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Based on observation and staff interview the facility fails to properly maintain their means of egress corridors as required in Life Safety Code 101. The deficient practice would affect no patients, and all visitors and staff in 1 of 3 smoke zones. The facility has a capacity of 25 with a census of 2 at the time of the survey.

Findings include:

During the survey conducted on 10/5/17 the following deficiency is noted:

1. During the survey at 2:33 PM it is observed that there are three chairs obstructing the exit corridor near the fathers room.

Maintenance staff was present and acknowledged the obstructions in the exit corridor.

NFPA Standard: Life Safety Code 101 2012 7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits or their access thereto, egress therefrom, or visibility thereof. 7.1.10.2.2 No obstruction by railings, barriers, or gates shall divide the means of egress into sections appurtenant to individual rooms, apartments, or other occupied spaces. Where the authority having jurisdiction finds the required path of travel to be obstructed by furniture or other movable objects, the authority shall be permitted to require that such objects be secured out of the way or shall be permitted to require that railings or other permanent barriers be installed to protect the path of travel against encroachment. Life Safety Code 101 2012.

Based on staff interview and observation, the facility fails to maintain their exit enclosures in accordance with Life Safety Code NFPA 101. The deficient practice would affect no patients or visitors and all staff in 1 of 3 smoke zones. The facility has a capacity of 25 with a census of 2 at the time of the survey.

Findings include:

During the survey conducted on 10/5/17 the following deficiency is noted:

1. During the survey at 4:19 PM it is observed that in the basement there are two pencil sized holes through the top of the door to the stairway enclosure. These would not resist the passage of smoke.

Maintenance staff was present and acknowledged the penetrations through the stairway door.

NFPA Standard: Life Safety Code 101 2012 7.1.3.2 Exits. 7.1.3.2.1 Where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following: (10) Penetrations into, and openings through, an exit enclosure assembly shall be limited to the following: (a) Door assemblies permitted by 7.1.3.2.1(9) (b)*Electrical conduit serving the exit enclosure (c) Required exit door openings (d) Ductwork and equipment necessary for independent stair pressurization (e) Water or steam piping necessary for the heating or cooling of the exit enclosure (f) Sprinkler piping (g) Standpipes (h) Existing penetrations protected in accordance with 8.3.5 (i) Penetrations for fire alarm circuits, where the circuits are installed in metal conduit and the penetrations are protected in accordance with 8.3.5 (11) Penetrations or communicating openings shall be prohibited between adjacent exit enclosures. (12) Membrane penetrations shall be permitted on the exit access side of the exit enclosure and shall be protected in accordance with 8.3.5.6.

Based on staff interview and observation, the facility fails to maintain their electrical systems in accordance with NFPA 70. The deficient practice would affect no patients or visitors and all staff in 1 of 3 smoke zones. The facility has a capacity of 25 with a census of 2 at the time of the survey.

Findings include:

During the survey conducted on 10/5/17 the following deficiency is noted:

2. During the survey at 4:04 PM it is observed that there is electrical outlet without a cover plate on the back wall in the subbasement storage room.

Maintenance staff was present and acknowledged the needed cover plate.

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

Based on document review and staff interview, the facility fails to conduct fire drills as required by Life Safety Code NFPA 101. This deficient practice would affect all patients, visitors, and staff in 3 of 3 smoke zones. The facility has a capacity of 25 with a census of 2 at the time of the survey.

Findings Include:

During the survey on 10/5/17 the following deficiency is noted:

1. During document review at 1:25 PM it is observed that the fire drill held on 2nd shift in the 3rd quarters of 2016 was held as coded silent drill. The drill times was 2:02 PM which is not between the approved hours for silent drills of 9 PM and 6 AM.

Maintenance Staff was present and acknowledged the finding.

NFPA Standard: NFPA 101 2012 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.

Based on staff interview and document review, the facility failed to maintain and test their electrical receptacles and systems in accordance with NFPA 99. This deficient practice would affect all patients, visitors, and staff in 3 of 3 smoke zones. The facility has a capacity of 25 with a census of 2 at the time of the survey.

Findings include:

During the survey conducted on 10/5/17 the following deficiency is noted:

1. During document review at 2:17 PM it is observed that there is no documentation at the time of survey for any testing of the electrical receptacles or electrical systems.

Maintenance Staff was present and acknowledged there was no documentation for the testing of electric receptacles or systems.

NFPA Standard: NFPA 99 2012 6.3.3.2 Receptacle Testing in Patient Care Rooms 6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection. 6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified. 6.3.3.2.3 correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. 6.3.4.1 Maintenance and testing of Electrical System 6.3.4.1. 1 Where hospital-grade receptacles are required at patient bed location and in location where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device. 6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data. 6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months. 6.3.4.1.4 The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch (see 6.3.2.6.3.6). For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators. 6.3.4.1.5 After any repair or renovation to an electrical distribution system, the LIM circuit shall be tested in accordance with 6.3.3.3.2 6.4.4.1.2.1* Circuit Breakers. Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer's recommendations. 6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modification. 6.3.4.2.1.2 At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter. 6.3.4.2.2 Isolated Power System (Where Installed). A permanent record shall be kept of the results of each of the tests.

Based on observation and staff interview, the facility failed to properly protect and store compressed gasses as required by NFPA 99. The deficient practice would affect no patients or visitors, and all staff in 1 of 3 smoke zones. The facility has a capacity of 25 with a census of 2 at the time of the survey.

Findings include:

During the survey conducted on 10/5/17 the following deficiency is noted:

1. During the survey at 3:18 PM it is observed that there is an unsecured E size O2 cylinder standing in the oxygen storage room near the director of nursing's office.

Maintenance staff was present and acknowledged the unsecured O2 cylinder.

NFPA Standard: NFPA 99 2012 11.3.2.8 Cylinder valve protection caps shall comply with 11.6.2.3 11.6.2.3 Cylinders shall be protected from damage by means of the following specific procedures: (1) Oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device. (2) Oxygen cylinders shall not be stored near elevators or gangways or in locations where heavy moving objects will strike them or fall on them. (3) Cylinders shall be protected from tampering by unauthorized individuals. (4) Cylinders or cylinder valves shall not be repaired, painted, or altered. (5) Safety relief devices in valves or cylinders shall not be tampered with. (6) Valve outlets clogged with ice shall be thawed with warm - not boiling - water. (7) A torch flame shall not be permitted, under any circumstances, to come in contact with a cylinder, cylinder valve, or safety device. (8) Sparks and flame shall be kept away from cylinders. (9) Even if they are considered to be empty, cylinders shall not be used as rollers, supports, or for any purpose other than that for which the supplier intended them. (10) Large cylinders (exceeding size E) and containers larger than 45 kg (100 lb) weight shall be transported on a proper hand truck or cart complying with 11.4.3.1. (11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart. (12) Cylinders shall not be supported by radiators, steam pipes, or heat ducts.

Based on staff interview and document review the facility fails to properly train and document their staff on the proper handling of compressed gas equipment in accordance with NFPA 99. The deficient practice would affect all patients, visitors, and staff in 3 of 3 smoke zones. The facility has a capacity of 25 with a census of 2 at the time of the survey.

Findings include:

During the survey conducted on 10/5/17 the following deficiency is noted:

1. During document review at 2:11 PM it is observed that there is no documentation available for the education or training of facility staff on the risk, safety guidelines, and usage requirements of compressed gas at the time of survey.

Maintenance staff was present and acknowledged there was no documentation available for the training or education of staff on handling compressed gas equipment.


NFPA Standard: NFPA 99 11.5.2 Gases in Cylinders and Liquefied Gases in Containers.
11.5.2.1 Qualification and Training of Personnel. 11.5.2.1.1* Personnel concerned with the application and maintenance of medical gases and others who handle medical gases and the cylinders that contain the medical gases shall be trained on the risks associated with their handling and use. 11.5.2.1.2 Health care facilities shall provide programs of continuing education for their personnel. 11.5.2.1.3 Continuing education programs shall include periodic review of safety guidelines and usage requirements for
medical gases and their cylinders. 11.5.2.1.4 Equipment shall be serviced only by personnel trained in the maintenance and operation of the equipment. 11.5.2.1.5 If a bulk cryogenic system is present, the supplier shall provide annual training on its operation.