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Based on staff interview and review of the facility drawing, the facility fails to properly maintain the 2 hour wall separating the different occupancies as required in Life Safety Code 101. The deficient practice would affect all patients, visitors, and staff in 8 of 8 smoke zones. The Facility has a capacity of 25 with a census of 24 at the time of the survey.

Findings include:

During the survey conducted on 3/28/17 the following deficiency is noted:


1. During the survey at 11:15 AM it is observed that there is an unsealed penetration by IT wires in the corner of the 2 hour wall above the doors to the LTCU unit.
2. During the survey at 11:21 AM is is observed that there are unsealed penetrations by pipes, wires, and conduit through the 2 hour wall above the doors between the hospital and radiology suite.
3. During the survey at 11:47 AM it is observed that there are unsealed penetration around pipes, and conduit through the 2 hour wall above the doors between the hospital and surgery suite.


Maintenance staff was present and acknowledged the unsealed penetrations in the 2 hour wall.

NFPA Standard: Sections of health care facilities shall be permitted to be classified as other occupancies, provided that they meet all of the following conditions: (1) They are not intended to provide services simultaneously for four or more inpatients for purposes of housing, treatment, or customary access by inpatients incapable of self preservation. (2) They are separated from areas of health care occupancies
by construction having a minimum 2-hour fire resistance rating in accordance with Chapter 8.
(3) For other than previously approved occupancy separation arrangements, the entire building is protected throughout by an approved, supervised automatic sprinkler system
in accordance with Section 9.7. NFPA Life Safety Code 101 19.1.3.3

Based on observation and staff interview the facility fails to properly maintain the sprinkler system as required by NFPA 13. The deficient practice would affect all patients, visitors, and staff in 8 of 8 smoke zones. The facility has a capacity of 25 with a census of 24 at the time of the survey.

Findings include:

During the survey conducted on 3/28/17 the following deficiencies are noted:


1. During document review at 3:50 PM it is observed that there is no documentation for a monthly inspection of the sprinkler system in April of 2016.
2. During the survey at 1:23 PM it is observed that there is storage on several shelves within the 18" limit of the sprinkler heads in the basement storage room near the elevator.


Maintenance staff was present and acknowledged the missed monthly inspection, and the storage on shelves within 18".



NFPA Standard: NFPA 13 2010 26.1* General. A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained by the property owner or their authorized representative in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. 8.5.5.3 Obstructions that prevent sprinkler discharge from reaching the Hazard. Continuous or non-continuous obstructions that interrupt the water discharge in a horizontal plane more than 18" below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 8.5.5.3. 8.5.6.1 Unless the requirements of 8.5.6.2, 8.5.6.3, 8.5.6.4, or 8.5.6.5 are met, the clearance between the deflector and the top of storage shall be 18" or greater.

Based upon observation and staff interview the facility is not maintaining their corridor doors in compliance with NFPA 101. This deficient practice could prevent the ability of the facility to properly confine smoke and prevent fire from spreading. This deficient practice would affect approximately 2 patients and all visitors or staff in 1 of 8 smoke zones. The facility has a capacity of 25 with a census of 24 at the time of this survey.

Findings include:

During the tour conducted on 3/28/17 the following deficiencies are observed:


-- 1. During the survey at 2:16 PM it is observed that the corridor door to the physical therapy room 411 has unsealed pencil sized hole penetrations through the door.

-- 2. During the survey at 2:30 PM it is observed that the corridor door to the storage closet in the XRay department near the dressing room 3 has unsealed pencil sized hole penetrations through the door.


Maintenance staff was present and acknowledged the penetrations through the corridor doors.

NFPA Standard: Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1-3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Doors shall be provided with a means suitable for keeping the door closed.

Based on observation and staff interview the facility fails to properly maintain their electrical systems in accordance with NFPA 70. The deficient practice would affect no patients or visitors and all staff in 2 of 8 smoke zones. The facility has a capacity of 25 with a census of 24 at the time of the survey.

Findings include:

During the survey conducted on 3/28/17 the following deficiencies are noted:


1. During the survey at 2:57 PM it is observed that there is a power outlet missing a cover plate on the wall in the basement boiler room near the overhead delivery door.
2. During the survey at 1:30 PM it is observed that there is a power outlet within 6' of a sink in the Library and Education center room in the basement that is not GFCI protected.

Maintenance staff was present and acknowledged the needed cover plate and the outlet was not GFCI protected.

NFPA Standard: NFPA 99 2012 6.3.2.1 Electrical Installation. Installation shall be in accordance with NFPA 70, National Electrical Code. NFPA 70 2011 210.8 Ground Fault Circuit-Interrupter protection for the personnel. Ground-fault circuit-interruption for personnel shall be provided as required in 210.8 (A) through (C). The ground-fault circuit-interrupter shall be installed in readily accessible location. (B) Other than dwelling units. All 125-volt, single-phase, 15- and 20-ampere receptacles installed in the locations specified in 210.8(B)(1) through (8) shall have ground-fault circuit-interrupter protection for personnel. (1) Bathrooms (2) Kitchens (3) Rooftops (4) Outdoors. (5) Sinks - where receptacles are installed within 6 feet of the outside edge of the sink.

Based on observation and interview, the facility failed to maintain proper usage of space heating appliances within the facility that have heating elements limited to 212 degrees Fahrenheit. The deficient practice would affect no patients and all visitors and staff in 2 of 8 smoke zones. This facility has a capacity of 25 and a census of 24 at the time of the survey.

Findings include:

During the survey conducted on 3/28/17 the following deficiencies are noted:


1. During the survey at 1:10 PM it is observed that there are 2 radiator space heaters in use in the kitchen offices. There is no documentation on these heaters not exceeding the 212 degrees limit.
2. During the survey at 1:37 PM it is observed that there are 2 radiator space heaters in use in the business office and registration area. There is no documentation on these heaters not exceeding the 212 degrees limit.


Maintenance Staff was present and acknowledged the space heaters.

NFPA Standard: Portable space heating devices shall be prohibited in all healthcare occupancies. Unless used in non-sleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit. 2012 NFPA 101, 18/19.7.8

Based upon a review of records and staff interview, the facility fails to properly maintain their gas and vacuum piped systems. The deficient practice reduces the reliability of the medical gas systems, affecting all patients, visitors, and staff in 1 of 8 smoke zones. The facility has a capacity of 25 with a census of 24 at the time of this survey.

Findings include:

During the survey conducted on 3/28/17 the following deficiencies are noted:


-- 1. During document review at 9:45 AM it is observed that the last annual service report from February 2016 for the piped gas system stated the following deficiencies: 1.9 No room to get around tank. 2.4 Not grounded. 3.2 No emergency oxygen supply connection. 3.8 No local alarm. There is no documentation at the time of survey that these have been addressed or corrected.


Maintenance Staff was present and acknowledged the deficiencies stated on the service report.

NFPA Standard: Medical gas, vacuum, WAGD, or support gas systems have documented maintenance programs. The program includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets. Inspection and maintenance schedules are established through risk assessment considering manufacturer recommendations. Inspection procedures and testing methods are established through risk assessment. Persons maintaining systems are qualified as demonstrated by training and certification or credentialing to the requirements of AASE 6030 or 6040.
5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14, 5.3.13.4.2 (NFPA 99)

Based on staff interview and observation, the facility fails to maintain their electrical systems in accordance with NFPA 70. The deficient practice would affect no patients or visitors and all staff in 1 of 8 smoke zones. The facility has a capacity of 25 with a census of 24 at the time of the survey.

Findings include:

During the survey conducted on 3/28/17 the following deficiency is noted:


1. During the survey at 1:19 PM it is observed that there is an extension cord powering a power strip and several devices in the center of the computer lab.


Maintenance staff was present and acknowledged the extension cord powering the power strip.

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 observation and staff interview, the facility failed to properly protect and store compressed gasses as required by NFPA 99. The deficient practice would affect no patients or visitors and all staff in 1 of 8 smoke zones. The facility has a capacity of 25 with a census of 24 at the time of the survey.

Findings include:

During the survey conducted on 3/28/17 the following deficiency is noted:


1. During the survey at 2:31 PM it is observed that there are several wheelchairs that are equipped with O2 cylinders stored in a room in the X-ray department near dressing room 3. The storage room door does not have any sign for the storage of oxygen.


Maintenance staff was present and acknowledged the needed sign on the oxygen storage room door.

NFPA Standard: NFPA 99 2012 11.3.4.1 A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure. 11.3.4.2 The sign shall include the following wording as a minimum: CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING