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Based on record review and staff interview, the facility failed to provide proper ventilation and fire protection of commercial cooking operations in accordance with NFPA 96. This deficient practice affects all residents in 1 of 6 smoke zones including the dining rooms. The facility has a capacity of 25 with a census of 5 at the time of survey.

Findings include:

During the survey on February 6th, 2019 the following is observed:

1) It was observed at 9:22 AM in the kitchen the hood suppression system the filters are covered with grease and debris.

Staff MD 1 was present during the survey and acknowledged the findings.

Based on observation, record review and interview the facility fails toeinsure that the facility' automatic sprinkler system is installed, maintained and tested in accordance with NFPA 25. This deficient practice fails to ensure that the sprinkler system will be properly prepared in the event of a fire, affecting all residents in one of five smoke zones. The facility has a capacity of 25 and census of 4 at the time of the survey.

Findings include:

During the survey on February 6th, 2019 the following observations were made:

1) It was observed at 7:55 AM in the OR sterile supply storage room surgical items located within 18 inches of the sprinkler head.
2) It was observed at 9:24 AM in the dish area of the kitchen the sprinkler missing the escutcheon.

Staff MD 1 was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2012 NFPA 101, 9.7.5 Table 5.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.

Review of the following NFPA Standard revealed: Sprinklers shall be inspected from the floor level annually. 2011 NFPA 25, 5.2.1.1

Based upon observation and staff interview, the facility fails to assure that smoke barriers are constructed to a minimum 1/2-hour fire resistance rating. the deficient practice would not prevent the passage of smoke or fire to other areas of the building, affecting all residents, visitors and staff in 2 of 6 smoke zones. The facility has a capacity of 25 with a census of 4 at the time of this survey.

Findings include:

During the survey on February 6th, 2019 the following observations were made:

It was observed at 10:40 AM above the doors to the Surgery Center on the south side of wall there is a 2-inch pipe that is not sealed.

Staff MD 1 was present and acknowledged the observations:

NFPA Standard: Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)

Based on observation and staff interview the facility fails to maintain solid bonded wood-core smoke barrier doors to at least 20 minute fire resistance. This deficient practice could prevent containment of fire and smoke, affecting all residents and staff in 2 of 6 smoke zones including. The facility has a capacity of 25 and census of 4 at the time of the survey.

Findings include:

During the survey on February 6th, 2019 the following is observed:

1) It was observed at 8:09 AM the doors to the OR have 1/4-inch penetrations in the north and south doors.

Staff MD 1 was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: Openings in smoke barriers shall be protected using one of the following methods: (1) Fire-rated glazing (2) Wired glass panels in steel frames (3) Doors, such as 1 3/4 in. (44 mm) thick, solid-bonded woodcore doors (4) Construction that resists fire for a minimum of 20 minutes.

Based on observation and staff interview, the facility did not ensure that electrical wiring and equipment is installed and maintained in accordance with NAPA 70, National Electrical Code. This deficient practice does not ensure prevention of an electrical fire or electric shock hazard, affecting residents, visitors and staff in 1 of 6 smoke zones. The facility has a capacity of 25 with a census of 4 at the time of this survey.

Findings include:

During the survey on February 6th, 2019 the following was observed:

1) It was observed at 9:00 AM in the ER office there is a multi-plug adapter in use on the south wall.
2) It was observed at 9:19 AM in the kitchen behind the freezer an outlet missing the cover leaving wiring exposed.
3) It was observed at 9:27 am in the house keeping store room an open junction box and broken conduit on the west wall under the breaker box.

Staff MD 1 was present and acknowledged the findings.

Review of the following NAPA Standard revealed: Electrical wiring and equipment shall be in accordance with NAPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. 2012 NFPA 101, 9.1.2

Based upon interview and record review, the facility fails to provide documentation of employee training of the evacuation of the building's smoke zones directly affected by fire. The deficient practice affects all residents, patients, visitors and staff in 6 of 6 smoke zones. The facility has a capacity of 25 with a census of 4 at the time of this survey.

Findings include:

It was observed on February 5th, 2019 at 11:30 AM during documentation review the facility fails to provide documentation of staff training of the fire response and smoke zone evacuation plan.

Staff MD 1 was present and acknowledged the results of the records review.

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

Based on record review and staff interview, the facility is not conducting fire drills as required and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency, affecting all residents in all smoke zones. The facility has a capacity of 25 and a census of 4.

Findings include:

During the survey on February 5th, 2019 the following observations were made

1) It was observed at 11:45 AM during documentation review of the previous five quarters of fire drills the silent night shift drills performed on 3/1/18 and 9/27/18 the staff failed to test the fire alarm system following the drill.2) It was observed at 11:50 AM during the documentation review of the previous five quarters of fire drills the following drills 6/19/18, 10/18/18, and 12/28/17 were conducted as silent drills. The time of these drills are outside of the time frame permitted for silent drills.3) It was observed at 11:55 AM during the documentation review of the previous five quarters of fire drills there was not a drill performed for the 1st shift during the 3rd quarter of 2018.

Staff MD 1 was present and acknowledged the findings.

Review of the following NFPA Standard revealed: 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. Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 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. 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. Employees of health care occupancies shall be instructed in life safety procedures and devices. 2012 NFPA 101, 19.7.1.1-8

Based on observation and interview, the facility fails to prohibit the use of portable space heating devices within the facility without assurance that heating elements do not exceed 212 degrees Fahrenheit. The deficient practice would affect all residents, visitors and staff in 1 of 6 smoke zones. This facility has a capacity of 25 and a census of 4 residents at the time of the survey.

Findings include:

During the survey on February 6th, 2019 the following observations were made

It was observed at 8:44 AM in the Nurse Manager office a portable space heater was in use under the desk. Specification sheets on the space heater showing the heating element would not exceed 212 degrees Fahrenheit (100 degrees Celsius) were not available at the time of inspection.

Staff MD 1 was present and acknowledged the findings.

NFPA Standard: Prohibits the use of portable space heating devices in healthcare occupancies except for nonresident and staff sleeping areas with heating elements that do not exceed 212 degrees. 2012 NFPA 101, 18/19.7.8

Based on observation and staff interview, the facility did not ensure that electrical wiring and equipment is installed and maintained in accordance with NFPA 99, Health Care Facility Code. This deficient practice does not ensure prevention of an electrical fire or electric shock hazard, affecting residents in all smoke zones. This facility has a capacity of 25 with a census of 4 at the time of this survey.

Findings include:


During the survey conducted on February 6th, 2019 it is observed:

1) It was observed during documentation review at 11:00 AM the facility is not conducting and documenting annual assessments of power strips.
2) It was observed at 8:06 AM in the PACU room 1 a non-rated power strip in use within 6 ft of the patient care vicinity.

Staff MD 1 was present and acknowledged the findings.

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

NFPA Standard: Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

NFPA Standard: NFPA 70 2011, 400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following: (1) As a substitute for the fixed wiring of a structure (2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors (3) Where run through doorways, windows, or similar openings (4) Where attached to building surfaces Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B) (5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings (6) Where installed in raceways, except as otherwise permitted in this Code (7) Where subject to physical damage.