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Based on observation and interview, the facility failed to provide approved, readily visible signs to mark delayed egress doors. The deficient practice of not providing required signage may delay occupants from exiting, affecting 2 of 5 smoke zones. The facility has a capacity of 25 and a census of 12.

Findings Include.

1. At 8:31 AM on 12/13/16 the delayed egress signage (X2) posted on the east and west med surgery exit doors are red lettering on the clear glass background.

The director of facilities/plant operation was present during the findings.


NFPA Standard: A readily visible, durable sign in letters not less than 1 in. (25 mm) high and not less than 1/8 in. (3.2 mm) in stroke width on a contrasting background that reads as follows shall be located on the door leaf adjacent to the release device in the direction of egress: PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS. 2012 NFPA 101, 7.2.1.6.1.1 (4).

Based on observation, record review and interview the facility does not assure a fire watch procedure and policy is written and available for implementation when fire alarm system is out of service for more than 4 hours in a 24 hour period. This deficient practice would allow facility exposure to undetected smoke and/or fire without an automatic detection compensatory provision when it occurred, and without appropriately prepared staff response, affecting 5 of 5 smoke zones. The facility has a capacity of 25 and a census of 12.

Findings Include:
During the tour from 12/12/16 to 12/13/16 it is noted that:

1. At 1:10 PM on 12/12/16 out of service alarm fire watch policy does not include instructions to contact all AHJs, no information regarding specific training of the individuals conducting fire watch, the method of contacting emergency services, and the requirement of access to all areas.

The director of facilities/plant operation was present during the findings.


NFPA Standard: When a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the AHJ shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties until the fire alarm system has been returned to service. A fire watch should consist of trained personnel who continuously patrol the affected area, with ready access to fire extinguishers and the ability to promptly notify the fire department. During the patrol of the area, the person should look for fire, and that other fire protection features of the building such as egress routes and alarm systems are available and functioning properly. 2012 NFPA 101, 9.6.1.6. and A.9.6.1.6.

Based on observation and staff interviews, the facility does not assure that the automatic fire sprinkler system is maintained properly. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting 5 of 5 smoke zones. The facility has a capacity of 25 and a census of 12.

Findings Include:

During the tour from 12/12/16 to 12/13/16 it is noted that:

1. At 2:19 PM on 12/12/16 combustible materials stored within 18 " of the sprinkler head in the laundry clean storage room.
2. At 1:50 PM on 12/12/16 fire department connection observed missing cap.

The director of facilities/plant operation was present during the findings.


NFPA Standard: 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. 2012 NFPA 101, 4.6.12.1.

NFPA Standard: 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.

NFPA Standard: Obstructions That Prevent Sprinkler Discharge from Reaching the Hazard. Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. (457 mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 8.5.5.3. 2010 NFPA 13 8.5.5.3*

Based on observation, record review and interview the facility does not assure a fire watch procedure and policy is written and available for implementation when the fire sprinkler system is out of service for more than 10 hours in a 24 hour period. This deficient practice would allow facility exposure to undetected smoke and/or fire without an automatic sprinkler compensatory provision when it occurred, and without appropriately prepared staff response, affecting 5 of 5 smoke zones. The facility has a capacity of 25 and a census of 12.

Findings Include:

During the tour from 12/12/16 to 12/13/16 it is noted that:


1. At 1:00 PM on 12/12/16 no fire watch policy for an out of service sprinkler system is available for review.

The director of facilities/plant operation was present during the findings.



NFPA Standard: Sprinkler impairment procedures shall comply with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2012 NFPA 101, 9.7.6.

NFPA Standard: The following procedures shall be implemented: the extent and expected duration of the impairment shall be determined; the area or buildings involved shall be inspected and the increased risks determined; and recommendations submitted to management or building owner/manager. Where a required fire protection system is out of service for more than 10 hours in a 24 hour period, the impairment coordinator shall arrange for one of the following: evacuation of the building affected by the system out of service; an approved fire watch; establishment of a temporary water supply; implementation of a program to eliminate potential ignition sources and limit the amount of fuel available; notification of the fire department; the insurance carrier, the alarm company, building owner/manager, and other AHJ ' s; notification of the supervisors in the affected areas; a tag impairment system has been implemented; all necessary tools and materials have been assembled on the site for preplanned impairments. A fire watch should consist of trained personnel who continuously patrol the affected area, with ready access to fire extinguishers and the ability to promptly notify the fire department. During the patrol of the area, the person should be looking for fire, and other fire protection features of the building such as egress routes and alarm systems are available and functioning properly. 2011 NFPA 25, 15.1 - 15.7.

Based on observation and staff interview the facility fails to maintain smoke barriers to at least one half hour fire resistance and ensure that all penetrations are properly sealed. This deficient practice would prevent containment of fire and smoke, affecting 5 of 5 smoke zones. The facility has a capacity of 25 and a census of 12.

Findings Include:

1. At 9:05 AM on 12/13/16 1/2 " gap around 2 " piping above housekeeping and kitchen dry storage visible above ceiling level.
2. At 9:06 AM on 12/13/16 (X2) 1/2 " unsealed penetrations below the bracket above housekeeping and kitchen dry storage visible above ceiling level.
3. At 9:18 AM on 12/13/16 ½ " gap between HVAC ductwork and wall between therapy and FEMA room visible above ceiling level.
4. At 9:23 AM on 12/13/16 3 " unsealed gap around ½ " conduit between the lab and FEMA room visible above ceiling level.
5. At 9:35 AM on 12/13/16 1 " unsealed gap around uni-strut above the corridor doors near PT south side visible above ceiling level.
6. At 9:50 AM on 12/13/16 ½ " unsealed gap around conduit in the west wall above ceiling level in the doctors lounge.
7. At 9:52 AM on 12/13/16 (X3) unsealed 3 " pass through conduits in the west wall of the doctors lounge restroom visible above ceiling level.
8. At 10:24 AM on 12/13/16 (X5) unsealed ½ " gaps between conduit bundles in the north wall of the senior life therapist office visible above ceiling level.
9. At 10:28 AM on 12/13/16 1 " unsealed gap around bar joist in the east wall of the chapel visible above ceiling level.
10. At 10:32 AM on 12/13/16 (X3) unsealed ½ " gaps between conduit bundles in the east wall above the corridor doors near the chapel visible above ceiling level.
11. At 10:43 AM on 12/13/16 unsealed ½ " gap around conduit in the west wall above ceiling level in the ER janitorial closet.
12. At 10:46 AM on 12/13/16 (X3) unsealed ½ " gap around red conduit in the west wall of the IT office visible above ceiling level.
13. At 10:14 AM on 12/13/16 (X3) ½ " gaps around piping in the south wall above ceiling level in the doctors restroom.



NFPA Standard: Requires smoke walls to have a fire resistance rating of at least a half hour and to be continuous from floor to roof deck and from outside wall to outside wall. 2012 NFPA 101, 8.5.2.1, 19.3.7.3.

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, 8.5.2.2. 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. 2012 NFPA 101, 8.5.6.2.

Based on observation, record review and staff interview the facility failed to provide a written fire safety plan that addresses the evacuation of adjacent rooms or of the smoke compartment. The deficient practice may prevent the staff in identifying the need to evacuate occupants beyond the compartment of origin to another smoke compartment, affecting 5 of 5 smoke zones. The facility has a capacity of 25 and a census of 12.

Findings Include:
During the tour from 12/12/16 to 12/13/16 it is noted that:


1. At 12:45 PM on 12/12/16 provided evacuation policy does not include specific information regarding zone evacuation, usage of class K fire extinguishers, no method of marking evacuated rooms or information detailing the immediate evacuation of rooms adjacent to the room of origin. Current policy states to ' await evacuation orders if other patients on the floor do not appear in obvious danger of fire, smoke or panic ' .
The director of facilities/plant operation was present during the findings.

NFPA Standard: 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. A copy of the plan shall be readily available at all times in the telephone operator ' s position or at the security center. The provisions of 19.7.1.1 through 19.7.2.3 shall apply. 2012 NFPA 101, Section 19.7.1

NFPA Standard: For health care occupancies, 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. 2012 NFPA 101, Section 19.7.2.1.2.

NFPA Standard: A written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
2012 NFPA 101, Section 19.7.2.2.

Based on record review and staff interview, the facility is not conducting fire drills as required quarterly on each shift 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 5 of 5 smoke zones. The facility has a capacity of 25 and a census of 12.

Findings Include:

During the tour from 12/12/16 to 12/13/16 it is noted that:


1. At 1:30 PM on 12/12/16 no record of signal transmission for the fire drill conducted on 8/19/16.

The director of facilities/plant operation was present during the findings.

NFPA Standard: Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 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. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 2012 NFPA 101, 19.7.1.5.

Based on observation, record review and interview the facility failed to prevent the use of furnishings or decorations of highly flammable character in an egress corridor. This deficient practice will allow rapid flame spread across the wall surfaces of the room and allow fire products to grow rapidly, affecting 4 of 5 smoke zones. The facility has a capacity of 25 and a census of 12.

Findings Include:

During the tour on March 23, 2010 between 9:15 AM and 4:00 PM the following is observed:

1. At 8:15 AM on 12/13/16 no flame spread documentation available to review for the 12 ' artificial Christmas tree displayed in the main lobby.

The director of facilities/plant operation was present during the findings.


NFPA Standard: Combustible decorations shall be prohibited in any health care occupancy unless they are flame-retardant. Except that some combustible decorations, such as photographs and paintings, in such limited quantities that a hazard of fire development or spread is not present. 2012 NFPA 101, 18/19.7.5.6

Based on record review and staff interview the facility failed to assure that portable space heaters being used within the facility are code compliant. This deficient practice could cause a fire due to excessive heat, affecting 4 of 5 smoke zones. The facility has a capacity of 25 and a census of 12.

FINDINGS INCLUDE:

During the tour from 12/12/16 to 12/13/16 it is noted that:


1. At 2:34 PM on 12/12/16 space heater observed plugged into a power strip in the Directors office. No unit documentation was available for review.
2. At 2:35 PM on 12/12/16 space heater observed plugged in the Infection control office. No unit documentation was available for review.
3. At 2:38 PM on 12/12/16 space heater observed plugged in the Risk/Quality control office. No unit documentation was available for review.
4. At 2:56 PM on 12/12/16 space heater observed plugged in the HR Directors office. No unit documentation was available for review.
5. At 4:10 PM on 12/12/16 space heater observed plugged in the Senior life clinical office. No unit documentation was available for review.
6. At 8:00 AM on 12/13/16 no space heater policy is available for review.
7. At 8:14 AM on 12/13/16 space heater observed plugged in the case management office. No unit documentation was available for review.

The director of facilities/plant operation was present during the findings.


NFPA Standard: Portable Space-Heating Devices. Portable space heating
devices shall be prohibited in all health care occupancies,
unless both of the following criteria are met:
(1) Such devices are permitted to be used only in nonsleeping
staff and employee areas.
(2) The heating elements of such devices do not exceed
212°F (100°C). 2012 NFPA 101, Sections 18.7.8, 19.7.8

Based on observation and staff interview, the facility fails to assure that all electrical wiring and equipment is installed and maintained in accordance with the requirements NFPA 70. This deficient practice increases the risk of an electrical fire, affecting 4 of 5 smoke zones. The facility has a capacity of 25 and a census of 12.

FINDINGS INCLUDE:

During the tour from 12/12/16 to 12/13/16 it is noted that:

1. At 2:13 PM on 12/12/16 appliances observed plugged into a power strip in the laundry area.
2. At 2:48 PM on 12/12/16 appliances observed plugged into a power strip in the PT galley.
3. At 2:50 PM on 12/12/16 extension cord in use in the respiratory therapy office.
4. At 3:33 PM on 12/12/16 (X2) rolling computer carts in the ER nurses station missing cord ground plugs.
5. At 4:05 PM on 12/12/16 oncology refrigerator observed plugged into a power strip.
6. At 4:07 PM on 12/12/16 rolling computer cart in oncology missing cord ground plug.
7. At 9:59 AM on 12/13/16 construction lighting observed in the ceiling space above outreach clinic coordinator.

The director of facilities/plant operation was present during the findings.

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; where subject to physical damage. 2012 NFPA 70, 400.8
NFPA Standard: Temporary electrical power and lighting installations shall be permitted (600 volts or less): (a) During Construction - temporary electric power and lighting installations shall be permitted during the period of construction, remodeling, maintenance, repair, or demolition of buildings, structures, equipment, or similar activities; (b) 90 Days - temporary electrical power and lighting installations shall be permitted for a period not to exceed 90 days for Christmas decorative lighting and similar purposes; (c) Emergencies and Tests - temporary electrical power and lighting installations shall be permitted during emergencies and for tests, experiments, and developmental work.; (d) Removal - temporary wiring shall be removed immediately upon completion of construction or purpose for which the wiring was installed. 2011 NFPA 70, 590.2, 590.3
NFPA Standard: In no case shall the load exceed the branch-circuit ampere rating. An individual branch circuit shall be permitted to supply any load for which it is rated. A branch circuit supplying two or more outlets or receptacles shall supply only the loads specified according to its size as specified in (a) through (d) and as summarized in 210.23 A-D. A 15- or 20-ampere branch circuit shall be permitted to supply lighting units or other utilization equipment, or a combination of both. The rating of any one cord- and plug-connected utilization equipment shall not exceed 80 percent of the branch-circuit ampere rating. The total rating of utilization equipment fastened in place, other than lighting fixtures, shall not exceed 50 percent of the branch-circuit ampere rating where lighting units, cord- and plug-connected utilization equipment not fastened in place, or both, are also supplied. 2012 NFPA 70, 210.23