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Based on observation and staff interview, the facility failed to provide delayed-egress locks complying with 7.2.1.6.1. This deficient practice does not ensure full and instant access in the event of an emergency, affecting all patients, visitors and staff in 3 of 3 smoke zones. The facility has a capacity of 18 with a census of 3 at the time of this survey.

Findings include:

During the tour conducted on 07/19/18, at 4:15 p.m., it is observed:

-- 1. Exit door located at the patient room area west exit is equipped with at 15-second delayed egress magnetic lock. Door is not provided with a readily visible, durable sign indicating PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS.

-- 2. No keypad or electronic release is provided for the delayed egress exit door.

According to the facility layout, the door is considered required.

Staff J, Staff D and Staff T were present and acknowledged the results of the record review.
exits.

NFPA Standard: Approved, listed, delayed-egress locks shall be permitted to be installed on doors serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7, provided that the following criteria are met: doors shall unlock upon actuation of an approved, supervised automatic sprinkler system or any heat detector or activation of not more than two smoke detectors of an approved, supervised automatic fire detection system; the doors shall unlock upon loss of power; an irreversible process shall release the lock within 15 seconds upon application of a force not to exceed 15 pounds nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only; on the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 inch high and not less than 1/8 inch wide on a contrasting background that reads as follows: PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS. 2012 NFPA 101, 7.2.1.6.1

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, 19.2.2.2.4

NFPA Standard: Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2012 NFPA 101, 7.1.10.1

Based upon interview and record review, the facility fails to provide a written plan for the evacuation of the building's smoke zones directly affected by fire. The deficient practice affects all patients, visitors and staff in 3 of 3 smoke zones. affecting all patients, visitors and staff in 3 of 3 smoke zones. The facility has a capacity of 18 and a census of 3 at the time of this survey.

Findings include:

During the tour conducted on 07/19/18 between 1:00 p.m. and 3:00 p.m., a review of records revealed that the facility does not have a complete smoke zone evacuation plan. The evacuation plan for the facility was for evacuation of the entire building and not a smoke zone by smoke zone evacuation plan.

Staff J, Staff D, and Staff T were present and acknowledged the results of the records review.

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. 2012. NFPA 101, 18/19.7.1.1

NFPA Standard: A written health care occupancy fire safety plan shall provide for all of the following: (1) use of alarms; (2) transmission of alarms to fire department; (3) emergency phone call to fire department; (4) response to alarms; (5) isolation of fire; (6) evacuation of immediate area; (7) evacuation of smoke compartment; (8) preparation of floors and building for evacuation; (9) extinguishment of fire. 2012 NFPA 101 18/19.7.2.2

Based upon 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 patients, visitors and staff in 3 of 3 smoke zones. The facility has a capacity of 18 with a census of 3 at the time of this survey.

Findings include:

During the tour conducted on 07/19/18, between 1:00 p.m. and 3:00 p.m., a review of fire drill records for the last 4 quarters revealed the following:

-- 1. No documented drill for the second shift, 3rd quarter of 2017.

Staff J, Staff D and Staff T were present and acknowledged the results of the record review.

NFPA Standard: Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff (nurses, interns, maintenance engineers, and administrative staff) is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 18.7.1.4 through 18.7.1.7, 19.7.1.4 through 19.7.1.7

Based upon record review, observation, and staff interview, the facility fails to conduct and properly document testing, inspection, and maintenance of the generator in accordance with NFPA 110. This deficient does not ensure that the generator will run and not fail when needed in the event of an emergency, affecting all patients, visitors and staff in 3 of 3 smoke zones. The facility has a capacity of 18 with a census of 3 at the time of this survey.

Findings include:

During the tour conducted on 07/19/18, between 1:00 p.m. and 3:00 p.m., a review of records for the last 5 quarters revealed the following:

-- 1. No documented annual fuel quality testing within the last 12 months.

Staff J, Staff D and Staff T were present and acknowledged the results of the record review.

NFPA Standard: NFPA 110 2010 ed. 8.3.8 A fuel quality test shall be performed at least annually using tests approved by ASTM standards.