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Based on observation and interview, the facility failed to maintain a 2-hour separation in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.1.3.5), 2012 Edition. This facility has a capacity of 25 and a census of 2.

Findings include:

Observation and interview on 02/25/20 at 9:31 a.m., revealed an approximate 1 inch gap around a 3/8 inch flexible conduit that penetrated the 2-hour fire wall of the Connecting Link on the hospital side of the main level. The Facility Operations Manager and Maintenance Mechanic verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain minimum construction requirements in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.1.6), 2012 Edition. This facility has a capacity of 25 and a census of 2.

Findings include:

Observation and interview on 02/25/20 at 10:38 a.m., revealed the west wall of the 2nd Level IT Room contained an approximate 1 inch gap around the coax cables that penetrated the wall. The Facility Operations Manager and Maintenance Mechanic verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to install battery powered lighting in accordance with National Fire Protection Association (NFPA) 99, Health Care Facilities Code (Section-6.3.2.2.11.1), 2012 Edition. This deficient practice affects all patients receiving deep sedation and general anesthesia. This facility has a capacity of 25 and a census of 2.
Findings include:
Observation and interview on 02/25/20 at 11:18 a.m., revealed neither of the Operating Rooms contained battery powered lighting units. The battery powered lighting units are required in order to terminate procedures in the event that there was a loss of power and should the emergency generator happen to fail. The Facility Operations Manager and Surgery Supervisor verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to provide separation of hazardous areas in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.3.2.1.3), 2012 Edition. This facility has a capacity of 25 and a census of 2.

Findings include:

1. Observation and interview on 02/25/20 at 10:21 a.m., revealed the corridor door to the North Patient Wing Equipment Storage Room did not contain a self-closing device. This room was greater than 50 square feet and was being used for the storage of combustible materials.

2. Observation and interview on 02/25/20 at 10:59 a.m., revealed the corridor door to Patient Room #140 did not contain a self-closing device. This room was greater than 50 square feet and was now being used for the storage of combustible materials. The Facility Operations Manager and Maintenance Mechanic verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to provide a placard for the use of the K-type fire extinguisher in accordance with National Fire Protection Association (NFPA) 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations (Section-10.2.2), 2011 Edition. This deficient practice affects all staff in the Kitchen. This facility has a capacity of 25 and a census of 2.

Findings include:

Observation and interview on 02/25/20 11:11 a.m., revealed the facility failed to provide a placard at the K-type fire extinguisher located in the Kitchen that states the extinguisher is to be used only after the fixed suppression system has been actuated. The Facility Operations Manager and Maintenance Mechanic verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to test all components of the fire alarm system in accordance with National Fire Protection Association (NFPA) 72, National Fire Alarm and Signaling Code (Section-14.4.5), 2010 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 2.

Findings include:

Record review and interview on 02/25/20 at 10:39 a.m., revealed the test reports from the facility's fire alarm contractor (Johnson Controls) did not contain documentation for testing of the magnetic door hold open/releasing devices that are tied to the fire alarm system. The Facility Operations Manager verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to provide a fire watch policy for the fire alarm system being out of service in accordance with National Fire Protection Association (NFPA 101), Life Safety Code (Section-9.6.1.6), 2012 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 2.

Findings include:

Record review and interview on 02/25/20 at 11:12 a.m., revealed that the facility was unable to provide a fire watch policy for the fire alarm system being out of service for 4 or more hours in a 24 hour period. The facility was able to provide phone numbers of whom to contact in the event of an outage. To include the State Fire Marshal, Department of Inspections and Appeals, and the Local Fire Department. The Facility Operations Manager verified this observation at the time of the survey process.

Based on observation, interview, and record review, the facility failed to test and maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (Sections-5.1.1.2, 5.2.2.2, and 14.3.2.1), 2011 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 2.

Findings include:

1. Record review and interview on 02/25/20 at 9:15 a.m., revealed the facility was unable to provide documentation for the quarterly inspection of the sprinkler system for the 3rd quarter of 2019.

2. Observation and interview on 02/25/20 at 9:48 a.m., revealed the sprinkler piping in the Pharmacy Hallway contained low voltage wiring suspended from the piping.

3. Observation and interview on 02/25/20 at 12:12 p.m., revealed the sprinkler piping in Air Handler Room #3 contained low voltage wiring suspended from the piping.

4. Record review and interview on 02/25/20 at 9:15 a.m., revealed the last 5-year internal obstruction inspection for the sprinkler system was conducted on 11/13/14. The test report from the facility's sprinkler contractor (Continental Sprinklers) also stated that this inspection was due. The Facility Operations Manager and Maintenance Mechanic verified these observations at the time of the survey process.

Based on record review and interview, the facility was unable to provide an impairment policy for the sprinkler system being out of service in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (Section-15.1.1), 2011 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 2.

Findings include:

Record review and interview on 02/25/20 at 11:11 a.m., revealed the facility was unable to provide an impairment policy for the sprinkler system being out of service for 10 or more hours in a 24 hour period. To include pre-planned and emergency impairments. The facility did have phone numbers for whom to contact in the event of an outage. To include the State Fire Marshal, Department of Inspections and Appeals, the Local Fire Department, and their Insurance Carrier. The Facility Operations Manager verified this observation at the time of the survey process.

Based on observation, interview, and record review, the facility failed to inspect portable fire extinguishers in accordance with National Fire Protection Association (NFPA) 10, Standard for Portable Fire Extinguishers (Section-7.2.1.2), 2010 Edition. This facility has a capacity of 25 and a census of 2.

Findings include:

Observation, interview, and record review on 02/25/20 during the survey process revealed several portable fire extinguishers throughout the facility were missing monthly inspection documentation for the month of May 2019. To include extinguisher's identified by the facility as #2, #6, #7, #8, #9, and #12. The Facility Operations Manager and Maintenance Mechanic verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain electrical junction boxes in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-9.1.2), 2012 Edition and National Fire Protection Association (NFPA) 70, National Electrical Code, 2011 Edition. This facility has a capacity of 25 and a census of 2.

Findings include:

1. Observation and interview on 02/25/20 at 9:53 a.m., revealed an open junction box with exposed electrical wires located above the North Patient Wing double doors.

2. Observation and interview on 02/25/20 at 11:36 a.m., revealed an open junction box with exposed electrical wires located along the southeast corner of the Lower Level Pump Room.

3. Observation and interview on 02/25/20 at 11:47 a.m., revealed an open junction box with exposed electrical wires located along the southeast corner of the ceiling of the Lower Level Pump Room.

4. Observation and interview on 02/25/20 at 12:01 p.m., revealed an open junction box with exposed electrical wires located along the east wall of the Pump Room near breaker panels VF #1 and EF #1. The Facility Operations Manager and Maintenance Mechanic verified these observations at the time of the survey process.

Based on record review and interview, the facility failed to provide a complete fire safety plan in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.7.2.2(9)), 2012 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 2.

Findings include:

Record review and interview on 02/25/20 at 11:38 a.m., revealed the provided Fire Safety Plan did not address the use of the different types of portable fire extinguishers in the facility. Nor did the plan address the use of the ansul extinguishment system for the kitchen hood. The Facility Operations Manager verified this observation at the time of the survey process.

Based on record review and interview, the facility is not initiating a fire alarm signal during drills in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Sections-19.7.1.4 and 19.7.1.7), 2012 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 2.
Findings include:
Record review and interview on 02/25/20 at 9:40 a.m., revealed the facility is conducting coded/paged drills for what they consider 2nd shift as well as 3rd shift. Coded drills are allowed between the hours of 9:00 p.m. and 6:00 a.m. The Facility Operations Manager and Maintenance Mechanic verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to inspect and test fire door assemblies in accordance with National Fire Protection Association (NFPA) 80, Standard for Fire Doors and Other Opening Protectives (Section-5.2.1), 2010 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 2.

Findings include:

Record review and interview on 02/25/20 at 10:46 a.m., revealed the facility was unable to provide documentation for annual inspection and testing of the required fire rated door assemblies throughout the facility. The Facility Operations Manager verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to inspect the emergency generator in accordance with National Fire Protection Association (NFPA) 110, Standard for Emergency and Standby Power Systems (Section-8.4.1), 2010 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 2.

Findings include:

Record review and interview on 02/25/20 at 10:16 a.m., revealed the weekly inspections for the facility's Level 1 diesel powered emergency generator did not include checking the oil level and the condition of the belts and hoses. The Facility Operations Manager verified this observation at the time of the survey process.

Based on observation and interview, the facility is not assuring that power strips are being used in accordance with National Fire Protection Association (NFPA) 99, Health Care Facilities Code (Section-10.2.3.6), 2012 Edition. This facility has a capacity of 25 and a census of 2.

Findings include:

Observation and interview on 02/25/20 at 11:32 a.m., revealed the Pump Room contained a surge protector being used to supply power to 4 foot light fixture. The Facility Operations Manager and Maintenance Mechanic verified this observation at the time of the survey process.