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Based on observation and staff interview, the facility failed to provide walls free from holes and penetrations. This deficient practice would allow smoke products to travel from room to room and into the attic area, affecting residents and staff in 1 of 7 smoke zones. The facility has a capacity of 42 and census of 1 at the time of the survey.

Findings include:

During the survey on September 19th, 2018 the following observations were made

1) 1:29 p.m. It was observed in the OB family room there are 5 penetration holes 1/2 in diameter on the north wall.

Staff M1 was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: Any vertical opening shall be enclosed or protected in accordance with Section 8.6, unless otherwise modified by 19.3.1.1 through 19.3.1.8. (2012) NFPA 101, 19.3.1.

Review of the following NFPA Standard revealed: Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating. (2012) NFPA 101, 19.3.1.1

Review of the following NFPA Standard revealed: Unprotected vertical openings in accordance with 8.6.9.1 shall be permitted. (2012) NFPA 101, 19.3.1.2

Review of the following NFPA Standard revealed: 8.4.4 Penetrations. The provisions of 8.4.4 shall govern the materials and methods of construction used to protect through penetrations and membrane penetrations of smoke partitions.

Review of the following NFPA Standard revealed: .4.4.1 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 smoke partition shall be protected by a system or material that is capable of limiting the transfer of smoke.

Based on observation and staff interview, the facility failed to provide egress doors without a latch or a lock that requires the use of a tool or key or special knowledge to exit the facility in an emergency. This deficient practice affects all patient, staff and visitors in 2 of 7 smoke zones. This facility has a capacity of 42 with a census of 1 at the time of this survey.

Findings include:

During the survey on September 19th, 2018 the following is observed:

1) 11:14 a.m. It was observed the two inside south egress doors from the business office hall have a dead bolt lock on the east door and flush bolt locks on the west door that are in use.

2) 11:23 a.m. It was observed in the southeast annex office the east egress door in the south hallway has a deadbolt lock on the door.

3) 11:24 a.m. It was observed in the southeast annex office the east egress door in the north hallway has a deadbolt lock.

4) 11:32 a.m. It was observed in the south west annex - HR hall the west egress door has a dead bolt lock in use.

5) 11:37 a.m. It was observed the south west annex the Hospice west egress door has a deadbolt in use.

6) 1:51 p.m. It was observed in the basement corridor west of PT the egress door has a deadbolt lock.

7) 1:52 p.m. It was observed in the basement corridor west of PT the outside egress door is a cellar type door that lays horizontal requiring special knowledge and strength to exit the egress door.


Staff M1 was present and acknowledged the findings:


NFPA Standard: Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the
egress side. (2012) NFPA 101 7.2.1.5.3

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 residents, visitors, and staff in 3 of 7 smoke zone. The facility has a capacity of 42 with a census of 1 at the time of the survey.

Findings include:

During the survey conducted on September 19th, 2018 the following deficiency is noted:

1) 11:19 a.m. It was observed in the south east annex office the emergency light on the south hallway wall will not illuminate upon test.

2) 11:24 a.m. It was observed in the southeast annex office the north hallway the emergency light does not illuminate upon test.

3) 1:14 p.m. It was observed in the pharmacy the emergency light does not illuminate upon test.

4) 1:15 p.m. It was observed in Respiratory Therapy the emergency light on the north wall does not illuminate upon test.

5) 1:53 p.m. It was observed in the basement corridor west of PT the emergency light for the north egress door does not illuminate upon test.

Staff member M1 was present and acknowledged the finding.
NFPA Standard: Emergency lighting of at least 1 1/2 hour duration is provided automatically in accordance with (2012) NFPA 10 7.9, 19.2.9.1

NFPA Standard: 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. NFPA 101 2012 7.9.3.1.

Based on observation, record review and interview the facility fails to ensure 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 staff and residents in 3 of 7 smoke zones. The facility has a capacity of 42 and census of 1 at the time of the survey.

Findings include:

During the survey on September 19th, 2018 the following observations were made:

1. 12:13 p.m. It was observed in the X-ray storage room area the fire inspection pipe is blocked by storage and is inaccessible.

2) 1:45 p.m. It was observed in the basement west storage room the riser needs a hydraulic data plate.

3) 2:43 p.m. It was observed in the laundry room the north sprinkler head is dirty.

Staff M1 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 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 patients, visitors and staff in 3 of 7 smoke zones. The facility has a capacity of 42 with a census of 1 at the time of this survey.

Findings include:

During the survey on September 19th, 2018 the following was observed:
1) 11:37 a.m. It was observed in the south annex office's the sinks have receptacles within 6' with no GFCI.
2) 12:12 p.m. It was observed in the X-ray storage area the electrical panel is blocked.
3) 2:16 p.m. It was observed in the basement old beauty parlor the electrical panel have an open spot with electrical components exposed.
Staff M1 was present at the time of the survey and acknowledged the finding.

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 NAPA 101, 9.1.2

Based upon interview and record review, the facility fails to provide training for the staff on basic response, the fire safety plan and for the evacuation of the building's smoke zones directly affected by fire. The deficient practice affects all patients, staff and visitors in 7 of 7 smoke zones. The facility has a capacity of 42 with a census of 1 at the time of this survey.

Findings include:

During the survey on September 18th, 2018 the following observations were made:

1) (Repeat Violation) It was observed during the records review there is no documentation of in service training for the staff of the facility for fire response, smoke zone evacuation and the fire safety plans. (Fire drills have been conducted)

Staff member M1 was present and acknowledged the findings.

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 observation and interview, the facility failed to maintain proper space heating appliances within the facility that have heating elements limited to 212 degrees Fahrenheit. The deficient practice would affect all residents, visitors and staff in 1 of 7 smoke zones. This facility has a capacity of 42 and a census of 1 patient at the time of the survey.

Findings include:

During the tour conducted on September 19th, 2018 (3) portable space heaters were observed in the south annex office areas. as follows: (2) in the HR offices and (1) in the CFO's Office. (Noted in the HR office area one of the rooms has been made into a bedroom for staff to sleep). 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 M1 was present and acknowledged the findings.

NFPA Standard: Portable Space-Heating Devices. Portable spaceheating devices shall be prohibited in all health care occupancies,
unless both of the following criteria are met: (2012) NFPA 101 19.7.8

(1) Such devices are used only in nonsleeping staff and employee areas.

(2) The heating elements of such devices do not exceed 212°F (100°C).

Based upon a review of records and staff interview, the facility fails to provide a documented repair maintenance program for gas and vacuum piped systems. The deficient practice reduces the reliability of the medical gas systems, affecting the entire hospital. The facility has a capacity of 42 with a census of 1 at the time of this survey.

Findings include:

During the survey conducted on September 18th, 2018 the following discrepancies were observed:

1) It was observed there was an inspection of the hospital's medical gas (Med Gas) on 08/28/2017; (35) discrepancies were noted at that time. Documentation reveals that many of the 35 items have been repaired however the following list of items were not repaired by the July 2018 completion date submitted by the hospital to the Office of the State Fire Marshal.

a) #1 Vacuum: No flexible connectors on compressor outlet pipes.

b) #4 Vacuum: Receiver cannot be isolated from system.

c) #10 Vacuum: Medical vacuum exhaust is not located remote from any door, window, or other building opening.

d) #11 Vacuum: Vacuum exhaust is not located 10 feet away from any air intake into the facility.

e) #12 Vacuum: Vacuum exhaust discharge is not turned down.

f) #13 Vacuum: Vacuum exhaust discharge is not screened.

g) #27 ER: No area alarm panel.


Staff Members CNO and M1 were present and acknowledged the findings.

NFPA Standard: Medical gas, vacuum, WAGD, or support gas systems have documented maintenance programs. The program includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets. Inspection and maintenance schedules are established through risk assessment considering manufacturer recommendations. Inspection procedures and testing methods are established through risk assessment. Persons maintaining systems are qualified as demonstrated by training and certification or credentialing to the requirements of AASE 6030 or 6040.
5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14, 5.3.13.4.2 (NFPA 99)

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, impacting all residents, staff, and visitors in 2 of 7 smoke zones. The facility has a capacity of 42 with a census of 1 at the time of the survey.

Findings include:

During the survey conducted on September 18th and 19th, 2018 it is observed:

1) It was observed during documentation review that the facility does not have a policy in place to ensure that assessments of power strips are conducted on a yearly basis.

2) 11:34 a.m. It was observed in the HR hall the bedroom has a multi-plug extension cord in use.

3) 11:47 a.m. It was observed in the payroll office there are daisy chained power strips under the desk.

4) 2:10 p.m. It was observed in the basement IT room there are multiple (7) daisy chained power strips.

Staff M1 was present and acknowledged the finding.

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.