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Based on observation that not all hazardous areas are separated from the remainder of the building. These deficiencies could affect all patients, staff within the smoke compartment, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the exit access corridor.

Findings include:

A. On 08/03/15 at 11:20 am during the survey walk-through while accompanied by the Head of Maintenance, the surveyor observed the non sprinklered gift shop is deemed a hazardous area due to the following:
1. The amount of combustibles stored
2. The wood slat finished walls
3. The room is greater than 50 square feet
The entry door is a fully glazed aluminum door and sidelight. This room lacks fire resistant separation from the corridor to comply with 19.3.2.1(7) or 8.4.1 for an automatic extinguishing system.

B. On 08/03/15 at 9:15 am during the survey walk-through while accompanied by the Head of Maintenance, the surveyor observed the door to the clean linen storage room (sprinklered) was observed to contain a separate padlock which does not allow for egress from the room to comply with 7.2.1.5.1 and 7.2.1.5.4.

C. On 08/03/15 at 9:20 am during the survey walk-through while accompanied by the Head of Maintenance, the surveyor observed part of the gypsum board ceiling missing within the clean linen storage room which does not comply with 19.3.2.1.

D. On 07/03/15 at 10:00 am during the survey walk-through while accompanied by the Head of Maintenance, the surveyor observed that conduit penetrates an unpatched hole through the fire rated wall between soiled linen and the generator enclosure which does not comply with 19.3.2.1.

Based on observation not all exterior exit discharges are arranged or maintained to make clear the direction of egress. This deficient practice could affect patients, visitors and staff by delaying emergency exiting to a public way.

Findings include:

A. On 08/03/2015 at 9:45 am during the survey walk-through while accompanied by the Head of Maintenance, the surveyor observed the exterior discharge door located adjacent to the staff service wing (includes laundry and central supply) sticks on attempt to open which does not comply with 19.2.2 and 7.2.1.4.5 for required force to open.

Based on observation not all designated fire barriers are constructed or maintained as fire resistive assemblies. These deficiencies could affect all patients, visitors and staff within the areas of the fire compartment, as well as any persons in the adjacent compartment, because failure to construct and maintain fire resistive assemblies could allow fire and smoke to pass from one compartment into adjacent fire/smoke compartments.

Findings include:

On 08/03/2015 at 9:00 am the Head of Maintenance indicated to the surveyor that a designated 2 hour barrier wall exists between the healthcare occupancy and the staff service wing (laundry, central supply and shop offices). Deficiency's found include the following:

1. The wall is not continuous to an outside wall to comply with 8.2.2.2.
2. The wall has numerous unprotected penetrations which does not comply with 8.2.3.2.3.1.
3. The wall contains door opening which lack a fire resistant rating to comply with 8.2.3.2.1.
4. Sections of the wall are not of design that has been tested to meet the conditions of acceptance of NFPA 251 to consist of a U.L. listed wall design.

Based on observation exit signs were not provided, were not fully visible or properly located to clearly designate the path of egress in all cases. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

Findings include:

A. On 08/03/15 at 9:50 am during the survey walk-through while accompanied by the Head of Maintenance, the surveyor observed that the corridor adjacent to the 2-hour barrier between healthcare and staff service area contained an exit sign with two chevrons. One chevron indicated exiting into the designated hazardous area does not comply with 7.10.1.1.

B. On 08/03/15 at 10:50 am during the survey walk-through while accompanied by the head of maintenance, the surveyor observed that the corridor leading past Medical Records and Inpatient Pharmacy contains an exit sign directing passage through a door labeled "biohazard room" and "soiled linen room" which does not comply with 19.2.10.

Based on document review and the survey walk through the location for smoke barriers is not known. This deficiency could result in a delayed evacuation from the smoke compartment of fire origin to an area of refuge during a fire emergency. This condition could affect patients, staff and visitors.

Findings include:

On 08/03/2015 at 8:45 am during review of the facility's floor plan, and discussion with staff, the surveyor observed that the staff is not familiar with the use of and purpose of a smoke barrier and smoke compartment locations to comply with 19.3.7.1, 19.3.7.3 and 19.7.2.2 (6). The surveyor was informed that there are so many exit discharges available, staff knows to use those.

Based on observation not all areas of the building fire alarm system components are installed to initiate an alarm without delay or are able to be located during a fire emergency. This condition could affect all visitors, staff and patients.

Findings include:

A. On 08/03/2015 at 10:25 am during the survey walk through while accompanied by the Head of Maintenance, the surveyor observed a pull station within the E.D. which is not located within reach of staff manning the nurse station to comply with NFPA 72 1999, 2-8.2.2. The nearest pull station is located across the hallway around the corner from the nurse station. This same pull station is more than 5 feet from an exit.

B. On 08/03/2015 at 9:25 am during the survey walk-through while accompanied by the Head of Maintenance, the surveyor observed a pull station within the staff service area that is not within reach of staff due to the location of folding tables, and other items preventing ease of access to comply with NFPA 72 1999, 2-8.2.2.


Based on document review, the facility's fire alarm system is not inspected and tested on a regular basis. This deficiency could affect patients, staff, and visitors in the building because fire alarm system components may not be operational.

Findings include:

C. On 08/03/2015 at 1:30 pm the surveyor reviewed documents. Fire alarm test records were requested. The facility does not test the fire alarm system components on a periodic basis to comply with NFPA 72 1999 Table 7-3.2. The most recent available inspection record is dated January 20, 2015.
.

Based on observation the sprinkler system is not maintained. This deficiency could result in failure of the sprinkler system and delayed response during a fire event, which could affect patients, staff and visitors.

Findings include:

On 08/03/2015 at 12:40 pm during document review while accompanied by the Head of Maintenance, the surveyor observed the most recent quarterly sprinkler inspection provided was March 9, 2015. The sprinkler system is not tested on a regular basis to comply with NFPA 13 and NFPA 25 1998 2-2.6.

Based on observation the generator equipment does not meet all requirements. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised without the facility being aware that the emergency generators are not functioning properly.

Findings include:

On 08/03/2015 at 11:45 am during the survey walk-through while accompanied by the Head of Maintenance, the surveyor observed the remote generator annunciator is mounted within the nurse station of the Rural Health Clinic. The clinic is not staffed on a 24 hour basis, therefore the location of the remote annunciator does not comply with NFPA-110, Section 3-5.5.2 for a continuously observed location.

Based on observations and staff interviews during the survey walk-through, and based on document review, the surveyor finds the facility is not in compliance with the life safety code and other code requirements that are documented under the K-tags of this survey.

Findings include:

Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

Base on observation the facility's emergency power system is not maintained on a regular basis. Failure to test and maintain the emergency generator could result in failure during a loss of normal power to the facility and affect all visitors, patients and staff during a fire emergency.

On 08/03/2015 at 1:15 pm during document review with the Head of Maintenance the current generator annual load bank test report was requested, there was no document pertaining to the test to comply with NFPA 110 1999, 3-5 and 6-4.2(a), 6-4.2(b). The available document is dated July 12, 2013.

Based on observation that not all hazardous areas are separated from the remainder of the building. These deficiencies could affect all patients, staff within the smoke compartment, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the exit access corridor.

Findings include:

A. On 08/03/15 at 11:20 am during the survey walk-through while accompanied by the Head of Maintenance, the surveyor observed the non sprinklered gift shop is deemed a hazardous area due to the following:
1. The amount of combustibles stored
2. The wood slat finished walls
3. The room is greater than 50 square feet
The entry door is a fully glazed aluminum door and sidelight. This room lacks fire resistant separation from the corridor to comply with 19.3.2.1(7) or 8.4.1 for an automatic extinguishing system.

B. On 08/03/15 at 9:15 am during the survey walk-through while accompanied by the Head of Maintenance, the surveyor observed the door to the clean linen storage room (sprinklered) was observed to contain a separate padlock which does not allow for egress from the room to comply with 7.2.1.5.1 and 7.2.1.5.4.

C. On 08/03/15 at 9:20 am during the survey walk-through while accompanied by the Head of Maintenance, the surveyor observed part of the gypsum board ceiling missing within the clean linen storage room which does not comply with 19.3.2.1.

D. On 07/03/15 at 10:00 am during the survey walk-through while accompanied by the Head of Maintenance, the surveyor observed that conduit penetrates an unpatched hole through the fire rated wall between soiled linen and the generator enclosure which does not comply with 19.3.2.1.

Based on observation not all exterior exit discharges are arranged or maintained to make clear the direction of egress. This deficient practice could affect patients, visitors and staff by delaying emergency exiting to a public way.

Findings include:

A. On 08/03/2015 at 9:45 am during the survey walk-through while accompanied by the Head of Maintenance, the surveyor observed the exterior discharge door located adjacent to the staff service wing (includes laundry and central supply) sticks on attempt to open which does not comply with 19.2.2 and 7.2.1.4.5 for required force to open.

Based on observation not all designated fire barriers are constructed or maintained as fire resistive assemblies. These deficiencies could affect all patients, visitors and staff within the areas of the fire compartment, as well as any persons in the adjacent compartment, because failure to construct and maintain fire resistive assemblies could allow fire and smoke to pass from one compartment into adjacent fire/smoke compartments.

Findings include:

On 08/03/2015 at 9:00 am the Head of Maintenance indicated to the surveyor that a designated 2 hour barrier wall exists between the healthcare occupancy and the staff service wing (laundry, central supply and shop offices). Deficiency's found include the following:

1. The wall is not continuous to an outside wall to comply with 8.2.2.2.
2. The wall has numerous unprotected penetrations which does not comply with 8.2.3.2.3.1.
3. The wall contains door opening which lack a fire resistant rating to comply with 8.2.3.2.1.
4. Sections of the wall are not of design that has been tested to meet the conditions of acceptance of NFPA 251 to consist of a U.L. listed wall design.

Based on observation exit signs were not provided, were not fully visible or properly located to clearly designate the path of egress in all cases. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

Findings include:

A. On 08/03/15 at 9:50 am during the survey walk-through while accompanied by the Head of Maintenance, the surveyor observed that the corridor adjacent to the 2-hour barrier between healthcare and staff service area contained an exit sign with two chevrons. One chevron indicated exiting into the designated hazardous area does not comply with 7.10.1.1.

B. On 08/03/15 at 10:50 am during the survey walk-through while accompanied by the head of maintenance, the surveyor observed that the corridor leading past Medical Records and Inpatient Pharmacy contains an exit sign directing passage through a door labeled "biohazard room" and "soiled linen room" which does not comply with 19.2.10.

Based on document review and the survey walk through the location for smoke barriers is not known. This deficiency could result in a delayed evacuation from the smoke compartment of fire origin to an area of refuge during a fire emergency. This condition could affect patients, staff and visitors.

Findings include:

On 08/03/2015 at 8:45 am during review of the facility's floor plan, and discussion with staff, the surveyor observed that the staff is not familiar with the use of and purpose of a smoke barrier and smoke compartment locations to comply with 19.3.7.1, 19.3.7.3 and 19.7.2.2 (6). The surveyor was informed that there are so many exit discharges available, staff knows to use those.

Based on observation not all areas of the building fire alarm system components are installed to initiate an alarm without delay or are able to be located during a fire emergency. This condition could affect all visitors, staff and patients.

Findings include:

A. On 08/03/2015 at 10:25 am during the survey walk through while accompanied by the Head of Maintenance, the surveyor observed a pull station within the E.D. which is not located within reach of staff manning the nurse station to comply with NFPA 72 1999, 2-8.2.2. The nearest pull station is located across the hallway around the corner from the nurse station. This same pull station is more than 5 feet from an exit.

B. On 08/03/2015 at 9:25 am during the survey walk-through while accompanied by the Head of Maintenance, the surveyor observed a pull station within the staff service area that is not within reach of staff due to the location of folding tables, and other items preventing ease of access to comply with NFPA 72 1999, 2-8.2.2.


Based on document review, the facility's fire alarm system is not inspected and tested on a regular basis. This deficiency could affect patients, staff, and visitors in the building because fire alarm system components may not be operational.

Findings include:

C. On 08/03/2015 at 1:30 pm the surveyor reviewed documents. Fire alarm test records were requested. The facility does not test the fire alarm system components on a periodic basis to comply with NFPA 72 1999 Table 7-3.2. The most recent available inspection record is dated January 20, 2015.
.

Based on observation the sprinkler system is not maintained. This deficiency could result in failure of the sprinkler system and delayed response during a fire event, which could affect patients, staff and visitors.

Findings include:

On 08/03/2015 at 12:40 pm during document review while accompanied by the Head of Maintenance, the surveyor observed the most recent quarterly sprinkler inspection provided was March 9, 2015. The sprinkler system is not tested on a regular basis to comply with NFPA 13 and NFPA 25 1998 2-2.6.

Based on observation the generator equipment does not meet all requirements. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised without the facility being aware that the emergency generators are not functioning properly.

Findings include:

On 08/03/2015 at 11:45 am during the survey walk-through while accompanied by the Head of Maintenance, the surveyor observed the remote generator annunciator is mounted within the nurse station of the Rural Health Clinic. The clinic is not staffed on a 24 hour basis, therefore the location of the remote annunciator does not comply with NFPA-110, Section 3-5.5.2 for a continuously observed location.

Based on observations and staff interviews during the survey walk-through, and based on document review, the surveyor finds the facility is not in compliance with the life safety code and other code requirements that are documented under the K-tags of this survey.

Findings include:

Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

Base on observation the facility's emergency power system is not maintained on a regular basis. Failure to test and maintain the emergency generator could result in failure during a loss of normal power to the facility and affect all visitors, patients and staff during a fire emergency.

On 08/03/2015 at 1:15 pm during document review with the Head of Maintenance the current generator annual load bank test report was requested, there was no document pertaining to the test to comply with NFPA 110 1999, 3-5 and 6-4.2(a), 6-4.2(b). The available document is dated July 12, 2013.