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42 CFR 482.41(b)
Horn Memorial Hospital was found to be not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 482.41(b), Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101 - 2012 edition.

Horn Memorial is a two story building that was built in 1989 with additions in 2004, 2007 and 2017. The building is composed of construction type II construction. The facility is fully sprinklered and there is supervised smoke detection located in the corridors, resident rooms and the spaces open to the corridors.

The facility has 25 certified beds. At the time of the survey the census was census 11.
The requirement at 42 CFR 482.41(b) is NOT MET as evidenced by:

Based on observations and interviews, the facility was a (Type III Construction) facility and the facility was a two story building which is not in accordance with the construction type as required by Section 19.1.6.2 through 19.1.6.7, of the 2012 Life Safety Code. This deficient practice would affect approximately all residents and all smoke zones within the facility. This facility had a capacity of 25 residents and a census of 11 residents on the date of inspection.

Findings Include:

1. Observations and staff interviews on 04/19/18 at 9:38 am , revealed a gap (approximately 1/2 inch) around a 3 pipe penetration located above the fire doors on the 2hr wall between the New Addition and Same Day Surgery.
2. Observations and staff interviews on 04/19/18 at 9:38 am, revealed a gap (approximately 1 inch) around a 1 ft x3 ft HVAC Duct located above the door on the 2 hr wall between the New Addition and Same Day Surgery.


Maintenance Staff A verified these observations

Based on record review and interview, the facility failed to provide emergency lighting units throughout the facility as required by Sections 19.2.9.1 and 7.9 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition. This deficient practice would affect all residents and staff using the Basement Storage Room and one of 11 smoke zones. This facility had a capacity of 25 residents and a census of 11 residents on the date of inspection.
Findings included:
Observations and staff interviews on 04/19/18 at 10:23 am, revealed the emergency light located in the Basement Storage Room was not functioning properly when tested during this survey.
Maintenance Staff A verified these observations.

Based on observations and interviews this facility failed to provide a fire alarm system that could be initiated by manual means according to 18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2 and 9.6.2.5 of the National Fire Protection Association Code 101 Life Safety Code 2012 Edition. This deficiency would affect all residents and staff and all smoke zones in the building. The facility had a capacity of 25 and a census of 11 at the time of this survey.

Findings Include:

1. Observations and staff interviews on 04/19/18 at 9:50 am, revealed the access to the pull station located by the ER exit was blocked by several wheel chairs.

2. Observations and staff interviews on 04/19/18 at 9:56 am, revealed a para glide that was blocking the access to the pull station located in the Basement Stairway.

Maintenance Staff A verified these observations.

Based on observation, record review, and interview, the facility failed to provide/maintain the building ' s sprinkler system in reliable operating condition and/or maintain proper testing and maintenance in accordance with the National Fire Protection Association (NFPA) Standard 25, Inspections, Testing, and Maintenance of Sprinkler Systems, 2010 edition, the NFPA Standard 13, Standard for the Installation of Sprinkler Systems, 2010 edition, and Sections 19.7.6 of the NFPA Standard 101, Life Safety Code, 2012 edition. This deficient practice would affect approximately all residents within the facility. This facility had a capacity of 25 residents and a census of 11 residents on the date of inspection.

Findings Include:

Observations and staff interviews on 04/19/18 at 9:07 am, revealed the facility failed to provide documentation of any quarterly sprinkler inspections for 2017.


Maintenance Staff A verified these observations.

Based on record review and interview, the facility failed to provide an approved fire watch policy that was in accordance with Section 9.7.5(NFPA 25) and Section19.3.5.1 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition. This deficient practice would affect approximately all residents within the facility. This facility had a capacity of 25 residents and a census of 11 residents on the date of inspection.
Findings Include:
Observations, record review and staff interviews on 04/19/18 at 9:50 am, revealed the facility failed to provide proper documentation of instruction in the event of a sprinkler system failure.
Maintenance Staff A verified these observations.

Based on record review and interview, the facility failed to inspect and maintain the fire extinguishers according as required by National Fire Protection Association 10 and Sections 18.3.5.12, 19.3.5.12, of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition. This facility had a capacity of 25 residents and a census of 11 residents on the date of inspection.

Findings Include:

Observations, record review and staff interviews on 04/19/18 at 9:18 pm, revealed a flash light on a fire extinguisher located in the Mail Room. This flashlight would hamper the access to the fire extinguisher.


Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to maintain the building ' s electrical wiring and equipment in accordance with the National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 2010 edition. This facility had a capacity of 25 residents and a census of 11 residents on the date of inspection.

Findings Include:

Observations and staff interviews on 04/19/18 at 9:05 am, revealed Breakers 2,4,6,8,10,13,15,17 located in Panel LS1 were labled spare and were in the on position.


Maintenance Staff A verified these observations.

Based on record review and interview, the facility failed to provide fire drills that were conducted at times and dates that were varied as required by Section A.19.7.1.2 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition. This deficient practice would affect all residents and all smoke zones within the facility This facility had a capacity of 25 residents and a census of 11 residents on the date of inspection.

Findings Include:

Observations, record review and staff interviews on 04/19/18 at 9:50 am, revealed a second quarter fire drill was not conducted for the evening shift and a third quarter night shift fire drill was also not documented.

Maintenance Staff verified these observations.

Observations and staff interviews revealed the facility failed to properly labile and store the oxygen containers in accordance to 11.3.1,11.3.2,11.3.3,.11.3.4,.of the National Fire Protection Association Standard 101 Life safety Code 101 2012 Edition and 6.5 of National Fire Protection Standard 99 2012 Edition. The facility has a capacity of 25 and a census of 11 at the time of the survey.

Findings Include:

Observations and staff interviews on 04/19/18 at 9:50 am, revealed two full and two empty oxygen containers that were not properly marked located in the Oxygen Storage Room.


Maintenance Staff A verified these observations.