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Based on observation and staff interview, the facility fails to assure that communicating openings in 2 hour rated fire barriers are permitted only in corridors. The deficient practice compromises the fire resistance rating of the 2 hour wall, affecting no patients, and all visitors and staff in 1 of 9 smoke zones. The facility has a capacity of 25 and a census of 7 at the time of the survey.

Findings Include:

During the tour conducted on 9/25/17 the following deficiency is noted:

1. During the survey at 11:00 AM it is observed that the fire wall separation between the Hospital and the Clinic has two existing fire doors that are not located in connecting corridors. They connect the dining room and the small board room, and the Hospital and Clinic outpatient waiting room. There is an active waiver is place.

Maintenance Staff was present and acknowledged the finding.

NFPA Standard: 19.1.1.4.1 Additions. Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition. (See 4.6.7 and 4.6.11.) 19.1.1.4.1.1 Communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire door assemblies. (See also Section 8.3.)

Based on document review and staff interview, the facility fails to test and maintain their emergency light systems in accordance with NFPA 101. This deficient practice would affect all patients, visitors, and staff in 9 of 9 smoke zones. The facility has a capacity of 25 with a census of 7 at the time of the survey.

Findings include:

During the survey conducted on 9/25/17 the following deficiencies are noted:

1. During document review at approximately 12:33 PM it is observed that there is no documentation for monthly testing of the emergency lights in December of 2016.
2. During document review at approximately 12:33 PM it is observed that the last annual 90 minute test of the emergency lights was performed in March of 2016 and is past due to be retested.

Maintenance staff was present and acknowledged the missed monthly and annual tests of the emergency lights.

NFPA Standard: NFPA 101 2012 7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows: (1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2). (2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction. (3) Functional testing shall be conducted annually for a minimum of 11?2 hours if the emergency lighting system is battery powered. (4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3). (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Based on document review and staff interview the facility fails to properly inspect and maintain their exit signs as required in Life Safety Code 101. The deficient practice would affect all patients, visitors, and staff in 9 of 9 smoke zones. The facility has a capacity of 25 with a census of 7 at the time of the survey.

Findings include:

During the survey conducted on 9/25/17 the following deficiency is noted:

1. During document review at 12:40 PM it is observed that there is no documentation for any monthly inspections of the exit signs in December of 2016.

Maintenance staff was present and acknowledged the missed monthly inspections of the exit signs.

NFPA Standard: NFPA 101 2012 19.2.10.1 Means of egress shall have signs in accordance with Section 7.10, unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4. 7.10.1.2.1* Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access. 7.10.5.1* General. Every sign required by 7.10.1.2, 7.10.1.5, or 7.10.8.1, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode. 7.10.5.2* Continuous Illumination. 7.10.5.2.1 Every sign required to be illuminated by 7.10.6.3, 7.10.7, and 7.10.8.1 shall be continuously illuminated as required under the provisions of Section 7.8, unless otherwise provided in 7.10.5.2.2. 7.9.3 Periodic Testing of Emergency Lighting Equipment. 7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3. 7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2). (2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction. (3) Functional testing shall be conducted annually for a minimum of 11/2 hours if the emergency lighting system is battery powered. (4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3). (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Based on observation and staff interview the facility fails to properly protect and maintain their hazardous areas in accordance with NFPA 101. The deficient practice would affect no patients, and all visitors and staff in 3 of 9 smoke zones. The facility has a capacity of 25 with a census of 7 at the time of the survey.

Findings include:

During the survey conducted on 9/25/17 the following deficiencies are noted:

1. During the survey at approximately 1:28 PM it is observed that the door to the soiled linen room in the basement is not equipped with a self closing device.
2. During the survey at approximately 2:16 PM it is observed that there is an unsealed penetration by conduit in the wall of the basement boiler room near the north stairway.
3. During the survey at approximately 2:39 PM it is observed that the door to the rated door to the kitchen storage room is held open by a door wedge.

Maintenance staff was present and acknowledged the findings.

NFPA Standard: NFPA 101 19.3.2.1.3 The doors shall be self-closing or automatic-closing.
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 (8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard
19.3.2.1.2* Where the sprinkler option of 19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4.

Based upon a document review and staff interview, the facility fails to assure that cooking equipment is protected and maintained in a in accordance with the requirements of NFPA 96. The deficient practice increases the risk of an uncontrolled kitchen fire, affecting no patients, and all visitors and staff in 1 of 9 smoke zones. The facility has a capacity of 25 and a census of 7 at the time of this survey.

Findings include:


During the survey conducted on 9/25/17 the following deficiency is noted:

1. During document review at 12:46 PM it is observed that the annual service report from 9/13/17 stated the following deficiencies: Panni Skillet not covered by a nozzle. Stove and Oven not connected to suppression system. There is no documentation at the time of survey for these deficiencies being corrected.

Maintenance staff was present and acknowledged the deficiencies on the hood system.

NFPA Standard: 11.2.1* Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction at least every 6 months.

Based on observation and staff interview, the facility is not confirming that the interior finish in their corridors is in compliance with NFPA 101. The deficient practice would affect approximately 5 patients, and all visitors and staff in 1 of 9 smoke zones. The facility has a capacity of 25 with a census of 7 at the time of the survey.

Findings include:

During the survey conducted on 9/25/17 the following deficiency is noted:

1. During the survey at 3:50 PM it is observed that there is a line of material called Optix down a portion of the corridor ceiling of the B Wing towards the exit at the end of the corridor. This material on the ceiling clearly states: Optix is a combustible thermoplastic, and this should be taken into consideration when reviewing building codes. There is no documentation available for this material being treated or tested for fire ratings.

Maintenance staff was present and acknowledged the combustibles on the ceiling.

NFPA Standard: 19.3.3.2* Interior Wall and Ceiling Finish. Existing interior wall and ceiling finish materials complying with Section 10.2 shall be permitted to be Class A or Class B. 10.2.1.4* Fixed or movable walls and partitions, paneling, wall pads, and crash pads applied structurally or for decoration, acoustical correction, surface insulation, or other purposes shall be considered interior finish and shall not be considered decorations or furnishings. 10.2.3* Interior Wall or Ceiling Finish Testing and Classification. Interior wall or ceiling finish that is required elsewhere in this Code to be Class A, Class B, or Class C shall be classified based on test results from ASTM E 84, Standard Test Method for Surface Burning Characteristics of Building Materials, or ANSI/UL 723, Standard for Test for Surface Burning Characteristics of Building Materials, except as indicated in 10.2.3.1 or 10.2.3.2. 10.2.3.2 Interior wall and ceiling finish tested in accordance with NFPA 286, Standard Methods of Fire Tests for Evaluating Contribution of Wall and Ceiling Interior Finish to Room Fire Growth, and meeting the conditions of 10.2.3.7.2 shall be permitted to be used where interior wall and ceiling finish is required to be Class A in accordance with ASTM E 84, Standard Test Method for Surface Burning Characteristics of Building Materials, or ANSI/UL 723, Standard for Test for Surface Burning Characteristics of Building Materials.

Based on staff interview and document review, the facility does not have a proper fire watch plan and procedure in accordance with NFPA 101. The deficient practice would affect all patients, visitors, and staff in 9 of 9 smoke zones. The facility has a capacity of 25 with a census of 7 at the time of the survey.

Findings include:

During the survey conducted on 9/25/17 at 1:11 PM it is observed that the facility does not have a complete fire watch policy regarding the procedures to be taken in the event that the fire alarm was out of service for more than 4 hours in a 24 hour period. The policy lacked the contact information for the Local Fire Department and State Fire Marshals Office.

Maintenance staff was present and acknowledged the incomplete fire watch policy.

NFPA Standard: NFPA 101 2012 9.6.1.6* Where a required fire alarm system is out of service
for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated, or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

Based on observation and staff interview the facility fails to properly install and maintain the fire extinguishers as required by NPFA 10. The deficient practice would affect no patients, and all visitors and staff in 1 of 9 smoke zones. The facility has a capacity of 25 with a census of 7 at the time of the survey.

Findings include:

During the survey conducted on 9/25/17 the following deficiency is noted:

1. During the survey at 2:28 PM it is observed that the fire extinguisher in the physical therapy room was last serviced in May of 2016 and is past due for annual service.

Maintenance staff was present and acknowledged the fire extinguisher was past due for service.

NFPA Standard: NFPA 101 9.7.4.1* Where required by the provisions of another section
of this Code, portable fire extinguishers shall be selected, installed,
inspected, and maintained in accordance with
NFPA 10, Standard for Portable Fire Extinguishers.

Based upon observation and staff interview the facility is not inspecting 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 8 patients, and all visitors and staff in 1 of 9 smoke zones. The facility has a capacity of 25 with a census of 7 at the time of the survey.

Findings include:

During the tour conducted on 9/25/17 the following deficiencies are observed:

1. During the survey at 3:35 PM it is observed that the corridor door to the equipment room in the B Wing is obstructed from closing by equipment.
2. During the survey at 3:42 PM it is observed that the corridor door to room 141 in the B Wing is obstructed from closing by equipment.

Maintenance staff was present and acknowledged the obstructions.

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 maintain their smoke barrier walls as required by Life Safety Code NFPA 101. This deficient practice would affect approximately 8 patients, and all visitors and staff in 2 of 9 smoke zones. The facility has a capacity of 25 with a census of 7 at the time of the survey.

Findings Include:

During the survey on 9/25/17 the following deficiency is noted:

1. During the survey at 3:27 PM it is observed that there is are unsealed penetrations by IT wires and conduit in the smoke barrier wall above the smoke barrier doors to the C Wing.

Maintenance Staff was present and acknowledged the unsealed penetrations.

NFPA Standard: NFPA 101 2012 19.3.7.3 Any required smoke barrier shall be constructed in
accordance with Section 8.5 and shall have a minimum 1/2-hour fire resistance rating, unless otherwise permitted by one of the following: (1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply: (a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c). (b) Not less than two separate smoke compartments shall be provided on each floor. (2)*Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier. 8.5.6.2 Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke.

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, and all visitors and staff in 1 of 9 smoke zones. The facility has a capacity of 25 with a census of 7 at the time of the survey.

Findings include:

During the survey conducted on 9/25/17 the following deficiency is noted:

1. During the survey at 2:50 PM it is observed that there is exposed wire coming out of conduit in the radiology room from removed equipment.

Maintenance staff was present and acknowledged the exposed wires out of conduit.

NFPA Standard: Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2

Based upon staff interview and record review, the facility fails to provide a complete 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 9 of 9 smoke zones. The facility has a capacity in the 25 with a census of 7 at the time of survey.

Findings include:

During the survey on 9/25/17 the following deficiency is noted:

1. During document review at 1:13 PM, it is revealed that the facility does not have an adequate smoke zone evacuation plan. The evacuation plan provided at the time of survey is incomplete, and does not have any information for the evacuation of individual smoke compartments or any plans for total evacuation.

Maintenance staff was present and acknowledged the incomplete evacuation plan.


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 on document review and staff interview, the facility fails to conduct fire drills as required by Life Safety Code NFPA 101. This deficient practice would affect all patients, visitors, and staff in 9 of 9 smoke zones. The facility has a capacity of 25 with a census of 7 at the time of the survey.

Findings Include:

During the survey on 9/25/17 the following deficiencies are noted:

1. During document review at 12:15 PM it is observed that there is no documentation for a fire drill on 2nd shift in the 1st quarter of 2017.
2. During document review at 12:15 PM it is observed that the last three fire drills on 2nd shift all occurred between 5:51 Pm and 6:45 PM.

Maintenance and Administrative Staff were present and acknowledged the missed fire drill and the time variance.

NFPA Standard: NFPA 101 2012 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 and staff 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 1 of 9 smoke zones. The facility has a capacity of 25 with a census of 7 at the time of the survey.

Findings include:

During the survey conducted on 9/25/17 the following deficiency is noted:

1. During the survey at 4:23 PM it is observed that there is a space heater in use in Room 101 Out Patient Nursing Service Office. There is no documentation on the heater not exceeding the 212 degrees limit.

Maintenance Staff was present and acknowledged the space heater.

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

Based on staff interview and document review, the facility failed to maintain and test the emergency generator power supply as required by NFPA 99. The deficient practice would affect all patients, visitors, and staff in 9 of 9 smoke zones. The facility has a capacity of 25 with a census of 7 at the time of the survey.

Findings include:

During the survey conducted on 9/25/17 the following deficiency is noted:

1. During document review at 1:00 PM it is observed that there is no documentation for a monthly run under load for November of 2016.

Maintenance staff was present and acknowledged the missed monthly run of the generator.

NFPA Standard: NFPA 99 6.4.4.1.1.4 Inspection and Testing. Criteria, conditions, and personnel requirements shall be in accordance with 6.4.4.1.1.4(A) through 6.4.4.1.1.4(C). (A)* Test Criteria. Generator sets shall be tested 12 times a year, with testing intervals of not less than 20 days nor more than 40 days. Generator sets serving essential electrical systems shall be tested in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 8. (B) Test Conditions. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads. (C) Test Personnel. The scheduled tests shall be conducted by competent personnel to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures. NFPA 99 6.4.4.1.1.4
NFPA Standard: Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods: (1)Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer (2) Under Operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating NPFA 110 8.4.2
NFPA Standard: Diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads of not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours.

Based on staff interview and observation, the facility fails to maintain proper usage of electrical cords in compliance with NFPA 70. The deficient practice would affect no patients, and all visitors and staff in 2 of 9 smoke zones. The facility has a capacity of 25 with a census of 7 at the time of the survey.

Findings include:

During the survey conducted on 9/25/17 the following deficiencies are noted:

1. During the survey at 1:55 PM it is observed that there is an extension cord plugged into a power strip, powering a fan, in the basement business office.
2. During the survey at 2:47 PM it is observed that there is a power strip hanging powering devices in Radiology.

Maintenance staff was present and acknowledged the extension cord and 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 9 smoke zones. The facility has a capacity of 25 with a census of 7 at the time of the survey.

Findings include:

During the survey conducted on 9/25/17 the following deficiency is noted:

1. During the survey at 1:39 PM it is observed that there is an unsecured CO2 cylinder standing in the maintenance office in the basement.

Maintenance staff was present and acknowledged the unsecured CO2 cylinder.

NFPA Standard: NFPA 99 2012 11.3.2.8 Cylinder valve protection caps shall comply with 11.6.2.3 11.6.2.3 Cylinders shall be protected from damage by means of the following specific procedures: (1) Oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device. (2) Oxygen cylinders shall not be stored near elevators or gangways or in locations where heavy moving objects will strike them or fall on them. (3) Cylinders shall be protected from tampering by unauthorized individuals. (4) Cylinders or cylinder valves shall not be repaired,
painted, or altered. (5) Safety relief devices in valves or cylinders shall not be tampered with. (6) Valve outlets clogged with ice shall be thawed with warm - not boiling - water. (7) A torch flame shall not be permitted, under any circumstances, to come in contact with a cylinder, cylinder valve, or safety device. (8) Sparks and flame shall be kept away from cylinders. (9) Even if they are considered to be empty, cylinders shall not be used as rollers, supports, or for any purpose other than that for which the supplier intended them. (10) Large cylinders (exceeding size E) and containers larger than 45 kg (100 lb) weight shall be transported on a proper hand truck or cart complying with 11.4.3.1. (11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart. (12) Cylinders shall not be supported by radiators, steam pipes, or heat ducts.

Based on staff interview and document review the facility fails to properly train and document their staff on the proper handling of compressed gas equipment in accordance with NFPA 99. The deficient practice would affect all patients, visitors, and staff in 9 of 9 smoke zones. The facility has a capacity of 25 with a census of 7 at the time of the survey.

Findings include:

During the survey conducted on 9/25/17 the following deficiency is noted:

1. During document review at 11:31 AM it is observed that there is no documentation available for the education or training of facility staff on the risk, safety guidelines, and usage requirements of compressed gas at the time of survey.

Maintenance staff was present and acknowledged there was no documentation available for the training or education of staff on handling compressed gas equipment.


NFPA Standard: NFPA 99 11.5.2 Gases in Cylinders and Liquefied Gases in Containers.
11.5.2.1 Qualification and Training of Personnel. 11.5.2.1.1* Personnel concerned with the application and maintenance of medical gases and others who handle medical gases and the cylinders that contain the medical gases shall be trained on the risks associated with their handling and use. 11.5.2.1.2 Health care facilities shall provide programs of continuing education for their personnel. 11.5.2.1.3 Continuing education programs shall include periodic review of safety guidelines and usage requirements for
medical gases and their cylinders. 11.5.2.1.4 Equipment shall be serviced only by personnel trained in the maintenance and operation of the equipment. 11.5.2.1.5 If a bulk cryogenic system is present, the supplier shall provide annual training on its operation.