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Based on observation and staff interview, the facility fails to prevent doors within a means of egress from having latches and locks that require the use of a key or tool or more than one motions to open the door. This deficient practice could impede occupants from exiting in the event of a fire or other emergency, affecting staff only in 2 of 3 smoke zones. The facility has a capacity of 25 with a census of 2 at the time of this survey.

Findings include:

During the survey conducted on August 10, 2022, it was noted:

1) It was observed at 2:14 PM, the main floor housekeeping closet located next to central supply has a latch and keyed padlock installed on the door. The housekeeping closet is approximately 4ft x 4ft and is large enough to enter and close the door.

2) It was observed at 2:20 PM, there is a thumb turn deadbolt installed on the x-ray storage room door in addition to the standard door knob requiring more than one motion to exit the room

Maintenance Staff A was present and acknowledged the findings.

NFPA Standard: Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side, except delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path. 2012 NFPA 101, 18/19.2.2.2.4

Based on observation and staff interview, the facility fails to assure that hazardous areas are separated from other spaces by ¾-hour fire rated doors. The deficient practice fails to provide separation of hazardous areas and would not stop the spread of smoke and fire, affecting all staff in the basement. The facility has a capacity of 25 with a census of 2 at the time of this survey.

Findings include:

During the survey conducted on August 10, 2022, it was noted:

1) It was observed at 3:55 PM, the basement storage room exceeding 100 sq ft has (2) doors that are not ¾-hour fire rated doors and are not self-closing or automatic-closing

Maintenance Staff A was present and acknowledged the findings.

NFPA Standard: Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4-hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. 2012 NFPA 101 19.3.2.1

Based on observation and staff interview the facility failed to maintain the corridor doors. The deficient practice of not inspecting, testing, and maintaining corridor door restricts the ability of the facility to properly confine fire and smoke products and to properly defend occupants in place, affecting all patients, 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 this survey.

Findings include:

During the survey conducted on August 10, 2022, it was noted:

1) It was observed at 2:22 PM, the double doors to x-ray do not fully close and latch into the frame due to the tight fit at the meeting edges of the doors

Maintenance Staff A was present and acknowledged the findings.

NFPA Standard: 19.3.6.3* Corridor Doors. 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following: (1) 13?4 in. (44 mm) thick, solid-bonded core wood (2) Material that resists fire for a minimum of 20 minutes 19.3.6.3.2 The requirements of 19.3.6.3.1 shall not apply where otherwise permitted by either of the following: (1) Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials shall not be required to comply with 19.3.6.3.1. (2) In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7, the door construction materials requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke. 101-212 LIFE SAFETY CODE
2012 Edition 19.3.6.3.3 Compliance with NFPA 80, Standard for Fire Doors and Other Opening Protectives, shall not be required. 19.3.6.3.4 A clearance between the bottom of the door and the floor covering not exceeding 1 in. (25 mm) shall be permitted for corridor doors.19.3.6.3.5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction,and the following requirements also shall apply: (1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.
(2) Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7.

Based on observation and staff interview the facility fails to ensure 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 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 this survey.

Findings include:

During the survey conducted on August 10, 2022, it was noted:

1) It was observed at 2:29 PM, there is an approximate ¼-inch opening above a 3-inch grouping of yellow wires where the previous firestopping product has pulled away from the wall, located above the ceiling on the north side of the west fire doors

2) It was observed at 2:32 PM, there is an approximate ¼-inch opening above a 3-inch grouping of yellow wires where the previous firestopping product has pulled away from the wall, located above the ceiling on the south side of the west fire doors

3) It was observed at 2:45 PM, the drywall terminates slightly above the drop-in ceiling and does not extend to the roof deck in order to complete the ½ hour fire resistance rating of the smoke barrier wall located on the east side of the east 90-minute fire doors

Maintenance Staff A was present and acknowledged the findings.

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 NFPA 70, National Electrical Code. This deficient practice does not ensure prevention of an electrical fire or electric shock hazard, affecting all patients, visitors, and staff in 2 of 3 smoke zones and the basement. The facility has a capacity of 25 with a census of 2 at the time of this survey.

Findings include:

During the survey conducted on August 10, 2022, it was noted:

1) It was observed at 1:57 PM and 3:44 PM., the water bottle filling stations are plugged into electrical outlets that are not protected with Ground Fault Circuit Interrupters (GFCIs) located in the corridor near ER 2, between rooms 5 and 6, and in the basement

2) It was observed at 2:20 PM, there is an electrical outlet that is broken, and missing half of the cover located in the back corner of the x-ray storage room

Maintenance Staff A 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

Based on record review and staff interview the facility is not conducting fire drills as required, and has not implemented a documented training program related to the current fire plan in place of conducting fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency, affecting all patients, visitors, and staff in 3 of 3 smoke zones. The facility has a capacity of 25 and census of 2 at the time of the review.

Findings include:

During the survey conducted on August 10, 2022, it was noted:

1) It was revealed during records review of the previous (5) quarters of fire drills that (4) day shift fire drills were all conducted between 9-10 AM in 2021 and 2022.

2.) It was revealed during records review of the previous (5) quarters of fire drills that (3) night shift fire drills were all conducted between 7-8 PM in 2021 and 2022.

Maintenance Staff A was present and acknowledged 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 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.

Review of the COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers revealed: Due to the inadvisability of quarterly fire drills that move and mass staff together, we will instead permit a documented orientation training program related to the current fire plan, which considers current facility conditions. The training will instruct employees, including existing, new or temporary employees, on their current duties, life safety procedures and the fire protection devices in their assigned area.

Based on record review and staff interview, the hospital failed to ensure that the piped-in oxygen system is maintained in accordance with the National Fire Protection Association (NFPA) 99 which resulted in an Immediate Jeopardy (IJ a situation in which the providers noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairments, or death to a patient) finding. This deficient practice failed to ensure patients are being provided with the minimum amount of oxygen flow from the wall outlet. The deficient practice affects patients in (3) emergency rooms and all patient care rooms. The facility has 25 certified beds and at the time of the survey had a census of 2 patients.

Documentation review during a routine survey at 11:36 AM on August 10, 2022, revealed that the facility had not established a maintenance program for their piped-in oxygen system as required by NFPA 99. During the interview Maintenance Staff A stated they did not have an inspection or testing program implemented for the piped-in oxygen system. It was stated that the facility had a contract with Advance Compliance Solutions to upgrade the entire system. The initial bid for replacement was received by the hospital on February 18, 2022.

The hospital was notified at 2:59 PM on August 10, 2022, that this deficiency represents an Immediate Jeopardy, and they were placed into fire watch at 3:00 PM pending abatement.

The hospital removed the IJ on August 10, 2022, at 5:07 PM when they submitted a plan to shut off the piped-in oxygen supply and notified staff to utilize oxygen e-cylinders until the new system was installed. The oxygen valves were shut off and verified by this inspector at 5:10 PM to be shut off.

NFPA review: 5.1.14.2.3.1 General. The elements in 5.1.14.2.2.2 through 5.1.15 shall be inspected or tested as part of the maintenance program as follows:
(1)*Medical air source, as follows:
(a) Room temperature
(b) Shaft seal condition
(c) Filter condition
(d) Presence of hydrocarbons
(e) Room ventilation
(f) Water quality, if so equipped
(g) Intake location
(h) Carbon monoxide monitor calibration
(i) Air purity
(j) Dew point
(2)*Medical vacuum source - exhaust location
(3) WAGD source - exhaust location
(4)*Instrument air source - filter condition
(5)*Manifold sources (including systems complying with 5.1.3.5.10, 5.1.3.5.11, 5.1.3.5.12, and 5.1.3.5.13), as follows:
(a) Ventilation
(b) Enclosure labeling
(6) Bulk cryogenic liquid source inspected in accordance with NFPA 55, Compressed Gases and Cryogenic Fluids Code
(7) Final line regulation for all positive pressure systems -delivery pressure
(8)*Valves - labeling
(9)*Alarms and warning systems-lamp and audio operation
(10) Alarms and warning systems, as follows:
(a) Master alarm signal operation
(b) Area alarm signal operation
(c) Local alarm signal operation
(11)*Station outlets/inlets, as follows:
(a) Flow
(b) Labeling
(c) Latching/delatching
(d) Leaks
5.1.14.4.4 Central supply systems for nonflammable medical gases shall conform to the following:
(1) They shall be inspected annually.
(2) They shall be maintained by a qualified representative of the equipment owner.
(3) A record of the annual inspection shall be available for review by the authority having jurisdiction.

Based on record review and staff interview, the hospital failed to ensure that the piped-in oxygen system is maintained in accordance with the National Fire Protection Association (NFPA) 99 which resulted in an Immediate Jeopardy (IJ a situation in which the providers noncompliance with one or more requirements of
participation has caused or is likely to cause serious injury, harm, impairments, or death to a patient) finding. This deficient practice failed to ensure patients are being provided with the minimum amount of oxygen flow from the wall outlet. The deficient practice affects patients in (3) emergency rooms and all patient care rooms. The facility has 25 certified beds and at the time of the survey had a census of 2 patients.

Documentation review during a routine survey at 11:36 AM on August 10, 2022, revealed that the facility had not had their piped-in oxygen system inspected annually as required by NFPA 99. During the interview Maintenance Staff A stated they did not have knowledge of the system ever having been inspected previously. It was stated that the facility had a contract with Advance Compliance Solutions to upgrade the entire system. The initial bid for replacement was received by the hospital on February 18, 2022.

The hospital was notified at 2:59 PM on August 10, 2022, that this deficiency represents an Immediate Jeopardy, and they were placed into fire watch at 3:00 PM pending abatement.

The hospital removed the IJ on August 10, 2022, at 5:07 PM when they submitted a plan to shut off the piped-in oxygen supply and notified staff to utilize oxygen e-cylinders until the new system was installed. The oxygen valves were shut off and verified by this inspector at 5:10 PM to be shut off.

NFPA review: 5.1.14.2.3.1 General. The elements in 5.1.14.2.2.2 through 5.1.15 shall be inspected or tested as part of the maintenance program as follows:
(1)*Medical air source, as follows:
(a) Room temperature
(b) Shaft seal condition
(c) Filter condition
(d) Presence of hydrocarbons
(e) Room ventilation
(f) Water quality, if so equipped
(g) Intake location
(h) Carbon monoxide monitor calibration
(i) Air purity
(j) Dew point
(2)*Medical vacuum source - exhaust location
(3) WAGD source - exhaust location
(4)*Instrument air source - filter condition
(5)*Manifold sources (including systems complying with 5.1.3.5.10, 5.1.3.5.11, 5.1.3.5.12, and 5.1.3.5.13), as follows:
(a) Ventilation
(b) Enclosure labeling
(6) Bulk cryogenic liquid source inspected in accordance with NFPA 55, Compressed Gases and Cryogenic Fluids Code
(7) Final line regulation for all positive pressure systems -delivery pressure
(8)*Valves - labeling
(9)*Alarms and warning systems-lamp and audio operation
(10) Alarms and warning systems, as follows:
(a) Master alarm signal operation
(b) Area alarm signal operation
(c) Local alarm signal operation
(11)*Station outlets/inlets, as follows:
(a) Flow
(b) Labeling
(c) Latching/delatching
(d) Leaks
5.1.14.4.4 Central supply systems for nonflammable medical gases shall conform to the following:
(1) They shall be inspected annually.
(2) They shall be maintained by a qualified representative of the equipment owner.
(3) A record of the annual inspection shall be available for review by the authority having jurisdiction.