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Based on staff interview, and review of the code foot print, the facility does not have a 2 hour wall separating the different occupancies as required by NFPA 101 Life Safety Code. The deficient practice would affect all residents, visitors, and staff in 6 of 6 smoke zones. The Hospital and LTCU were both inspected as there is no 2 hour fire wall between the facilities. The Hospital has a capacity of 25 with a census of 19 at the time of the survey. The LTCU has a capacity of 37 with a census of 37 at the time of the survey.

Findings include:

During the portion of the tour conducted on 12/19/18 at approximately 1:30 p.m., a review of the code compliance document reveals that there is no 2 hour wall separation between the Hospital and the LTCU.

Staff M-1 was present and acknowledged there was no 2 hour wall separation.

NFPA Standard: Sections of health care facilities shall be permitted to be classified as other occupancies, provided that they meet all of the following conditions: (1) They are not intended to provide services simultaneously for four or more inpatients for purposes of housing, treatment, or customary access by inpatients incapable of self preservation. (2) They are separated from areas of health care occupancies by construction having a minimum 2-hour fire resistance rating in accordance with Chapter 8. (3) For other than previously approved occupancy separation arrangements, the entire building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. NFPA Life Safety Code 101 19.1.3.3

Based upon observation and staff interview, the facility fails to assure that proper delayed egress signage is posted as required. Failure to have the delayed egress signage posted could result in the door operator not completing the pressure requirement for the required time and not being able to exit the building during an emergency, affecting all LTCU residents, visitors and staff in 3 of 6 smoke zones, including the activity and dining rooms. The LTCU portion of the facility has a capacity of 37 with a census of 37 at the time of this survey. The hospital portion of the facility has a capacity of 25 with a census of 19 at the time of this survey.

Findings include:

During the tour conducted on 12/20/18, it is observed:

-- 1. At 12:27 p.m., clear glass egress doors located at the LTCU west wing exit have signage that is red letters on a clear background posted adjacent to the release device in the direction of egress. Proper signage is posted above the doors but is not located on the door leaf adjacent to the release device in the direction of egress as required.

-- 2. At 12:44 p.m., clear glass egress door located at the LTCU south wing exit has signage that is red letters on a clear background and not a contrasting background as required.

NFPA Standard: 101 2012 ed. 7.2.1.6.1.1 Approved, listed, delayed-egress locking systems shall be permitted to be installed on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6 or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 11 through 43, provided that all of the following criteria are met: (1) The door leaves shall unlock in the direction of egress upon actuation of one of the following: (a) Approved, supervised automatic sprinkler system in accordance with Section 9.7 (b) Not more than one heat detector of an approved, supervised automatic fire detection system in accordance with Section 9.6 (c) Not more than two smoke detectors of an approved, supervised automatic fire detection system in accordance with Section 9.6 (2) The door leaves shall unlock in the direction of egress upon loss of power controlling the lock or locking mechanism. (3)*An irreversible process shall release the lock in the direction of egress within 15 seconds, or 30 seconds where approved by the authority having jurisdiction, upon application of a force to the release device required in 7.2.1.5.10 under all of the following conditions: (a) The force shall not be required to exceed 15 lbf (67 N). (b) The force shall not be required to be continuously applied for more than 3 seconds. (c) The initiation of the release process shall activate an audible signal in the vicinity of the door opening. (d) Once the lock has been released by the application of force to the releasing device, relocking shall be by manual means only. (4)*A readily visible, durable sign in letters not less than 1 in. (25 mm) high and not less than 1?8 in. (3.2 mm) in stroke width on a contrasting background that reads as follows shall be located on the door leaf adjacent to the release device in the direction of egress: PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS (5) The egress side of doors equipped with delayed-egress locks shall be provided with emergency lighting in accordance with Section 7.9.

NFPA standard: 7.1.10.1* General. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on observation and staff interview the facility fails to ensure proper separation of hazardous areas from other spaces. This deficient practice would not prevent the passage of smoke and fire into other areas of the building, affecting all LTCU residents, visitors and staff in 1 of 6 smoke zones, including the living room and dining rooms. The LTCU portion of the facility has a capacity of 37 with a census of 37 at the time of this survey. The hospital portion of the facility has a capacity of 25 with a census of 19 at the time of this survey.

Findings include:

During the portion of the tour conducted on 12/20/18, at 12;07 p.m., in the LTCU portion of the facility, it is observed that the office for the Activities Director is also used as a storage room for activities supplies and miscellaneous combustible items. The door is not self-closing and no automatic door closer is provided.

Staff M-1 and Staff A-1 were present and acknowledged the findings at the time of discovery.

NFPA Standard: Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. 2012 NFPA 101, 19.3.2.1

NFPA Standard: Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. 19.3.2.1

Based upon observation and staff interview, the facility fails to assure that fuel sources for appliances under the kitchen exhaust hood system are arranged to have the source automatically interrupted during activation of the fixed fire extinguishing system as required in NFPA 96. The deficient practice would allow the fuel supplying the appliances to continue operation affecting no patients or residents and any visitors or staff in 1 of 6 smoke zones. The LTCU portion of the facility has a capacity of 37 with a census of 37 at the time of this survey. The hospital portion of the facility has a capacity of 25 with a census of 19 at the time of this survey.

Findings include:

During the portion of the tour conducted on 12/20/18, at 11:30 a.m., it is observed that there is no shutoff device to assure discontinuation of the natural gas supply to the cooking stove.

Staff M-1 was present and acknowledged the findings at the time of discovery.

NFPA Standard: Upon activation of any fire-extinguishing system for a cooking operation, all sources of fuel and electrical power that produce heat to all equipment requiring protection by that system shall automatically shut off. Steam supplied from an external source shall not be required to automatically shut off. Any gas appliance not requiring protection but located under the same ventilating equipment shall also automatically
shut off upon activation of any extinguishing system. Shutoff devices shall require manual reset. NFPA 96, 2011 ed. 10.4.1

Based on observation and record review, the facility fails to assure that the fire alarm system is installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. The deficient practice does not assure that all devices will operate as designed, affecting all patients, residents, staff and visitors in 6 of 6 smoke zones. The LTCU portion of the facility has a capacity of 37 with a census of 37 at the time of this survey. The Hospital portion of the facility has a capacity of 25 with a census of 19 at the time of this survey.

Findings include:

During the portion of the tour conducted on 12/19/18, at 2:44 p.m., during records review, it is observed:

-- 1. Review of the last fire alarm inspection form dated 01/25/2018 from the service vendor revealed that devices located in roof top penthouses (3) were not tested. Vendor report noted "Did not test due to possibly ice on roof". Observation of the Fire Alarm Control Panel revealed "System Is Normal".

Staff M-1 was present and acknowledged the findings.

NFPA Standard: A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. 2012 NFPA 101, 9.6.1.3

NFPA Standard: A complete record of the tests and operations of each system shall be kept until the next test and for 1 year thereafter. The record shall be available for examination and, if required, reported to the authority having jurisdiction. Archiving of records by any means shall be permitted if hard copies of the records can be provided promptly when requested. If off-premises monitoring is provided, records of all signals, tests, and operations recorded at the supervising station shall be maintained for not less than 1 year. 2010 NFPA 72 10.18.3

NFPA Standard: Smoke detector sensitivity shall be checked within one year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed. 2010 NFPA 72, 14.4.5.3

Based on observation and record review, the facility fails to assure that the fire alarm system is installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. The deficient practice does not assure that all devices will operate as designed, affecting all patients, residents, staff and visitors in 6 of 6 smoke zones. The LTCU portion of the facility has a capacity of 37 with a census of 37 at the time of this survey. The Hospital portion of the facility has a capacity of 25 with a census of 19 at the time of this survey.

Findings include:

During the portion of the tour conducted on 12/19/18, at 2:44 p.m., during records review, it is observed:

-- 1. Review of the last fire alarm inspection form dated 01/25/2018 from the service vendor revealed that devices located in roof top penthouses (3) were not tested. Vendor report noted "Did not test due to possibly ice on roof". Observation of the Fire Alarm Control Panel revealed "System Is Normal".

Staff M-1 was present and acknowledged the findings.

NFPA Standard: A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. 2012 NFPA 101, 9.6.1.3

NFPA Standard: A complete record of the tests and operations of each system shall be kept until the next test and for 1 year thereafter. The record shall be available for examination and, if required, reported to the authority having jurisdiction. Archiving of records by any means shall be permitted if hard copies of the records can be provided promptly when requested. If off-premises monitoring is provided, records of all signals, tests, and operations recorded at the supervising station shall be maintained for not less than 1 year. 2010 NFPA 72 10.18.3

NFPA Standard: Smoke detector sensitivity shall be checked within one year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed. 2010 NFPA 72, 14.4.5.3

Based on observation and record review, the facility fails to assure that the fire alarm system is installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. The deficient practice does not assure that all devices will operate as designed, affecting all patients, residents, staff and visitors in 6 of 6 smoke zones. The LTCU portion of the facility has a capacity of 37 with a census of 37 at the time of this survey. The Hospital portion of the facility has a capacity of 25 with a census of 19 at the time of this survey.

Findings include:

During the portion of the tour conducted on 12/19/18, at 2:44 p.m., during records review, it is observed:

-- 1. Review of the last fire alarm inspection form dated 01/25/2018 from the service vendor revealed that devices located in roof top penthouses (3) were not tested. Vendor report noted "Did not test due to possibly ice on roof". Observation of the Fire Alarm Control Panel revealed "System Is Normal".

Staff M-1 was present and acknowledged the findings.

NFPA Standard: A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. 2012 NFPA 101, 9.6.1.3

NFPA Standard: A complete record of the tests and operations of each system shall be kept until the next test and for 1 year thereafter. The record shall be available for examination and, if required, reported to the authority having jurisdiction. Archiving of records by any means shall be permitted if hard copies of the records can be provided promptly when requested. If off-premises monitoring is provided, records of all signals, tests, and operations recorded at the supervising station shall be maintained for not less than 1 year. 2010 NFPA 72 10.18.3

NFPA Standard: Smoke detector sensitivity shall be checked within one year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed. 2010 NFPA 72, 14.4.5.3

Based on observation and staff interview, the facility did not ensure that electrical wiring and equipment is installed and maintained in accordance with NFPA 70, National Electrical Code. This deficient practice does not ensure prevention of an electrical fire or electric shock hazard, affecting all residents, visitors and staff in 6 of 6 smoke zones including the living room and dining rooms. The LTCU portion of the facility has a capacity of 37 with a census of 37 at the time of this survey. The hospital portion of the facility has a capacity of 25 with a census of 19 at the time of this survey.

Findings include:

During the portion of the tour conducted on 12/19/18, during a review of records between 1:15 p.m. and 4:00 p.m., it is revealed:

-- 1. The facility does not have a policy in place to ensure that assessments of power strips are conducted on a yearly basis.

During the portion of the tour conducted on 12/20/18, it is revealed:

-- 2. At various times in the afternoon and in multiple resident rooms throughout the LTCU portion of the facility, standard UL rated power strips were in use in patient care rooms. The power strips do not meet the requirements of NFPA 99.

-- 3. At 12:30 p.m., in resident room 101 in the LTCU portion of the facility, multiple multi-plug adapters were used to power personal electronics.

Staff M-1 was present and acknowledged the findings.

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.

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