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Based on observation and staff interview, the facility failed to provide walls free from holes and penetrations. This deficient practice would allow smoke products to travel from room to room and into the attic area, affecting all residents, visitors and staff in 3 of 3 smoke zones. The facility has a capacity of 16 and census of 3 at the time of the survey.

Findings include:

During the survey on October 28, 2021, the following was observed.

1) 11:31 a.m. In mechanical room F108B there is a penetration around conduit that is not sealed.

2) 11:40 a.m. In the Bio Waste room on the east wall there is a penetration around conduit that is not sealed.

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

Review of the following NFPA Standard revealed: Any vertical opening shall be enclosed or protected in accordance with Section 8.6, unless otherwise modified by 19.3.1.1 through 19.3.1.8. (2012) NFPA 101, 19.3.1.

Review of the following NFPA Standard revealed: Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating. (2012) NFPA 101, 19.3.1.1

Review of the following NFPA Standard revealed: Unprotected vertical openings in accordance with 8.6.9.1 shall be permitted. (2012) NFPA 101, 19.3.1.2

Review of the following NFPA Standard revealed: 8.4.4 Penetrations. The provisions of 8.4.4 shall govern the materials and methods of construction used to protect through penetrations and membrane penetrations of smoke partitions.

Review of the following NFPA Standard revealed: .4.4.1 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 smoke partition shall be protected by a system or material that is capable of limiting the transfer of smoke.

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 all residents in 1 of 3 smoke zones including the dining room. The facility has a capacity of 16 with a census of 3 at the time of survey.

Findings include:

During the survey on October 28th, 2021 the following was observed:

1) 12:15 p.m. The surgery exit door was obstructed by a wheelchair.

Staff 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 sq. ft. (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 correctly provide task orientated emergency lighting. This deficiency affects staff only in 3 of 3 smoke zones. The facility has a capacity of 16 with a census of 3 at the time of survey.

Findings include:

During the survey on October 28, 2021 the following was observed:

1) 11:55 a.m. The light in the pharmacy med room is switched, emergency task lighting cannot be switched as it would defeat the purpose of emergency lighting, it would be reliant upon human action.

2) 12:11 p.m. The light in the surgery med room is switched, emergency task lighting cannot be switched as it would defeat the purpose of emergency lighting, it would be reliant upon human action.

3) 12:24 p.m. The light in the nurse floor med room is switched, emergency task lighting cannot be switched as it would defeat the purpose of emergency lighting, it would be reliant upon human action.

4) 12:40 p.m. The light in the clinic clean med room is switched, emergency task lighting cannot be switched as it would defeat the purpose of emergency lighting, it would be reliant upon human action.

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

Review of the following National Fire Protection Association (NFPA) Standard revealed: Emergency lighting shall be provided in accordance with Section 7.9. 2012 NFPA 101, 19.2.9.1

Based on observation, interview and record review, the facility failed to maintain the inspection, testing, and maintenance of systems, their initiating devices, and notification appliances in accordance with National Fire Protection Association (NFPA) 72. Failure to maintain initiating devices, and notification appliances delay's 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 16 with a census of 3 at the time of this survey.

Findings include:

During the survey records review on October 28, 2021 the following was revealed:

1) There is no documentation of a semi annual fire alarm system test being completed.

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

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: A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Based upon record review, and observation the facility fails to ensure that the automatic sprinkler system is installed, maintained, and tested in accordance with National Fire Protection Association (NFPA) 25. This deficient practice fails to ensure that the sprinkler system will be properly prepared in the event of a fire, affecting all residents in 1 of 3 smoke zones. The facility has a capacity of 16 beds and census of 3 at the time of the survey.

Findings include:

During the survey on October 28, 2021 the following was observed:

1) 11:43 a.m. It was observed the sprinkler head inside the clean linen room is loaded with dust and debris.

Staff member 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 upon observation, and staff interview the facility fails to assure that smoke barriers are constructed to a minimum 1/2-hour fire resistance rating. The deficient practice would not prevent the passage of smoke, or fire to other areas of the building, affecting all residents, visitors, and staff in 3 of 3 smoke zones. The facility has a capacity of 16 with a census of 3 at the time of this survey.

Findings include:

During the survey on October 28, 2021 the following was observed:

1) 12:48 p.m. Above the freight hallway double doors there is a penetration around conduit that is not sealed.

2) 1:03 p.m. Above the ADON double doors there is a penetration around conduit that is not sealed.

3) 1:10 p.m. Above the ER floor double doors there is a penetration around conduit that is not sealed.

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

National Fire Protection Association (NFPA) Standard: Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1)

Based on observation and staff interview, the facility did not ensure that electrical wiring and equipment is installed and maintained in accordance with National Fire Protection Association (NFPA) 70, National Electrical Code. This deficient practice does not ensure prevention of an electrical fire or electric shock hazard, affecting staff in 1 of 3 smoke zones. The facility has a capacity of 16 with a census of 3 at the time of this survey.

Findings include:

During the survey on October 28, 2021 the following was observed:

1) 12:05 p.m. At the surgery main desk there multi-plug adapter in use on the east wall.

2) 12:44 p.m. In the physical hydrotherapy pump room there is a junction box without a cover.

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

Review of the following NFPA Standard revealed: Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. 2012 NFPA 101, 9.1.2

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 and staff in 3 of 3 smoke zones. The facility has a capacity of 16 and a census of 3.

Findings include:

During the survey records review on October 28, 2021 the following was revealed:

1) The previous (5) quarters of fire drills; there is only documentation of three fire drills being completed. 2/18/21, 3/31/21, 4/30/21.

2) The fire drill on 4/30/21 was ran as a silent drill and there is no documentation of an audible test being completed.

3) The fire drill on 2/18/21 there is paperwork indicting a fire drill was performed, however there is no documentation on the monitoring company call log of a test on this date.

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. A copy of the plan 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

Based on record review, the facility fails to maintain and test its electrical receptacles and systems in accordance with National Fire Protection Association (NFPA) 99 and NFPA 70 the National Electrical Code. This deficient practice would affect all residents, visitors, and staff in 3 of 3 smoke zones. The facility has a capacity of 16 and a census of 3 at the time of this survey.

Findings include:

During records review on October 28, 2021 the following was revealed.

1) There was no documentation provided for annual inspection, testing, and maintenance of the main circuit breakers.

Staff member M1 was present and acknowledged the findings.

NFPA Standard: 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. 2012 NFPA 99