based on observation and staff interview the facility fails to ensure that all means of egress are free of all obstructions or impediments to a full instant use. This deficient practice could impede occupants from exiting in the event of a fire or other emergency situation, affecting patients, residents and staff in 1 of 3 smoke zone. The facility has a capacity of 25 with a census of 0 at the time of survey.

Findings include:

During the survey on March 26, 2019 the following is observed:

1) 1:00 PM it was observed in the north hallway corridor there was an unattended medical bed obstructing the egress pathway.

2) 1:30 PM it was observed in the east patient corridor there was a wheelchair being stored obstructing the egress pathway.
Staff member M1 was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: Any required aisle, corridor, or ramp shall be not less than 48 in. (1220 mm) in clear width where serving as means of egress from patient sleeping rooms, unless otherwise permitted by one of the following:

(1) Aisles, corridors, and ramps in adjunct areas not intended for the housing, treatment, or use of inpatients shall be not less than 44 in. (1120 mm) in clear and unobstructed width.
(2) Where corridor width is at least 6 ft (1830 mm), noncontinuous projections not more than 6 in. (150 mm) from the corridor wall, above the handrail height, shall be permitted.
(3) Exit access within a room or suite of rooms complying with the requirements of 19.2.5 shall be permitted.
(4) Projections into the required width shall be permitted for wheeled equipment, provided that all of the following conditions are met:
(a) The wheeled equipment does not reduce the clear unobstructed corridor width to less than 60 in. (152.5 mm).
(b) The health care occupancy fire safety plan and training program address the relocation of the wheeled equipment during a fire or similar emergency.
(c) The wheeled equipment is limited to the following:
i. Equipment in use and carts in use
ii. Medical emergency equipment not in use
iii. Patient lift and transport equipment
(5) Where the corridor width is at least 8 ft (2440 mm), projections into the required width shall be permitted for fixed furniture, provided that all of the following conditions are met:
(a) The fixed furniture is securely attached to the floor or to the wall.
(b) The fixed furniture does not reduce the clear unobstructed corridor width to less than 6 ft (1830 mm), except as permitted by 19.2.3.4(2).
(c) The fixed furniture is located only on one side of the corridor.
(d) The fixed furniture is grouped such that each grouping does not exceed an area of 50 ft2 (4.6 m2).
(e) The fixed furniture groupings addressed in 19.2.3.4(5) (d) are separated from each other by a distance of at least 10 ft (3050 mm).
(f) The fixed furniture is located so as to not obstruct access to building service and fire protection equipment.
(g) Corridors throughout the smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the fixed furniture spaces are arranged and located to allow direct supervision by the facility staff from a nurses' station or similar space.
(h) The smoke compartment is protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.8. 2012 NFPA 101, 19.2.3.4

Based on observation and staff interview the facility failed to provide task orientated emergency lighting. This deficiency affects staff only in 1 of 3 smoke zones. The facility has a capacity of 25 with a census of 0 at the time of survey.

Findings include:

During the survey on March 26, 2019 the following observations were made:

1) 2:18 PM it was observed in the generator room; the emergency light did not illuminate when tested.

Staff M1 was present at the time of the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: Emergency lighting shall be provided in accordance with Section 7.9. 2012 NFPA 101, 19.2.9.1

Review of the following NFPA Standard revealed: Emergency illumination shall be provided for a minimum of 1 ½ 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 ft-candle (l0.8 lux) and, at any point, not less than 0.1 ft-candle (1.1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6.5 lux) and, at any point, not less than 0.06 ft-candle (0.65 lux) at the end of 1 ½ hours. A maximum-to minimum illumination uniformity ratio of 40 to 1 shall not be exceeded. 2012 NFPA 101, 7.9.2.1

Based on staff interview and observation, the facility fails to install and maintain their Alcohol Based Hand Rub dispensers in accordance with NFPA 101. The deficient practice would affect patients and staff in 1 of 3 smoke zones. The facility has a capacity of 25 and census of 0 at the time of the survey.

Findings include:

During the survey on March 26, 2019 the following deficiency is noted:

1) 1:08 PM it was observed in room 301 there was an ABH alcohol-based hand-rub dispenser installed above the light switch.

Staff member M1 was present and acknowledged the finding.

NFPA Standard: Life Safety Code 101 2012 19.3.2.6* Alcohol-Based Hand-Rub Dispensers. Alcohol-based hand-rub dispensers shall be protected in accordance with 8.7.3.1, unless all of the following conditions are met: (8) Dispensers shall not be installed in the following locations: (a) Above an ignition source within a 1 in. (25 mm) horizontal distance from each side of the ignition source (b) To the side of an ignition source within a 1 in. (25mm) horizontal distance from the ignition source (c) Beneath an ignition source within a 1 in. (25 mm) vertical distance from the ignition source.

Based on observation, interview and record review, the facility failed to maintain the fire alarm system in accordance with NFPA 72. Failure to maintain smoke detectors and smoke alarms decreases the possibility of detection of smoke and smoke products in the facility delaying the notification of residents and staff in the event of a fire affecting all residents, visitors and staff in 3 of 3 smoke zones. The facility has a capacity of 25 with a census of 0 at the time of this survey.

Findings include:

During the survey on March 26, 2019 the following observations were made:

1) 1:17 PM it was observed there were no dates of installation on the batteries in the fire alarm panel in the store room.

Staff member M1 was present and acknowledged the findings.

NFPA Standard: A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. 2012 NFPA 101, 9.6.1.3

NFPA Standard: A complete record of the tests and operations of each system shall be kept until the next test and for 1 year thereafter. The record shall be available for examination and, if required, reported to the authority having jurisdiction. Archiving of records by any means shall be permitted if hard copies of the records can be provided promptly when requested. If off-premises monitoring is provided, records of all signals, tests, and operations recorded at the supervising station shall be maintained for not less than 1 year. 2010 NFPA 72 10.18.3

NFPA Standard: Smoke detector sensitivity shall be checked within one year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed. 2010 NFPA 72, 14.4.5.3

Based on observation, record review and interview the facility fails to ensure that the facility's automatic sprinkler system is installed, maintained and tested in accordance with NFPA 25. This deficient practice fails to ensure that the sprinkler system will be properly prepared in the event of a fire, affecting staff and residents in 3 of 3 smoke zones. The facility has a capacity of 25 and census of 0 at the time of the survey.

Findings include:

During the survey on March 26, 2019 the following observations were made:

1) 12:56 PM it was observed in room 307, the east recessed sprinkler head is missing the cover plate.

2) 2:07 PM it was observed in the laboratory, there were three sprinkler heads missing their escutcheon rings.

Staff M1 was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2012 NFPA 101, 9.7.5 Table 5.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.

Review of the following NFPA Standard revealed: Sprinklers shall be inspected from the floor level annually. 2011 NFPA 25, 5.2.1.1

Based on observation and staff interview the facility fails to maintain solid bonded wood-core smoke barrier doors to at least 20-minute fire resistance. This deficient practice could prevent containment of fire and smoke, affecting all residents and staff in 1 of 3 smoke zones. The facility has a capacity of 25 and census of 0 at the time of the survey.

Findings include:

During the survey on March 26, 2019, the following is observed:

1) 1:10 PM it was observed, the fire rated doors leading from the east entrance by the nurse's station were missing the fire door rating tag and had two dime size penetration on the east side of the door.

Staff Member M1 was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: Openings in smoke barriers shall be protected using one of the following methods: (1) Fire-rated glazing (2) Wired glass panels in steel frames (3) Doors, such as 1 3/4 in. (44 mm) thick, solid-bonded wood core doors (4) Construction that resists fire for a minimum of 20 minutes.

Based on observation and staff interview, the facility did not ensure that electrical wiring and equipment is installed and maintained in accordance with NFPA 70, National Electrical Code. This deficient practice does not ensure prevention of an electrical fire or electric shock hazard, in 1 of 3 smoke zones. The facility has a capacity of 25 with a census of 0 at the time of this survey.

Findings include:

During the survey on March 26, 2019 the following was observed:
1) 12:56 PM it was observed in room 307, on the north wall, a multi-plug adapter was in use.
2) 1:18 PM it was in the store room on the south wall just inside the door there is a receptacle without a cover plate.
Review of the following NFPA Standard revealed: Electrical wiring and equipment shall be in accordance with NAPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. 2012 NAPA 101, 9.1.2

Based on record review and staff interview the facility failed to provide a properly written plan for the protection of all patients and for their evacuation in the event of an emergency and carry out the provisions of the written fire safety plan during drill activities. The deficient practice may prevent the staff from identifying the proper procedures to take during an actual emergency, affecting all residents in all smoke zones. The facility has a capacity of 25 and census of 0 at the time of the survey.

Findings include:

During the survey on March 26, 2019 the following observations were made:

It was observed during documentation review of the fire procedures; evacuation plan and disaster plans are not specific to Sedan City Hospital. Plans do not include the triangle of rooms response, where to move patients, how to evacuate patients and where to horizontally evacuate patients when moving them from one smoke zone to another smoke zone. There is no detailed information of roles and responsibilities for the nursing staff.

Staff member M1 was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan required by 19.7.1.1. A copy of the plan required by 19.7.1.1 shall be readily available at all times in the telephone operator's location or at the security center. 2012 NFPA 101, 19.7.1.1, 19.7.1.2, 19.7.1.

Based on record review and staff interview, the facility is not conducting fire drills as required and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency, affecting all residents in all three smoke zones. The facility has a capacity of 25 and a census of 0.

Findings include:

During the survey on March 26, 2019 the following observations were made

1) It was observed during documentation review of the previous five quarters of fire drills none of the fire drills on any shift in 2019 or 2018 have a documented scenario.
2) It was observed during the documentation review of the previous five quarters of fire drills during all five quarters of 2019 and 2018 the fire drills have been conducted within the same hour as follows: 3/19/19 at 8:00 PM, 12/18/18 at 7:45 PM, 8/24/18 at 7:30 PM, 7/14/18 at 8:10 PM, 6/22/18 at 8:03 PM, and 3/19/18 at 8:00 PM.

Staff member M1 was present and acknowledged the findings.

Review of the following NFPA Standard revealed: The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan required by 19.7.1.1. A copy of the plan required by 19.7.1.1 shall be readily available at all times in the telephone operator's location or at the security center. Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 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. 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. Employees of health care occupancies shall be instructed in life safety procedures and devices. 2012 NFPA 101, 19.7.1.1-8

Based upon a review of records and staff interview the facility is not inspecting and maintaining fire-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 areas of the building. This deficient practice would affect all residents, visitors, and staff in 3 of 3 smoke zones. The facility has a capacity of 25 with a census of 0 at the time of this survey.


Findings include:


During the survey conducted on March 26, 2019 the following deficiency is noted:


1) No documented records of inspections on the fire-rated door assemblies.


Staff member M1 were present and acknowledged the findings.


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 on observation and staff interview, the facility did not ensure that electrical wiring and equipment is installed and maintained in accordance with NFPA 99, Health Care Facility Code. This deficient practice does not ensure prevention of an electrical fire or electric shock hazard, affecting residents in 3 of 3 smoke zones. This facility has a capacity of 25 with a census of 0 at the time of this survey.

Findings include:


During the survey conducted on March 26, 2019 it is observed:

1) The facility does not have a policy in place to assure that assessments of power strips are conducted on a yearly basis.

2) 1:04 PM it was observed in room 305 there were three extension cords plugged into a power strip.

3) 1:25 PM it was observed in room 206, there is an unapproved power strip.

4) 1:27 PM it was observed in room 209, there is an unapproved power strip.

5) 2:03 PM it was observed in the clinic break room there was an extension cord extending into the ceiling tiles in place of permanent wiring.

Staff member M1 was present and acknowledged the findings.

NFPA Standard: Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction. 2012 NFPA 101, 9.1.2

NFPA Standard: Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

NFPA Standard: NFPA 70 2011, 400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following: (1) As a substitute for the fixed wiring of a structure (2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors (3) Where run through doorways, windows, or similar openings (4) Where attached to building surfaces Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B) (5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings (6) Where installed in raceways, except as otherwise permitted in this Code (7) Where subject to physical damage.