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Based on observation and staff interview the facility failed to maintain the proper 2 hour fire resistive ratings for occupancies as described in the Life Safety Code (NFPA 101) 2012 edition section 19.1.3.3. This deficient practice could allow for the transfer of smoke or fire from another occupancy and affect all 14 patients and an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 8:00 am to 2:00 pm on 05/23/2017 observations and staff interview revealed a conduit in the 2 hour fire barrier along the clinic separation did not have the proper fire stopping in it.

This deficient condition was confirmed by the Environmental Services Director.

Based on observation and staff interview, the facility failed to maintain the sprinkler system in accordance with the 2012 Life Safety Code (NFPA 101) and NFPA 25 section 5.2.1.1.2. The standard for testing and maintenance of sprinkler systems. This deficient condition could cause the sprinkler system not to function properly and allow for the spread of fire. This could affect all of the 14 patients and an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 8:00 am to 2:00 pm on 05/23/2017 observations and staff interview revealed a ceiling tile in procedure room 9 has a corner broken out of it and 2 ceiling tiles are missing in the IT server room C110.

This deficient condition was confirmed by the Environmental Services Director.

Based on record review and staff interview the facility failed to maintain smoke dampers in accordance with The Standard for Fire Doors and Other Opening Protective's, NFPA 80 , 2010 edition section 19.4.1.1. This deficient practice could allow smoke to travel throughout smoke compartments affecting the exiting capabilities of all of the 14 patients and an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 8:00 am to 2:00 pm on 05/23/2017 documentation review and staff interview revealed no documentation was available to confirm damper testing.

This deficient condition was confirmed by the Environmental Services Director.

Based on record review and staff interview the facility failed to maintain a Fire Safety Plan as required in NFPA 101 Life Safety Code, 2012 edition section 19.7.2.2. This deficient practice could cause confusion in an emergency and affect all 14 patients and an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 8:00 am to 2:00 pm on 05/23/2017 documentation review and staff interview revealed the Fire Safety Plan does not address all points listed in the Life Safety Code.

This deficient condition was confirmed by the Environmental Services Director.

Based on record review and staff interview the facility failed to conduct fire drills at least quarterly on each shift under varied conditions as required by the Life Safety Code (NFPA 101) 2012 edition, section 19.7.1.4 to 19.7.1.7. This deficient practice could reduce the ability of staff to conduct a safe and timely response to a fire emergency, which would affect all 14 patients an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 8:00 am to 2:00 pm on 05/23/2017 documentation review and staff interview revealed the fire drills were not conducted under various conditions.

Based on record review, observation and staff interview the facility failed to provide a policy for the use of portable heaters and ensure they met the requirements based on the 2012 edition of the Life Safety Code (NFPA 101) section 19.7.8. This deficient practice could cause injury to an undetermined amount of staff.

Findings include:

On the facility tour between 8:00 am to 2:00 pm on 05/23/2017 documentation review and staff interview revealed no policy is in place to address the 2 portable heaters being used, one in the business office and one in the rehab office.


This deficient condition was confirmed by the Environmental Services Director.

Based on observation and staff interview the facility failed to provide for the proper lighting where deep sedation and general anesthesia is administered according to the Health Care Facilities Code, NFPA 99, 2012 edition section 6.3.2.2.11. This deficient practice could possibly cause harm to a patient in the event of a power outage.

Findings include:

On the facility tour between 8:00 am to 2:00 pm on 05/23/2017 observations and staff interview revealed the operating room did not have a battery operated emergency light.

This deficient condition was confirmed by the Environmental Services Director.