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Based on observation, record review and facility staff interview, facility staff failed to provide one and one half hour rated doors in a two-hour fire barrier rated wall separating the hospital from the rural healthcare clinic. Facility staff failed to provide a two-hour fire barrier rated wall separating the hospital from the closed long term care building. This compromises the fire-resistance rating and would allow the passage of smoke, fumes and products of combustion to the hospital corridors in the event of a fire. This deficient practice as the potential to effect all patients, staff and visitors in the building. This facility had a capacity of 25. The facility census was 6.

1. Observation on 2/28/19, at approximately 10:40 A.M., during the facility tour, showed the corridor door between the purchasing storage room and the unused long term care building did not have a fire resistance rating or self closing device.

2. Observation on 2/28/19, at approximately 10:40 A.M., during the facility tour, showed the 1 1/2 hour double doors separating the unused long term care building and the hospital contained facility added screws through the door holding a full length hinge on both door leaves. Additional observation showed the door frame contained a wire backed glass transom (unknown fire resistance rated) above the doors. Observation above the lay in ceiling showed a large quantity of plaster covering the wall and extending to the underside of the roof (unknown depth and size of plaster does not have a fire resistance rating).

3. Observation on 3/01/2019 at approximately 12:50 P.M., during the facility tour, of the back clinic door separating the rural health clinic from the hospital, did not show a fire resistance rating.

4. Observation on 3/01/2019, during the facility tour, of the main front corridor between the rural health clinic and the hospital did not show a 2 hour occupancy corridor separation with 1 1/2 hour fire resistance rated corridor double door set.

5. Record review on 3/01/2019 of facility supplied construction plans for the rural health clinic dated 6/19/1996 showed a 2 hour separation wall with 1 1/2 hour rated doors required in the main front corridor between the rural health clinic and the hospital.

During an interview on 3/07/2019 at approximately 2:52 P.M., the Maintenance Director said he/she did not know the multiple occupancy separation requirements.

19.1.3.4 Contiguous Non-Health Care Occupancies.

19.1.3.4.1* Ambulatory care facilities, medical clinics, and
similar facilities that are contiguous to health care occupancies,
but are primarily intended to provide outpatient services,
shall be permitted to be classified as business occupancies or
ambulatory health care facilities, provided that the facilities
are separated from the health care occupancy by not less than
2-hour fire resistance-rated construction, and the facility is
not intended to provide services simultaneously for four or
more inpatients who are litterborne.

19.1.3.5 Where separated occupancies provisions are used in
accordance with either 19.1.3.3 or 19.1.3.4, the most stringent
construction type shall be provided throughout the building,
unless a 2-hour separation is provided in accordance with
8.2.1.3, in which case the construction type shall be determined
as follows:
(1) The construction type and supporting construction of the
health care occupancy shall be based on the story on
which it is located in the building in accordance with the
provisions of 19.1.6 and Table 19.1.6.1.
(2) The construction type of the areas of the building enclosing
the other occupancies shall be based on the applicable
occupancy chapters of this Code.

Based on observation, record review and facility staff interview, facility staff failed to provide two exits without passing through intervening rooms. This facility had a capacity of 25. The facility census was 6.

1. Observation on 3/01/19, during the facility tour, showed an unused room containing lockers and a shower open to the old 200 hall corridor. Observation showed the small room opened up to another room through an empty door frame. Observation showed the back room back wall had an empty door frame installed which led to a room with an exposed brick wall (old exterior wall). Observation showed the exposed brick wall contained a door leading to the corridor between radiology and the emergency department. Observation showed the original doorways in the rooms did not contain any doors and did not provide for a straight unobstructed view/walking path of the door leading to the corridor between radiology and the emergency department. Record review of the facility evacuation plan showed the intervening rooms corridor called College Avenue Exit.

2. Record review of the facility evacuation plan showed the intervening rooms corridor called College Avenue Exit and designated for patient, staff and visitors to provide two exits remote and opposite from the radiology and the emergency department.

During an interview on 3/07/2019 at 2:54 P.M., the Maintenance Director said the corridor was constructed before he/she started working at the facility. Additionally, he/she said he/she did not know when the corridor was constructed.

National Fire Protection Association 101, 2012 edition, section 19.2.5.4 Intervening Rooms or Spaces states: "Every corridor shall provide access to not less than two approved exits in accordance with Sections 7.4 and 7.5 without passing through any intervening rooms or spaces other than corridors or lobbies."

Based on observation, staff interview, and record review, the facility staff failed to provide continuously maintained exit ways free of all obstructions or impediments continuous to a public way such as a parking lot. This deficient practice affects one exit discharge area. This deficient practice has the potential to affect all patients, staff and visitors in the facility. Failure to ensure exterior exit ways comply with LSC requirements could delay evacuation out of the building in the event of a fire or other emergency. The census was 6 with a capacity of 25.


1. Observation on 3/01/19 at approximately 2:23 P.M., during the facility tour, showed the designated old 200 hall/College avenue exterior exit discharge area led to a grass covered yard that required residents, staff, and visitors to traverse approximately 35 feet grass to reach the parking lot.

Record review of the facility layout showed the exit discharge area from the old 200 hall/College avenue corridor intersection designated for use.

During an interview on 3/07/2019 at 2:55 P.M., the Maintenance Director said the building was constructed in 1960 without a sidewalk from the old 200 hall/College avenue exit.


The National Fire Protection Association 101, Life Safety Code 2012 Edition, section 7.7 states:


7.7 Discharge from Exits.

7.7.1* Exit Termination. Exits shall terminate directly, at a
public way or at an exterior exit discharge, unless otherwise
provided in 7.7.1.2 through 7.7.1.4.

Based on observation and facility staff interview, the facility staff failed to ensure all designated exit corridors are illuminated with emergency egress lights not controlled by a light switch. One designated exit corridor contained switches controlling the emergency egress lighting fixtures. One exterior discharge had lighting controlled by a switch. One exterior discharge had lighting controlled by a timer. Failure to provide emergency egress lighting fixtures not controlled by a light switch has the potential to affect all patients and staff within the corridor. This deficient practice could delay the safe evacuation of patients, staff and visitors in the event of an emergency. This facility had a capacity of 25. The facility census was 6.

1. Observation on 3/01/2019, during the building tour, showed the following designated exitways missing lights, contained switches or timers controlling the emergency egress lighting fixtures:

-East wing purchasing missing exterior lights;
-Old front lobby/employee entrance/designated exit missing interior lights;
-Old front lobby/employee entrance/designated exit exterior lights controlled by a timer.

During an interview on 3/07/2019 at 2:56 P.M., the Maintenance Director said he/she did not know light switches were not allowed.

19.2.8 Illumination of Means of Egress. Means of egress shall
be illuminated in accordance with Section 7.8.


7.8.1.2 Illumination of means of egress shall be continuous
during the time that the conditions of occupancy require that
the means of egress be available for use, unless otherwise provided
in 7.8.1.2.2.

Based on observation and facility staff interview, facility staff failed to provide emergency lighting not controlled by light switches inside two of two operating rooms and one medication room. This deficient practice has the potential to affect all patients within the facility served by the operating rooms and a medication room. Failure to provide emergency lighting could prevent proper illumination of required areas in the event of power loss. This facility had a capacity of 25. The facility census was 6.

1. Observations on 3/01/19, during the Life Safety Code (LCS) tour, showed the following light fixtures controlled by a light switch:

-2 of 2 operating rooms;
-Med surge hall medication room

During an interview on 3/07/2019 at 2:56 P.M., the Maintenance Director said he/she did not know the emergency lighting requirements.


NFPA 99, 2012 edition, section 6.4.2.2.4.2 states:

"6.4.2.2.4.2 The critical branch shall supply power for task illumination,
fixed equipment, select receptacles, and select power
circuits serving the following areas and functions related to patient
care:
(1) Critical care areas that utilize anesthetizing gases, task illumination,
select receptacles, and fixed equipment
(2) Isolated power systems in special environments
(3) Task illumination and select receptacles in the following:
(a) Patient care rooms, including infant nurseries, selected
acute nursing areas, psychiatric bed areas (omit receptacles),
and ward treatment rooms
(b) Medication preparation areas
(c) Pharmacy dispensing areas
(d) Nurses ' stations (unless adequately lighted by corridor
luminaires)
(4) Additional specialized patient care task illumination and
receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7)*Telephone equipment rooms and closets
(8) Task illumination, select receptacles, and select power circuits
for the following areas:
(a) General care beds with at least one duplex receptacle
per patient bedroom, and task illumination as required
by the governing body of the health care facility
(b) Angiographic labs
(c) Cardiac catheterization labs
(d) Coronary care units
(e) Hemodialysis rooms or areas
(f) Emergency room treatment areas (select)
(g) Human physiology labs
(h) Intensive care units
(i) Postoperative recovery rooms (select)
(9) Additional task illumination, receptacles, and select power
circuits needed for effective facility operation, including
single-phase fractional horsepower motors, which are permitted
to be connected to the critical branch"

Based on observation, the facility staff failed to provide a 1-hour rated separation between a hazardous area (areas that pose a degree of hazard greater than normal to the general occupancy of the building such as areas used for storage or use of combustibles or flammables, toxic, noxious, or corrosive materials, or heat producing appliances) and designated exit corridors in the facility per NFPA (National Fire Protection Association) requirements. Failure to separate the designated exits and provide rated one hour walls and fire rated doors equipped with a self-closing device puts all patients, staff and visitors at risk of injury or death from a fire by not containing the fire and smoke within the hazardous area and eliminating the two required means of egress. This facility had a capacity of 25. The facility census was 6.


1. Observation on 3/01/2019, during the facility tour, showed the following hazardous areas not separated from the designated exit corridors:

- Approximately 1,375 square feet purchasing storage room to old long term care building connecting door did not have a fire resistance rating or self closing device. The room contained a large amount of combustible storage and did not contain sprinkler coverage;

-Approximately 1,375 square feet purchasing storage room to hospital cafeteria designated exit corridor door did not have a fire resistance rating or a positive latching device. The room contained a large amount of combustible storage and did not contain sprinkler coverage;

- Old section of the hospital 200 hallway with combustible storage in the corridors, 200 hall unused patient rooms 201, 202, 203, 204, 205, 206, 207 208 lab tech sleep room, 209, 210 Dr sleep room, 211, x-ray tech sleep room, entire old section of unused O.B. department including housekeeping office, data processing, computer equipment storage, remainder of rooms in section converted to med records storage, maintenance storage room, 200/100 hallways old section nurse's station corridor and all rooms converted to medical records storage. The old section of the hospital did not have sprinkler coverage, rated doors with self closing devices or intact barriers. Observation showed 6 rooms on old 200 hallway converted to storage had roller latches (non positive latching devices prohibited by CMS). Observation did not show any intact rated door assembly/barrier wall in the old section of the hospital separating the storage from the rest of the facility.

-Lab corridor door by old 200 hall nurse's station contained a transfer grill;

-Electrical room contained a transfer grill and no self closing device;

-Laundry containing gas fired dryers and soiled holding rooms corridor door;

-Lab corridor door by Medical Records Director's office removed;

During an interview on 3/07/2019 at 2:56 P.M., the Maintenance Director said he/she did not know the hazardous areas separation requirements.


19.3.2.1.5 Hazardous areas shall include, but shall not be restricted
to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Rooms with soiled linen in volume exceeding 64 gal (242 L)
(6) Rooms with collected trash in volume exceeding 64 gal
(242 L)
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including
repair shops, used for storage of combustible supplies and
equipment in quantities deemed hazardous by the authority
having jurisdiction

Based on record review and facility staff interview, facility staff did not ensure all devices connected to the fire alarm system were inspected and tested per NFPA 72, National Fire Alarm and Signaling Code, 2010 edition. This facility had a capacity of 25. The facility census was 6.

Record review of the annual fire alarm inspection for 2018 did not show connection function tests for the following devices:

-audible/visual alarms
-fire and smoke dampers
-6 fire alarm annunciator panels
-door magnetic hold open devices
-powered exit corridor door in surgery

Record review of the annual fire alarm inspections for 2017 did not show smoke detector sensitivity testing for the facility smoke detectors.

During an interview on 3/07/2019 at 2:56 P.M., the Maintenance Director said he/she believed the fire alarm inspection company did the inspections per code requirements.

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, Table 14.3.1, Table 14.4.2.2, Table 14.4.5, sections 14.4.5, 14.4.5.3.1 through section 14.4.5.4 for additional testing information. Refer to section 10.12 for trouble signal information.

Based on observation and facility staff interview, facility staff failed to ensure corridors contain smoke detection
per NFPA 72, National Fire Alarm and Signaling Code, 2010 edition. This deficient practice has the potential to effect all facility patients, staff and visitors. This facility had a capacity of 25. The facility census was 6.

Observations on 3/01/2019, during the facility tour, showed the following areas missing smoke detectors:

-Purchasing/Cafeteria corridor contained smoke detectors 50 feet apart,
-Insurance/Cafeteria corridor did not have smoke detectors,
-Old 200 hall had smoke detectors on both sides corridor double doors (not barrier doors) only.

During an interview on 3/07/2019 at 2:56 P.M., the Maintenance Director said he/she believed the fire alarm system installation company installed the fire alarm system per code requirements.

19.3.4.1 General. Health care occupancies shall be provided
with a fire alarm system in accordance with Section 9.6.

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, sections 17.6.3 Location and Spacing and 17.6.3.3.1 Spacing for additional information.

Based on facility staff interview and record review, facility staff failed to inspect one of one wet sprinkler systems per NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition. This facility had a capacity of 25. The facility census was 6.

Record review on 02/28/2019 did not show monthly sprinkler system inspections.

Record review of the facility's quarterly wet sprinkler system inspections did not show completed inspection forms.

Record review showed facility staff conducted the quarterly flow inspections (opened main sprinkler valve and flowed water to activate the system's alarms then reset sprinkler system).

During an interview on 3/07/2019 at 2:56 P.M., the Maintenance Director said the sprinkler inspection company told facility staff they could do their own quarterly inspections. Additionally, he/she said the sprinkler inspection company explained to facility staff how to do their own inspections when the hospital addition with a sprinkler system was constructed in 1998-1999.


NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition, section 4.1.1.2 states: "Inspection, testing and maintenance shall be performed by personnel who have developed competence through training and experience."

Based on observation and facility staff interview, facility staff failed to ensure dual leaf corridor doors equipped with flushbolts closed and latched without being blocked. Facility staff failed to ensure corridor doors resisted the passage of smoke. These deficient practices have the potential to affect all patients, staff and visitors. Failure to ensure corridor doors were not blocked from closing, latching and do not have a gap between door leaves has the potential to prevent or delay evacuation out of the building in the event of a fire or other emergency by allowing smoke, fumes and the products of fire from entering the exit corridors in the event of a fire. This facility had a capacity of 25. The facility census was 6.

1. Observation on 3/01/2019, during the building tour, showed the dual leaf corridor linen storage closet doors equipped with manual flushbolts. Observation did not show an astragal between the doors to prevent the passage of smoke. Observation did not show a rating for the doors. Additionally, the old part of the hospital did not have sprinkler coverage. Observation showed the manual flush bolts did not positive latch within the door frame upon closing the leaf.


2. Observation of the corridor doors on 3/01/2019, during the building tour, showed the following:

-Purchasing storage room (Approximately 1,375 square feet storage room with a large quantity of combustible storage, no sprinkler coverage) /Cafeteria corridor door did not have a self closing device & did not have a positive latching device;

-Purchasing storage room to Long term care facility door did not have a fire resistance rating or self closing device;

-Cafeteria swinging corridor door did not resist the passage of smoke & did not have a positive latching device;

-Computer equipment storage room (12 feet x 15 feet) corridor door did not have a fire resistance rating or self closing device. Additionally, the corridor door contained a roller latch (CMS does not allow roller latches).

-Old O.B./storage corridor door did not have a fire resistance rating, did not have self closing devices, and contained a large quantity of combustible storage.

-The following rooms contained a roller latch on the corridor door: #205, #206 (room converted to storage), #207, #208, #209 (room converted to storage);

-Main Lab corridor door by medical records director's office was missing;

-Maintenance storage room corridor door near old 200 nurse's station did not have a self closing device and the room measured approximately 70 square feet;

-Insurance corridor door contained a mail slot, a cut out in the door containing a sliding glass window and no fire resistance rating;

-Electrical room/Transfer switch/transformer room corridor door did not have a self closing device and the room contained 2-750 transformers;

-Laundry room corridor door did not have a fire resistance rating;

-Dutch door in emergency department did not have both upper and lower leaves latching devices and the door did not have a rabbet, bevel or astragal between the upper and lower leaves.


During an interview on 3/07/2019 at 3:03 P.M., the Maintenance Director said he/she did not know the specific corridor door requirements.


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.

19.3.6.3.10* Doors shall not be held open by devices other
than those that release when the door is pushed or pulled.

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.

19.3.6.3.13 Dutch doors shall be permitted where they conform
to 19.3.6.3 and meet all of the following criteria:
(1) Both the upper leaf and lower leaf are equipped with a
latching device.
(2) The meeting edges of the upper and lower leaves are
equipped with an astragal, a rabbet, or a bevel.
(3) Where protecting openings in enclosures around hazardous
areas, the doors comply with NFPA80, Standard for Fire
Doors and Other Opening Protectives.

Based on observation and facility staff interview, facility staff failed to ensure transfer grills were not installed in corridors. This deficient practice has the potential to affect all patients, staff and visitors. Failure to ensure transfer grills were not installed in corridors has the potential to prevent or delay evacuation out of the building in the event of a fire or other emergency by allowing smoke, fumes and the products of fire from entering the exit corridors in the event of a fire. This facility had a capacity of 25. The facility census was 6.

Observation on 3/01/2019, during the building tour, showed the following doors contained transfer grills. Observation showed the door openings on designated exit corridors.

-Secondary insurance office corridor door contained a door transfer grill measuring approximately 23 inches by 11 inches & did not resist the passage of smoke;

-Lab corridor door at old 200 nurse's station contained a door transfer grill measuring approximately 23 inches by 11 inches & did not resist the passage of smoke;

-Oxygen storage corridor door at old 200 nurse's station contained a door transfer grill measuring approximately 23 inches by 11 inches & did not resist the passage of smoke;

-Maintenance storage room corridor door near old 200 nurse's station contained a door transfer grill measuring approximately 23 inches by 11 inches & did not resist the passage of smoke;

-Electrical room/Transfer switch/transformer room corridor door contained a door transfer grill measuring approximately 23 inches by 11 inches & did not resist the passage of smoke;

-Radiology server room contained a door transfer grill measuring approximately 23 inches by 11 inches & did not resist the passage of smoke.

During an interview on 3/07/2019 at 3:06 P.M., the Maintenance Director said the facility was constructed in 1960 with the current doors containing transfer grills.


NFPA 101, 2012 edition, Section 19.3.6.4 states:

"19.3.6.4 Transfer Grilles.
19.3.6.4.1 Transfer grilles, regardless of whether they are
protected by fusible link-operated dampers, shall not be used
in corridor walls or doors."

Based on observation, facility staff failed to ensure the soiled linen holding room in the facility laundry was adequately vented and kept under a relative negative pressure. This deficient practice has the potential to effect all residents, staff and visitors. Failure to provide adequate ventilation could increase the concentration of smoke, products of combustion and noxious fumes. This facility had a capacity of 25. The facility census was 6.

Observation on 3/01/2019 at 3:35 P.M., showed the soiled area of the laundry room did not have functioning exhaust ventilation.

During an interview on 3/07/2019 at 3:07 P.M., the Maintenance Director said he/she did not know the laundry soiled area exhaust fan was not functioning. Additionally, he/she said all of the facility exhaust fans are checked quarterly.

Based on facility staff interview and record review, facility staff failed to conduct fire drills on all shifts for two of four quarters reviewed. This deficient practice has the potential to effect all facility residents. Failure to hold drills could effect facility staff response in a fire or other emergency. This facility had a capacity of 25. The facility census was 6.

1. Record review on 02/27/19 of the facility fire drill records, showed the following fire drills were not conducted:

-7 P.M.-7 A.M. shift on the 3rd quarter of 2018
-7 P.M.-7 A.M. shift on the 4th quarter 2018
-7 A.M.-7 P.M. shift on the 4th quarter 2018


During an interview on 03/07/19 at 3:11 P.M., the Maintenance Director said the fire drills were missed.

The National Fire Protection Association 101 Life Safety Code, 2012 edition, Section 19.7.1 states:

19.7.1 Evacuation and Relocation Plan and Fire Drills.

19.7.1.4* Fire drills in health care occupancies shall include
the transmission of a fire alarm signal and simulation of emergency
fire conditions.

19.7.1.5 Infirm or bedridden patients shall not be required
to be moved during drills to safe areas or to the exterior of the
building.

19.7.1.6 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.

19.7.1.7 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.

Based on observation, facility staff interview and record review, facility staff failed to inspect, test and maintain the fire egress doors in accordance with the 2010 Editions of NFPA 80 (Standard for Fire Doors and Other Opening Protectives) and NFPA 105 (Standard for Fire Doors and Other Opening Protectives). Facility staff failed to conduct a comprehensive annual inspection of the non rated doors in the building. This facility had a capacity of 25. The facility census was 6.

1. Review of the facility's "Quarterly Fire and Smoke Barrier Door" inspection records, dated 12/21/2018, showed all doors in the facility passed the inspection without any problems noted.

2. Review of the facility's "Corridor Doors Quarterly Inspections" inspection records, dated 12/18/2017, 3/13/2018, 6/19/2018, 9/20/2018 and 12/20/2018 showed all doors in the facility passed the inspection without any problems noted.

3. Observation during the facility tour 2/27-3/01/2019 showed the following doors deficient:

-Observation on 2/28/19, at approximately 10:40 A.M., during the facility tour, showed the corridor door between the purchasing storage room and the unused long term care building did not have a fire resistance rating or self closing device.

- Observation on 2/28/19, at approximately 10:40 A.M., during the facility tour, showed the 1 1/2 hour double doors separating the unused long term care building and the hospital contained facility added screws through the door holding a full length hinge on both door leaves. Additional observation showed the door frame contained a wire backed glass transom (unknown fire resistance rated) above the doors.

-Observation on 3/01/2019 at approximately 12:50 P.M., during the facility tour, of the back clinic door separating the rural health clinic from the hospital, did not show a fire resistance rating.

-Purchasing storage room to hospital cafeteria designated exit corridor door did not have a fire resistance rating or a positive latching device.

- Old section of the hospital 200 hall unused patient rooms 201, 202, 203, 204, 205, 206, 207 208 lab tech sleep room, 209, 210 Dr sleep room, 211, x-ray tech sleep room, entire old section of unused O.B. department including housekeeping office, data processing, computer equipment storage, remainder of rooms in section converted to med records storage, maintenance storage room, 200/100 hallways old section nurse's station corridor and all rooms converted to medical records storage. The old section of the hospital did not have rated doors with self closing devices. Observation showed 6 rooms on old 200 hallway converted to storage had roller latches (non positive latching devices prohibited by CMS). Observation did not show any intact rated door assembly/barrier wall in the old section of the hospital separating the storage from the rest of the facility.

-Electrical room contained a transfer grill and no self closing device;

-Laundry containing gas fired dryers and soiled holding rooms corridor door did not have a rating;

-Lab corridor door by Medical Records Director's office removed;

-Cafeteria swinging corridor door did not resist the passage of smoke & did not have a positive latching device;

-Computer equipment storage room corridor door did not have a fire resistance rating or self closing device. Additionally, the corridor door contained a roller latch (CMS does not allow roller latches).

-Maintenance storage room corridor door near old 200 nurse's station did not have a self closing device and contained a door transfer grill measuring approximately 23 inches by 11 inches & did not resist the passage of smoke;

-Insurance corridor door contained a mail slot, a cut out in the door containing a sliding glass window and no fire resistance rating;

-Electrical room/Transfer switch/transformer room corridor door did not have a self closing device and contained a door transfer grill measuring approximately 23 inches by 11 inches & did not resist the passage of smoke;

-Secondary insurance office corridor door contained a door transfer grill measuring approximately 23 inches by 11 inches & did not resist the passage of smoke;

-Lab corridor door at old 200 nurse's station contained a door transfer grill measuring approximately 23 inches by 11 inches & did not resist the passage of smoke;

-Oxygen storage corridor door at old 200 nurse's station contained a door transfer grill measuring approximately 23 inches by 11 inches & did not resist the passage of smoke;

-Radiology server room contained a door transfer grill measuring approximately 23 inches by 11 inches & did not resist the passage of smoke.

During an interview on 03/07/19 at 3:11 P.M., the Maintenance Director said he/she did not know the specific door inspection requirements.


NFPA 101, 2012 Edition states:

19.2.2.2.1 Doors complying with 7.2.1 shall be permitted.

7.2.1.15 Inspection of Door Openings.

7.2.1.15.1* Where required by Chapters 11 through 43, the
following door assemblies shall be inspected and tested not
less than annually in accordance with 7.2.1.15.2 through
7.2.1.15.8:
(1) Door leaves equipped with panic hardware or fire exit
hardware in accordance with 7.2.1.7
(2) Door assemblies in exit enclosures
(3) Electrically controlled egress doors
(4) Door assemblies with special locking arrangements subject
to 7.2.1.6

7.2.1.15.2 Fire-rated door assemblies shall be inspected and
tested in accordance with NFPA 80, Standard for Fire Doors and
Other Opening Protectives. Smoke door assemblies shall be inspected
and tested in accordance with NFPA 105, Standard for
Smoke Door Assemblies and Other Opening Protectives.

7.2.1.15.3 The inspection and testing interval for fire-rated
and nonrated door assemblies shall be permitted to exceed 12
months under a written performance-based program in accordance
with 5.2.2 of NFPA 80, Standard for Fire Doors and Other
Opening Protectives.

7.2.1.15.4 A written record of the inspections and testing
shall be signed and kept for inspection by the authority having
jurisdiction.

7.2.1.15.5 Functional testing of door assemblies shall be performed
by individuals who can demonstrate knowledge and
understanding of the operating components of the type of
door being subjected to testing.

7.2.1.15.6 Door assemblies shall be visually inspected from
both sides of the opening to assess the overall condition of the
assembly.

7.2.1.15.7 As a minimum, the following items shall be verified:
(1) Floor space on both sides of the openings is clear of obstructions,
and door leaves open fully and close freely.
(2) Forces required to set door leaves in motion and move to
the fully open position do not exceed the requirements
in 7.2.1.4.5.
(3) Latching and locking devices comply with 7.2.1.5.
(4) Releasing hardware devices are installed in accordance
with 7.2.1.5.10.1.
(5) Door leaves of paired openings are installed in accordance
with 7.2.1.5.11.
(6) Door closers are adjusted properly to control the closing
speed of door leaves in accordance with accessibility requirements.
(7) Projection of door leaves into the path of egress does not
exceed the encroachment permitted by 7.2.1.4.3.
(8) Powered door openings operate in accordance with
7.2.1.9.
(9) Signage required by 7.2.1.4.1(3), 7.2.1.5.5, 7.2.1.6, and
7.2.1.9 is intact and legible.
(10) Door openings with special locking arrangements function
in accordance with 7.2.1.6
(11) Security devices that impede egress are not installed on
openings, as required by 7.2.1.5.12.

19.3.6.3.13 Dutch doors shall be permitted where they conform
to 19.3.6.3 and meet all of the following criteria:
(1) Both the upper leaf and lower leaf are equipped with a
latching device.
(2) The meeting edges of the upper and lower leaves are
equipped with an astragal, a rabbet, or a bevel.
(3) Where protecting openings in enclosures around hazardous
areas, the doors comply with NFPA80, Standard for Fire
Doors and Other Opening Protectives.

Based on interview and record review the facility failed to develop a maintenance program for the medical gas, vacuum, WAGD (Waste Anesthetic Gas Disposal), or support gas system within the facility. This facility had a capacity of 25. The facility census was 6.

1. Review of the facility maintenance program documentation did not show the facility had a program in place which includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets, and an inspection and maintenance schedule for this system.

During an interview on 03/07/19 at 3:12 P.M., the Maintenance Director said he/she did not know about the maintenance program for the medical gas, vacuum, WAGD, or support gas system requirements.

Section 5.1.14.2.2.1 of the National Fire Protection Association (NFPA 99) states: Health care facilities with installed medical gas, vacuum, WAGD, or medical support gas systems, or combinations thereof, shall develop and document periodic maintenance programs for these systems and their subcomponents as appropriate to the equipment installed.

Based on observation, the facility staff failed to ensure extension cords were not used permanently and surge protectors met NFPA requirements. This facility had a capacity of 25. The facility census was 6.


Observations on 2/27-3/01/2019, during the facility tour, showed the following:


-Respiratory therapy office contained one unrated power tap with a fan connected to it and one extension cord with a coffee maker connected to it;

-Stress Lab contained one unrated power tap with two devices connected to it;

-Medical Records contained one unrated power tap with four devices connected to it;

-Data room contained one unrated power tap with a refrigerator connected to it, one unrated power tap with a fan connected to it and one unrated power tap with seven devices connected to it;

-Telephone room contained one extension cord connected to one unrated power tap with four devices connected to the unrated power tap;

-Insurance office contained one unrated power tap with one device connected to it, three unrated power taps in the insurance wiring closet, one unrated power tap with four devices connected to it, another unrated power tap with four devices connected to it, one unrated power tap with three devices connected to it and another unrated power tap with three devices connected to it;

-Room #202 (old hospital section) lab director's office contained four unrated power taps and one extension cord connected to an unrated power tap with a window air conditioner connected to the power tap;

-Director of nursing office contained an extension cord with a refrigerator connected to it, one unrated power tap with five items connected to it;

-Cafeteria contained an extension cord with a microwave and toaster connected to it;

-Emergency Department Director's office contained a yellow colored extension cord with a printer connected to it.

During an interview on 3/07/2019 at 3:13 P.M., the Maintenance Director said he/she did not know the specific requirements for power tap and extension cord use.

Refer to NFPA 70, National Electrical Code, 2011 edition, Article 400.8 for additional information.