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Based on observation, the facility failed to provide signage on one exterior exit access door equipped with a delayed locking device. This deficient practice has the potential to affect patients, staff and visitors. Failure to provide signage indicating a delayed lock door release procedure on an exit door has the potential to delay exiting the building in the event of an emergency. The census was 21.

Observation on 5/17/2017, during the facility tour, showed the designated exit/courtyard door in the New Hope unit equipped with a delayed egress locking mechanism. Observation did not show a sign adjacent to the locking device indicating the locking mechanism procedure.


7.2.1.6.1 Delayed-Egress Locking Systems.
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 UNTILALARM 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.

Based on observation, staff interview, and record review, the facility staff failed to provide continuously maintained exit ways free of all obstructions or impediments continuous to a public way such as a parking lot. This deficient practice affects two of five exit discharge areas. This deficient practice has the potential to affect all patients, staff and visitors in the facility. Failure to ensure exterior exit ways comply with LSC requirements could delay evacuation out of the building in the event of a fire or other emergency. The facility census was 21.


1. Observation on 05/17/17, during the facility tour, showed the following hallway exit discharge areas led to a grass covered yard that required residents, staff, and visitors to traverse grass, gravel and pass thru doorway exterior area to reach the parking lot:

-New Hope designated exit exterior cement sidewalk continuing 150 feet to the parking lot

-Stairwell #1 exit from courtyard gate thru loose gravel area, enter loading dock area through a door and travel through a loading dock containing large quantities of combustibles

Record review of the facility layout showed the exit discharge areas designated for patient use.

During an interview on 05/18/17, the Facilities Services Manager said the exit paths were constructed with the building.


The National Fire Protection Association 101, Life Safety Code 2012 Edition, section 7.7 states:


7.7 Discharge from Exits.

7.7.1* Exit Termination. Exits shall terminate directly, at a
public way or at an exterior exit discharge, unless otherwise
provided in 7.7.1.2 through 7.7.1.4.

Based on observation and facility staff interview, the facility staff failed to ensure all designated exit corridors are illuminated with emergency egress lights not controlled by a light switch. One designated exit corridor contained switches controlling the emergency egress lighting fixtures. Failure to provide emergency egress lighting fixtures not controlled by a light switch has the potential to affect all facility residents. This deficient practice could delay the safe evacuation of patients, staff and visitors in the event of an emergency. The facility census was 21.


1. Observation on 5/17/17, during the building tour, showed the New Hope Unit designated exit hallway contained switches controlling the emergency egress lighting fixtures.

During an interview on 5/17/17 at 1:40 P.M., the Facilities Services Manager said the emergency lights were installed during the building construction.


19.2.8 Illumination of Means of Egress. Means of egress shall
be illuminated in accordance with Section 7.8.


7.8.1.2 Illumination of means of egress shall be continuous
during the time that the conditions of occupancy require that
the means of egress be available for use, unless otherwise provided
in 7.8.1.2.2.

Based on observation and facility staff interview, facility staff failed to provide emergency lighting not controlled by light switches inside one medication room. This deficient practice has the potential to affect all patients within the nursing unit served by the medication room. Failure to provide emergency lighting could prevent proper illumination of required areas in the event of power loss. The facility census was 21.

1. Observations on 05/17/17, during the Life Safety Code (LCS) tour, showed the light fixtures in the New Hope unit medication room controlled by a light switch.

During an interview on 5/17/17 at 2:09 P.M., the Facilities Services Manager said the emergency lights always had light switches and were installed during the building construction.


NFPA 99, 2012 edition, section 6.4.2.2.4.2 states:

"6.4.2.2.4.2 The critical branch shall supply power for task illumination,
fixed equipment, select receptacles, and select power
circuits serving the following areas and functions related to patient
care:
(1) Critical care areas that utilize anesthetizing gases, task illumination,
select receptacles, and fixed equipment
(2) Isolated power systems in special environments
(3) Task illumination and select receptacles in the following:
(a) Patient care rooms, including infant nurseries, selected
acute nursing areas, psychiatric bed areas (omit receptacles),
and ward treatment rooms
(b) Medication preparation areas
(c) Pharmacy dispensing areas
(d) Nurses ' stations (unless adequately lighted by corridor
luminaires)
(4) Additional specialized patient care task illumination and
receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7)*Telephone equipment rooms and closets
(8) Task illumination, select receptacles, and select power circuits
for the following areas:
(a) General care beds with at least one duplex receptacle
per patient bedroom, and task illumination as required
by the governing body of the health care facility
(b) Angiographic labs
(c) Cardiac catheterization labs
(d) Coronary care units
(e) Hemodialysis rooms or areas
(f) Emergency room treatment areas (select)
(g) Human physiology labs
(h) Intensive care units
(i) Postoperative recovery rooms (select)
(9) Additional task illumination, receptacles, and select power
circuits needed for effective facility operation, including
single-phase fractional horsepower motors, which are permitted
to be connected to the critical branch"

Based on record review and facility staff interview, facility staff did not ensure all devices connected to the fire alarm system were inspected and tested per NFPA 72, National Fire Alarm and Signaling Code, 2010 edition. This deficient practice has the potential to affect all patients, staff and visitors. Failure to inspect/test all components connected to the fire alarm system could delay emergency services response and evacuation out of the building in the event of a fire or other emergency. The facility census was 21.

Record review of the annual fire alarm inspection dated 09/2016 did not show inspections and connection function tests for the following:

-smoke detector sensitivity testing
-semi annual fire alarm testing
-kitchen range hood to fire alarm connection

Record review of the annual fire alarm inspections for 2015 and 2016 did not show smoke detector sensitivity testing for the facility smoke detectors.

During an interview on 5/17/2017, the Facilities Services Manager said he believed the fire alarm inspection company did the inspections per code requirements.

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, Table 14.3.1, Table 14.4.2.2, Table 14.4.5, sections 14.4.5, 14.4.5.3.1 through section 14.4.5.4 for additional testing information.

Based on observation, facility staff failed to ensure areas open to the corridor contain smoke detection
per NFPA 72, National Fire Alarm and Signaling Code. This deficient practice has the potential to effect all facility patients, staff and visitors. This deficient practice could delay fire and emergency personnel response in the event of a fire. The facility census was 21.

Observations on 5/17/2017, during the facility tour, showed the following areas open to the designated exit corridors requiring smoke detectors:

-Lab waiting room
-Radiology hallway storage alcove
-Labor & Delivery waiting room


19.3.4.1 General. Health care occupancies shall be provided
with a fire alarm system in accordance with Section 9.6.

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, sections 17.6.3 Location and Spacing and 17.6.3.3.1 Spacing for additional information.

Based on observation and facility staff interview, facility staff failed to ensure the building sprinkler system met NFPA 13, Standard For The Installation Of Sprinkler Systems, 2010 edition installation requirements. This deficient practice could delay prompt fire extinguishment and evacuation in the event of a fire. The facility census was 21.

Observation on 5/17/2017, during the facility tour, did not show a sprinkler head at the first landing above the bottom of the shaft of stairwell #2. Observation showed the stairwell served the ground floor thru the second floor.

Record review of the emergency evacuation plan showed stairwell #2 designated for patient use.

During an interview on 5/17/2017 at 4:35 P.M., the Facilities Services Manager stated stairwell #2 was constructed in 2006 and never had sprinkler coverage.

NFPA 13, 2010 Edition, Section 8.15.3.2.1 states:

8.15.3.2 Noncombustible Construction.
8.15.3.2.1 In noncombustible stair shafts having noncombustible
stairs with noncombustible or limited-combustible
finishes, sprinklers shall be installed at the top of the shaft
and under the first accessible landing above the bottom of
the shaft.

Based on staff interview and record review, facility staff failed to inspect the one wet & one dry sprinkler systems per NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition. The facility census was 21.

Record review on 5/17/2017 did not show the 5 year internal pipe inspections & gauge replacements/calibrations for the one wet and one dry sprinkler systems.

During an interview on 5/17/2017 at 11:45 A.M., the Director of Facilities said the sprinkler inspections were missed.

Refer to NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition, Chapters 5, 13 and 14 for additional information.

Based on observation and facility staff interview, facility staff failed to ensure corridor doors closed and latched without being blocked when corridor doors had doorstops attached to the corridor door. This deficient practice has the potential to affect all patients, staff and visitors. Failure to ensure corridor doors were not blocked from closing and latching has the potential to prevent or delay evacuation out of the building in the event of a fire or other emergency by allowing smoke, fumes and the products of fire from entering the exit corridors in the event of a fire. The facility census was 21.

Observation on 5/17-18/2017, during the building tour, showed the following doors equipped with kick down doorstops:

-door between obstetrics breakroom and obstetrics nurse's station
-financial counselor's office
-Admitting to emergency department hallway door
-Mammography door on radiology hallway


During an interview on 5/17/2017, the Director of Facilities said he did not know when the doorstops were installed in the building.

19.3.6.3.10* Doors shall not be held open by devices other
than those that release when the door is pushed or pulled.

Based on observation, facility staff failed to ensure one soiled utility room was adequately vented and kept under a relative negative pressure. This deficient practice has the potential to effect all residents, staff and visitors. Failure to provide adequate ventilation could increase the concentration of smoke, products of combustion and noxious fumes. The facility census was 21.

Observation on 5/18/17 at 11:46 A.M., showed the soiled utility room on the radiology hallway did not have functioning exhaust ventilation.