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Based on observation and staff interview the facility fails to properly maintain their means of egress as required in Life Safety Code 101. The deficient practice would affect no patients, and all visitors and staff in 1 of 5 smoke zones. The facility has a capacity of 20 and at the time of the survey the census was 5.

Findings include:

During the survey conducted on 2/20/19 the following deficiency is noted:

1. During the survey at 3:07 PM, it is observed that there are wheel chairs and other medical equipment on both sides of the exit corridor near the back exit from the ER.

Staff A was present and acknowledged the finding.

NFPA Standard: Any required aisle, corridor, or ramp shall be not less than 48 in. (1220 mm) in clear width where serving as means of egress from patient sleeping rooms, unless otherwise permitted by one of the following: (1) Aisles, corridors, and ramps in adjunct areas not intended for the housing, treatment, or use of inpatients shall be not less than 44 in. (1120 mm) in clear and unobstructed width.
(2) Where corridor width is at least 6 ft (1830 mm), noncontinuous projections not more than 6 in. (150 mm) from the corridor wall, above the handrail height, shall be permitted. (3) Exit access within a room or suite of rooms complying with the requirements of 19.2.5 shall be permitted. (4) Projections into the required width shall be permitted for wheeled equipment, provided that all of the following conditions are met: (a) The wheeled equipment does not reduce the clear unobstructed corridor width to less than 60 in. (152.5 mm). (b) The health care occupancy fire safety plan and training program address the relocation of the wheeled equipment during a fire or similar emergency. (c) The wheeled equipment is limited to the following: i. Equipment in use and carts in use ii. Medical emergency equipment not in use iii. Patient lift and transport equipment (5) Where the corridor width is at least 8 ft (2440 mm), projections into the required width shall be permitted for fixed furniture, provided that all of the following conditions are met: (a) The fixed furniture is securely attached to the floor or to the wall.
(b) The fixed furniture does not reduce the clear unobstructed corridor width to less than 6 ft (1830 mm), except as permitted by 19.2.3.4(2). (c) The fixed furniture is located only on one side of the corridor. (d) The fixed furniture is grouped such that each grouping does not exceed an area of 50 ft2 (4.6 m2).
(e) The fixed furniture groupings addressed in 19.2.3.4(5) (d) are separated from each other by a distance of at least 10 ft (3050 mm). (f) The fixed furniture is located so as to not obstruct access to building service and fire protection equipment. (g) Corridors throughout the smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the fixed furniture spaces are arranged and located to allow direct supervision by the facility staff from a nurses' station or similar space. (h) The smoke compartment is protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.8. 2012 NFPA 101, 19.2.3.4

Based on staff interview and observation the facility fails to properly maintain their hazardous areas within the facility in accordance with NFPA 101. The deficient practice would affect no patients, and all visitors and staff in 2 of 5 smoke zones. The facility has a capacity of 20 and at the time of the survey the census was 5.

Findings include:

During the survey conducted on 2/20/19 the following deficiencies are noted:

1. During the survey at 2:16 PM, it is observed that there is an approximate ½" unsealed hole drilled above the door in the main electrical room.
2. During the survey at 2:59 PM, it is observed that the door to the soiled linen room in the ER did not properly close and latch when tested.

Staff A was present and acknowledged the findings.

NFPA Standard: NFPA 101 19.3.2.1.3 The doors shall be self-closing or automatic-closing.
19.3.2.1.5 Hazardous areas shall include, but shall not be restricted
to, the following: Boiler and fuel-fired heater room (2) Central/bulk laundries larger than 100 ft2 (9.3 m2) (3) Paint shops (4) Repair shops (5) Rooms with soiled linen in volume exceeding 64 gal (242 L)
(6) Rooms with collected trash in volume exceeding 64 gal (242 L) (7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction (8) Laboratories employing flammable or combustible material in quantities less than those that would be considered a severe hazard

Based on document review and staff interview, the facility fails to maintain their sprinkler system in accordance with NFPA 13. The deficient practice would affect all patients, visitors, and all staff in 5 of 5 smoke zones. The facility has a capacity of 20 and at the time of the survey the census was 5.

Findings include:

During the survey conducted on 2/20/19 the following deficiency is noted:

1. During document review at 1:05 PM, it is observed that the annual service report from 2/14/19 stated the following deficiencies: Both gauges are over 5 years old and need replaced. System is due for 5 year internal pipe inspection. There is no documentation for this being corrected.

Staff A was present and acknowledged the finding.

NFPA Standard: NFPA 13 2010 26.1* General. A sprinkler system installed in accordance with
this standard shall be properly inspected, tested, and maintained
by the property owner or their authorized representative in accordance
with NFPA 25, Standard for the Inspection, Testing, and
Maintenance of Water-Based Fire Protection Systems, to provide at least
the same level of performance and protection as designed. 8.5.5.3 Obstructions that prevent sprinkler discharge from reaching the Hazard. Continuous or non-continuous obstructions that interrupt the water discharge in a horizontal plane more than 18" below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 8.5.5.3. 8.5.6.1 Unless the requirements of 8.5.6.2, 8.5.6.3, 8.5.6.4, or 8.5.6.5 are met, the clearance between the deflector and the top of storage shall be 18" or greater.

Based upon observation and staff interview the facility is not maintaining their corridor doors in compliance with NFPA 101. This deficient practice could prevent the ability of the facility to properly confine smoke and prevent fire from spreading. This deficient practice would affect approximately 10 patients, and all visitors and staff in 1 of 5 smoke zones. The facility has a capacity of 20 and at the time of the survey the census was 5.

Findings include:

During the survey conducted on 2/20/19 the following deficiency is noted:

1. During the survey at 2:31 PM, it is observed that the corridor door to patient room 111 has 4 unsealed pencil sized holes drilled through the door near the handle that would not resist the passage of smoke.


Staff A was present and acknowledged the finding.

NFPA Standard: Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1-3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Doors shall be provided with a means suitable for keeping the door closed.

Based on observation and staff interview, the facility fails to utilize flexible cords and power strips in accordance with NFPA 70. The deficient practice would affect no patients, and all visitors and staff in 1 of 5 smoke zones. The facility has a capacity of 20 and at the time of the survey the census was 5.

Findings include:

During the survey conducted on 2/20/19 the following deficiency is noted:

1. During the survey at 3:45 PM, it is observed that the electrical panels in the CT scan control room are blocked by chairs.

Staff A was present and acknowledged the finding.

NFPA Standard: NFPA 70 110.26 Spaces About Electrical Equipment. Access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment. (A) Working Space. Working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of 110.26 (A) (1), (A)(2), and (A)(3) or as required or permitted elsewhere in this code.
NFPA Standard: Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2

Based on document review and staff interview, the facility fails to conduct fire drills as required by Life Safety Code NFPA 101. This deficient practice would affect all patients, visitors, and staff in 5 of 5 smoke zones. The facility has a capacity of 20 and at the time of the survey the census was 5.

Findings Include:

During the survey on 2/20/19 the following deficiencies are noted:

1. During document review at 1:39 PM, it is observed that several of the fire drill forms are incomplete with missing information.
2. During document review at 1:39 PM, it is observed that the fire drills held on 1st shift in the 3rd and 4th quarter of 2018 at 7:00 AM and 7:06 AM were held as silent drills.
3. During document review at 1:39 PM, it is observed that the 2nd shift fire drills held in the 1st and 3rd quarters of 2018 at 6:45 PM were held as silent drills.

Staff A was present and acknowledged the findings.

NFPA Standard: NFPA 101 2012 19.7.1.4* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 19.7.1.5 Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. 19.7.1.7 When drills are conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

Based upon document review, and staff interview the facility is not inspecting and maintaining their rated door assemblies in compliance with NFPA 80. This deficient practice could prevent the ability of the facility to properly confine smoke and prevent fire from spreading to other zones. This deficient practice would affect all residents, visitors, and staff in 5 of 5 smoke zones. The facility has a capacity of 20 and at the time of the survey the census was 5.

Findings include:

During the survey conducted on 2/20/19 the following deficiency is noted:

1. During document review at 1:16 PM, it is observed that there is no documentation for any qualifications of personnel who test and maintain their rated door assemblies.


Staff A was present and acknowledged the finding.

NFPA Standard: NFPA 80 2010 5.2.1 Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ. 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing. 5.2.4.2 As a minimum, the following items shall be verified: (1) No open holes or breaks exist in the surfaces of either the door or frame. (2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped. (3) The door, frame, hinges, hardware, and non combustible threshold are secured, aligned, and in working order with no visible signs of damage. (4) No parts are missing or broken. (5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7 (6) The self-closing device is operational; that is, the active door completely closes when operated from the open position. (7) If a coordinator is installed, the inactive leaf closes before the active leaf. (8) Latching hardware operates and secures the door when it is in the closed position. (9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame. (10) No field modifications to the door assembly have been performed that void the label. (11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity. 3.3.95 Qualified Person. A person who, by possession of a recognized degree, certificate, professional standing, or skill, and who by knowledge, training, and experience, has demonstrated the ability to deal with the subject matter, the work, or the project.

Based upon a review of records and staff interview, the facility fails to assure that the engineered smoke control system and dampers are maintained in accordance with NFPA 80. The deficient practice could allow the passage of smoke or fire to other areas of the building affecting all patients, visitors, and staff in 5 of 5 smoke ones. The facility has a capacity of 20 and at the time of the survey the census was 5.

Findings include:

During the survey conducted on 2/20/19 the following deficiency is noted:

1. During document review at 1:56 PM, it is observed that there is no documentation for the last annual service of the fire dampers.

Staff A was present and acknowledged the finding.

NFPA Standard: NFPA 80 19.4* Periodic Inspection and Testing. 19.4.1.1 The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years.

Based on staff interview and document review, the facility failed to maintain and test their electrical receptacles and systems in accordance with NFPA 99. This deficient practice would affect all patients, visitors, and staff in 5 of 5 smoke zones. The facility has a capacity of 20 and at the time of the survey the census was 5.

Findings include:

During the survey conducted on 2/20/19 the following deficiency is noted:

1. During document review at 1:50 PM, it is observed that there is no documentation at the time of survey for any testing of the electrical receptacles or electrical systems.

Staff A was present and acknowledged finding.

NFPA Standard: NFPA 99 2012 6.3.3.2 Receptacle Testing in Patient Care Rooms 6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection. 6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified. 6.3.3.2.3 correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. 6.3.4.1 Maintenance and testing of Electrical System 6.3.4.1. 1 Where hospital-grade receptacles are required at patient bed location and in location where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device. 6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data. 6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months. 6.3.4.1.4 The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch (see 6.3.2.6.3.6). For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators. 6.3.4.1.5 After any repair or renovation to an electrical distribution system, the LIM circuit shall be tested in accordance with 6.3.3.3.2 6.4.4.1.2.1* Circuit Breakers. Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer's recommendations. 6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modification. 6.3.4.2.1.2 At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter. 6.3.4.2.2 Isolated Power System (Where Installed). A permanent record shall be kept of the results of each of the tests.

Based on staff interview and observation, the facility fails to maintain their electrical systems in accordance with NFPA 70. The deficient practice would no patients, and all visitors and staff in 1 of 5 smoke zones. The facility has a capacity of 20 and at the time of the survey the census was 5.

Findings include:

During the survey conducted on 2/20/19 the following deficiency is noted:

1. During the survey at 2:20 PM, it is observed that there is an extension cord plugged into a power strip powering Christmas lights in the cafeteria.

Staff A was present and acknowledged the finding.

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 or 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 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