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Based on observation and staff interview, the facility failed to maintain all 2 hour rated walls with doors at least 1-1/2 hour fire rated in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 19.1.3.5 and 8.2.1.3. The facility has a capacity of 25 with a census of 3 patients.

Findings include:

Observation and staff interview on 7/15/21 at 1:18 p.m., revealed one of the fire doors in the 2 hour wall separating the Hospital from the Clinic failed to close and latch properly when tested. Maintenance Staff verified observations during the survey process.

Based on observations and staff interview, the facility is not properly separating hazardous areas from other compartments. Hazardous areas shall be separated from other compartments by fire rated construction and self-closing doors in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 19.3.2.1. The facility has a capacity of 25 with a census of 3 patients.

Findings include:

Observations and staff interview on 7/15/21, between 9:30 a.m. and 2:15 p.m., revealed the following deficiencies:
1. The Cafeteria Corridor Door did not close and latch properly upon the swing of the door. The Cafeteria is considered within the same smoke zone as the Kitchen.
2. The door to the Soiled Utility Room in the Patient Wing failed to close and latch properly upon the swing of the door.
3. The Laundry Room door separating the clean side from the soiled side did not close and latch properly upon the swing of the door.
Maintenance Staff verified observations during the survey process.

Based on observation and staff interview, the facility failed to provide placard at the K-rated fire extinguisher in the Kitchen which indicates to activate the Kitchen Hood and Duct Extinguishment System before use of the K-rated fire extinguisher in the event of a fire on or about the Kitchen cooking equipment in accordance with National Fire Protection Association, NFPA 96, 2011 edition. The facility has a capacity of 25 with a census of 3 patients.

Findings include:

Observation and staff interview on 7/15/21 at 1:12 p.m., revealed no placard at the K-rated fire extinguisher in the Kitchen which indicates to activate the Kitchen Hood and Duct Extinguishment System before use of the K-rated fire extinguisher in the event of a fire on or about the Kitchen cooking equipment. Maintenance Staff verified observations during the survey process.

Based on observation and staff interview, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association, NFPA 72, 2010 edition. A trouble signal shall be reported to a location that is monitored 24 hours a day in the event of a disruption of communication to the monitoring entity. The facility has a capacity of 25 with a census of 3 patients.

Findings include:

Observation and staff interview on 7/15/21 at 1:48 p.m., revealed a trouble signal was not sent to the fire alarm system annunciator at the Nurses' Station after unplugging a phone line. The communications line to the annunciator panel was unplugged, preventing the signal from reaching the panel. Maintenance Staff verified observations during the survey process.

Based on record review and staff interview, the facility failed to provide a policy regarding the procedures to be taken in the event the fire alarm system is out of service for more than four hours in any twenty-four hour period in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 9.6.1.6. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 3 patients.

Findings include:

Record review and staff interview on 7/15/21 at 11:31 a.m., revealed the facility's sprinkler system outage policy did not include all of the following required language:
"When the system is out of service for more than 4 hours in a 24 hour period, the Impairment Coordinator shall arrange for one of the following:
a) Evacuation of the building or portion of the building affected by the outage.
b) An approved fire watch.

Maintenance Staff verified record review during the survey process.

Based on record review and staff interview, the facility failed to provide a policy regarding the procedures to be taken in the event the sprinkler system is out of service for more than 10 hours in any twenty-four hour period in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 9.7.6 and NFPA 25, 2011 edition. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 3 residents.

Findings include:

Record review and staff interview on 7/15/21 at 11:31 a.m., revealed the following deficiencies:

1. The facility's sprinkler system outage policy did not contain language indicating that the extent and expected duration of the impairment have been determined.
2. The facility's sprinkler system outage policy did not contain language indicating that the areas or buildings involved have been inspected and increased risks determined.
3. The facility's sprinkler system outage policy did not contain language indicating that recommendations have been submitted to management or the property owner.
4. The facility's sprinkler system outage policy did not contain language indicating that the supervisors in the areas to be affected have been notified.
5. The facility's sprinkler system outage policy did not contain language indicating that a tag impairment system has been implemented.
6. The facility's sprinkler system outage policy did not contain language indicating that all necessary tools and materials have been assembled on the impairment site.
7. The facility's sprinkler system outage policy did not address all of the following conditions: system leakage, interruption of water supply, ruptured piping, equipment failure.
8. The facility's sprinkler system outage policy did not contain all of the following language:
"When the system is out of service for more than 10 hours in a 24 hour period, the Impairment Coordinator shall arrange for one of the following:
a) Evacuation of the building or portion of the building affected by the outage.
b) An approved fire watch.
c) Establishment of a temporary water supply.
d) Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire.
9. The facility's sprinkler system outage policy did not designate an Impairment Coordinator.

Maintenance Staff verified record review during the survey process.

Based on observation and staff interview, this facility is not assuring that all smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 19.3.7.3. The facility has a capacity of 25 with a census of 3 patients.

Findings include:

Observation and staff interview on 7/15/21 at 1:38 p.m., revealed a penetration, (approximately 3/16 inch), around a pipe extending through the Smoke Barrier Wall by Patient Room 14. Maintenance Staff verified observations during the survey process.

Based on observation and staff interview, the facility failed to provide and maintain smoke barrier doors with a 20 minute fire rating in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 19.3.7.6. The facility has a capacity of 25 with a census of 3 patients.

Findings include:

Observation and staff interview on 7/15/21 at 1:26 p.m., revealed one of the Smoke Barrier Doors by the Staff On-Call Room failed to close and latch properly when tested. Maintenance Staff verified observations during the survey process.

Based on record review and staff interview, the facility failed to provide emergency plans and procedures as required by National Fire Protection Association, NFPA 101, 2012 Edition, 19.7.2.2. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 3 patients.

Findings include:

Record review and staff interview on 7/15/21 at 11:36 a.m., revealed the following deficiencies:

1. The facility's fire emergency plan and procedures policy did not contain language on use of the different types of fire extinguishers in the facility.
2. The facility's fire emergency plan and procedures policy did not contain language on the use of the Kitchen Hood and Duct Extinguishment System.

Maintenance Staff verified record review during the survey process.

Based on record review and staff interview, the facility failed to maintain and test the generator set in accordance with National Fire Protection Association, NFPA 110, 2010 Edition. A monthly test under load shall be conducted. An annual fuel quality test is required. Main and feeder circuit breakers shall be exercised annually. The facility has a capacity of 25 with a census of 3 patients.

Findings include:

Record review and staff interview on 7/15/21 at 10:20 a.m., revealed the following deficiencies:

1. Available documentation of monthly generator tests under load did not indicate operation of the transfer switch as required.
2. Available documentation of monthly generator tests under load did not indicate start and stop meter readings.
3. Available documentation of monthly generator tests under load did not include verification of operation under load at least 30% of the generator set nameplate value. An annual load bank test was also not documented.
4. There was no available documentation of annual fuel quality testing.
5. There was no available documentation indicating that main and feeder circuit breakers have been exercised annually as required. There was no available documentation indicating that a program has been established for periodically exercising the components according the manufacturer's requirements.

Maintenance Staff verified record review during the survey process.