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Based on observations and interview, the facility failed to maintain a Type II (III) construction type in 1 location of the facility by allowing a penetration to be present. This effects 1 of 8 smoke zones within the facility. The facility had a capacity of 25 patients and a census of 6 patients.

Findings include:

Observations and interview on 4-25-14 revealed a conduit penetration (approximately 1/2 inch in size) located in the Clinic Electrical Room.


Maintenance Staff A verified this observation at the time of the inspection process.

Based on observations and interview, the facility failed to maintain 3 hazardous rooms properly separated by failing to ensure the door to these rooms automatically close. This affects 1 of 8 smoke zones. The facility had a license capacity of 25 patients and a census of 6 patients.

Findings include:

Observations and interview on 4-25-14 revealed the following storage room doors failed to be equipped with an approved automatic self-closing device. These storage rooms measured over 50 square feet and contained combustible storage items:

1. The Medical Records Room located in the Basement on the East side of the Hallway.
2. The Storage Room located in the Basement.
3. The Medical Records Room located in the Basement on the West side of the Hallway.

Maintenance Staff A verified these observations at the time of the survey process.

Based on observations and interview, the facility failed to provide an approved exit discharge from 5 exits located within the facility. This affects all occupants within the hospital. The facility had a license capacity of 25 patients and a census of 6 patients.

Finding include:

Observations and interview on 4-25-14 revealed the facility failed to provide concrete or asphalt sidewalks that were at least 48 inches wide that provide exit discharges to a public sidewalk, public street or parking lot from the following exits:

1. The south exit from the Basement.
2. The east exit from the Basement.
3. The exit from the O.B Department.
4. The northwest exit from the Clinic.
5. The southwest exit from the Clinic.

Maintenance Staff A verified these observations at the time of the survey process.

(A.)
Based on observations and record review, the facility failed to provide documentation that the battery back-up emergency lighting system was being properly tested on an annual basis. This affects all 8 smoke zones in the facility, affecting all patients and staff members. The facility had a license capacity of 25 patients and a census of 6 patients.

Findings include:

Observations and record review on 4-25-14 revealed the absence of the required 90 minute annual testing of the facilities battery back-up emergency lighting system.

Maintenance Staff A verified this observation at the time of the survey process.

(B.)
Based on observations and interview, the facility failed to maintain 1 emergency light unit is proper working order. This affects 1 of 8 smoke zones within the facility. The facility had a license capacity of 25 patients and a census of 6 patients.

Findings include:

Observations and interview on 4-25-14 revealed the emergency light unit located in the Basement Stairway failed to operate on battery backup when tested.

Staff Member A verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to comply with the fire drill requirements by failing to conduct and document a fire drill on each nursing shift during each quarter year. This would affect all 8 smoke zones, affecting all occupants and staff at the facility. The facility had a capacity of 25 patients and a census of 6 patients.

Findings include:

Record review and interview on 4-25-14 revealed the facility only conducted and documented 6 fire drills during the previous 12 month. They failed to conduct and document a 2nd shift fire drill during the 1st quarter year of 2014. They failed to conduct and document a fire drill during the 2nd and 3rd nursing shifts during the 2nd quarter year of 2013. They failed to conduct and document a fire drill during the 1st and 2nd nursing shifts during the 3rd quarter year of 2013. They failed to conduct and document a fire drill during the 1st nursing shift during the 4th quarter year of 2013.

Staff Member A verified these observations at the time of the survey process.

Based on observations and interview, the facility failed to provide the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code 1999 edition by improperly locating smoke detectors. This affects 2 of 8 smoke zones. The facility had a license capacity of 25 patients and a census of 6 patients.

Findings include:

Observations and interview on 4-25-14 revealed the following:

1. A smoke detector was located closer than 3 feet from an air diffuser (HVAC) in the ceiling near the main Nurses Station.

2. A smoke detector was located closer than 3 feet from an air diffuser (HVAC) in the ceiling in the O.B Department Nurses Area.

Maintenance Staff A verified these observations during the survey process.

Based on record review and interview, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code 1999 edition by failing to have the fire alarm system inspected on a semi-annual basis. This affects all 8 smoke zones, affecting all residents and staff within the facility. The facility had a license of 25 patients and a census of 6 patients.

Findings include:

Record review and interview on 4-25-14 revealed the facility failed to have the fire alarm inspected every six months. Within the previous 12 months, the facilities fire alarm system was only inspected 1 time (2-16-14).

Maintenance Staff A verified this observation during the survey process.

Based on record review and interview, the facility failed to properly document the required testing of the facilities emergency generator, in accordance with National Fire Protection Association (NFPA) Standards 99, 1999 Edition. This affects all 8 smoke zones. The facility had a license of 25 patients and a census of 6 patients.

Finding include:

Record review and interview on 4-25-14 revealed the facility failed to document the required weekly and monthly test of the buildings emergency generator.

Maintenance Staff A verified this observation at the time of the survey process.

Based on observations and interview, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition by a allowing non-operational Ground Fault Circuit Interrupter to be in use. This affects 1 of 8 smoke zones. The facility had a capacity of 25 patients and a census of patients.

Findings include:

Observations and interview on 4-25-14 revealed a faulty Ground Fault Circuit Interrupter (GFCI) located in the north side of the Kitchen.

Maintenance Staff A verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to have an adequate policy in writing that meets the requirements of the 2000 Life Safety Code 9.7.6.1 (plans for automatic sprinkler systems out of service for more than 4 hours in a 24 hour period). This affects all 8 smoke zones, affecting all occupants within the facility. The facility had a license of 25 patients and a census of 6 patients.

Findings include:

Record review and interview on 4-25-14 revealed the written policy that is intended to meet the requirements of the 2000 Life Safety Code 9.7.6.1 (plans for automatic sprinkler systems out of service for more than 4 hours in a 24 hour period) failed to contain the proper phone numbers for notifications. This policy also failed to state that the Department of Inspections and Appeals shall also be notified of the implementation of the fire watch.

Maintenance Staff A verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to have an adequate policy in writing that meets the requirements of the 2000 Life Safety Code 9.6.1.8 (plans for fire alarm systems out of service for more than 4 hours in a 24 hour period). This affects all 8 smoke zones, affecting all occupants within the facility. The facility had a license of 25 patients and a census of 6 patients.

Findings include:

Record review and interview on 4-25-14 revealed the written policy that is intended to meet the requirements of the 2000 Life Safety Code 9.6.1.8 (plans for fire alarm systems out of service for more than 4 hours in a 24 hour period) failed to contain the proper phone numbers for notifications. This policy also failed to state that the Department of Inspections and Appeals shall also be notified of the implementation of the fire watch.

Maintenance Staff A verified this observation at the time of the survey process.

Based on observations and interview, the facility failed to have 1 Alcohol Based Hand Rub Dispenser properly located in the facility. This affects 1 of 8 smoke zones in the facility. The facility has a capacity of 25 patients and a census of 6 patients.

Findings include:

Observations and interview on 4-25-14 revealed an Alcohol Based Hand Rub dispenser that was located above an electrical source (electrical outlet) in the Special Care Unit Room.

Maintenance Staff A verified this observation at the time of the survey process.

Based on observations and interview, the facility failed to maintain a Type II (III) construction type in 1 location of the facility by allowing a penetration to be present. This effects 1 of 8 smoke zones within the facility. The facility had a capacity of 25 patients and a census of 6 patients.

Findings include:

Observations and interview on 4-25-14 revealed a conduit penetration (approximately 1/2 inch in size) located in the Clinic Electrical Room.


Maintenance Staff A verified this observation at the time of the inspection process.

Based on observations and interview, the facility failed to maintain 3 hazardous rooms properly separated by failing to ensure the door to these rooms automatically close. This affects 1 of 8 smoke zones. The facility had a license capacity of 25 patients and a census of 6 patients.

Findings include:

Observations and interview on 4-25-14 revealed the following storage room doors failed to be equipped with an approved automatic self-closing device. These storage rooms measured over 50 square feet and contained combustible storage items:

1. The Medical Records Room located in the Basement on the East side of the Hallway.
2. The Storage Room located in the Basement.
3. The Medical Records Room located in the Basement on the West side of the Hallway.

Maintenance Staff A verified these observations at the time of the survey process.

Based on observations and interview, the facility failed to provide an approved exit discharge from 5 exits located within the facility. This affects all occupants within the hospital. The facility had a license capacity of 25 patients and a census of 6 patients.

Finding include:

Observations and interview on 4-25-14 revealed the facility failed to provide concrete or asphalt sidewalks that were at least 48 inches wide that provide exit discharges to a public sidewalk, public street or parking lot from the following exits:

1. The south exit from the Basement.
2. The east exit from the Basement.
3. The exit from the O.B Department.
4. The northwest exit from the Clinic.
5. The southwest exit from the Clinic.

Maintenance Staff A verified these observations at the time of the survey process.

(A.)
Based on observations and record review, the facility failed to provide documentation that the battery back-up emergency lighting system was being properly tested on an annual basis. This affects all 8 smoke zones in the facility, affecting all patients and staff members. The facility had a license capacity of 25 patients and a census of 6 patients.

Findings include:

Observations and record review on 4-25-14 revealed the absence of the required 90 minute annual testing of the facilities battery back-up emergency lighting system.

Maintenance Staff A verified this observation at the time of the survey process.

(B.)
Based on observations and interview, the facility failed to maintain 1 emergency light unit is proper working order. This affects 1 of 8 smoke zones within the facility. The facility had a license capacity of 25 patients and a census of 6 patients.

Findings include:

Observations and interview on 4-25-14 revealed the emergency light unit located in the Basement Stairway failed to operate on battery backup when tested.

Staff Member A verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to comply with the fire drill requirements by failing to conduct and document a fire drill on each nursing shift during each quarter year. This would affect all 8 smoke zones, affecting all occupants and staff at the facility. The facility had a capacity of 25 patients and a census of 6 patients.

Findings include:

Record review and interview on 4-25-14 revealed the facility only conducted and documented 6 fire drills during the previous 12 month. They failed to conduct and document a 2nd shift fire drill during the 1st quarter year of 2014. They failed to conduct and document a fire drill during the 2nd and 3rd nursing shifts during the 2nd quarter year of 2013. They failed to conduct and document a fire drill during the 1st and 2nd nursing shifts during the 3rd quarter year of 2013. They failed to conduct and document a fire drill during the 1st nursing shift during the 4th quarter year of 2013.

Staff Member A verified these observations at the time of the survey process.

Based on observations and interview, the facility failed to provide the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code 1999 edition by improperly locating smoke detectors. This affects 2 of 8 smoke zones. The facility had a license capacity of 25 patients and a census of 6 patients.

Findings include:

Observations and interview on 4-25-14 revealed the following:

1. A smoke detector was located closer than 3 feet from an air diffuser (HVAC) in the ceiling near the main Nurses Station.

2. A smoke detector was located closer than 3 feet from an air diffuser (HVAC) in the ceiling in the O.B Department Nurses Area.

Maintenance Staff A verified these observations during the survey process.

Based on record review and interview, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code 1999 edition by failing to have the fire alarm system inspected on a semi-annual basis. This affects all 8 smoke zones, affecting all residents and staff within the facility. The facility had a license of 25 patients and a census of 6 patients.

Findings include:

Record review and interview on 4-25-14 revealed the facility failed to have the fire alarm inspected every six months. Within the previous 12 months, the facilities fire alarm system was only inspected 1 time (2-16-14).

Maintenance Staff A verified this observation during the survey process.

Based on record review and interview, the facility failed to properly document the required testing of the facilities emergency generator, in accordance with National Fire Protection Association (NFPA) Standards 99, 1999 Edition. This affects all 8 smoke zones. The facility had a license of 25 patients and a census of 6 patients.

Finding include:

Record review and interview on 4-25-14 revealed the facility failed to document the required weekly and monthly test of the buildings emergency generator.

Maintenance Staff A verified this observation at the time of the survey process.

Based on observations and interview, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition by a allowing non-operational Ground Fault Circuit Interrupter to be in use. This affects 1 of 8 smoke zones. The facility had a capacity of 25 patients and a census of patients.

Findings include:

Observations and interview on 4-25-14 revealed a faulty Ground Fault Circuit Interrupter (GFCI) located in the north side of the Kitchen.

Maintenance Staff A verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to have an adequate policy in writing that meets the requirements of the 2000 Life Safety Code 9.7.6.1 (plans for automatic sprinkler systems out of service for more than 4 hours in a 24 hour period). This affects all 8 smoke zones, affecting all occupants within the facility. The facility had a license of 25 patients and a census of 6 patients.

Findings include:

Record review and interview on 4-25-14 revealed the written policy that is intended to meet the requirements of the 2000 Life Safety Code 9.7.6.1 (plans for automatic sprinkler systems out of service for more than 4 hours in a 24 hour period) failed to contain the proper phone numbers for notifications. This policy also failed to state that the Department of Inspections and Appeals shall also be notified of the implementation of the fire watch.

Maintenance Staff A verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to have an adequate policy in writing that meets the requirements of the 2000 Life Safety Code 9.6.1.8 (plans for fire alarm systems out of service for more than 4 hours in a 24 hour period). This affects all 8 smoke zones, affecting all occupants within the facility. The facility had a license of 25 patients and a census of 6 patients.

Findings include:

Record review and interview on 4-25-14 revealed the written policy that is intended to meet the requirements of the 2000 Life Safety Code 9.6.1.8 (plans for fire alarm systems out of service for more than 4 hours in a 24 hour period) failed to contain the proper phone numbers for notifications. This policy also failed to state that the Department of Inspections and Appeals shall also be notified of the implementation of the fire watch.

Maintenance Staff A verified this observation at the time of the survey process.