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Based on observation and staff interview, the facility fails to assure that communicating openings in fire barriers are permitted only in corridors. The deficient practice compromises the fire resistance rating of the 2 hour wall, affecting 1 of 7 smoke zones. The facility has a capacity of 25 with a census of 6 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 7/12/12, at 1:00 p.m., it is observed that the fire barrier wall separating the Hospital and the Clinic has two existing doors that are not located in connecting corridors. They connect the dining room and the small board room, and the Hospital and Clinic outpatient waiting room. The doors are 3 hour fire rated and automatic closing.

Maintenance Staff A was present and acknowledged the findings.

NFPA Standard: Additions shall be separated from any existing structure notconforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition. Communicating openings in the fire barriers shall be permitted only in corridors and protected by approved self-closing fire doors. 2000 NFPA 101, 18/19.1.1.4.1 and 18/19.1.1.4.2

Based upon a review of records and staff interview, the facility fails to assure that emergency lighting of at least 1? hour duration is provided in accordance with 7.9. The deficient practice could result in a failure to illuminate exit pathways in the event of an emergency or loss of power, affecting 7 of 7 smoke zones. The facility has a capacity of 25 with a census of 6 at the time of this survey.

Findings include:

During the tour conducted on 7/12/12, a review of records from 1:00 p.m. to 3:00 p.m. revealed that there is no record of a 90 minute annual emergency light test since 3/3/10.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Emergency illumination shall be provided for not less than 1? hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 foot-candle. 2000 NFPA 101, 7.9.2

Based upon a review of records and staff interview, the facility fails to assure that fire drills are held at unexpected times, under varying conditions and at least once per shift per quarter. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all residents, staff and visitors in the event of a fire, affecting 7 of 7 smoke zones. The facility has a capacity 25 of with a census of 6 at the time of the survey.

Findings include:

During the tour conducted on 7/12/12, a review of records between 1:00 p.m. and 3:00 p.m. for the last 5 quarters revealed the following:

--1. The drills for the 2nd, 3rd and 4th quarter of 2011 on the 1st shift were all held between 7:25 a.m. and 7:38 a.m..

--2. The drills for the 1st and 2nd quarter of 2012 and 2nd quarter of 2011 were all held between 6:00 p.m. and 6:22 p.m..

Maintenance Staff A was present and acknowledged the results of the record review.

NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 19.7.1.2

Based upon a review of records and staff interview, the facility fails to assure that the hood duct work is cleaned to bare metal at frequent intervals. The deficient practice could result in a fire in the kitchen hood system, affecting 1 of 7 smoke zones. The facility has a capacity of 25 with a census of 6 at the time of the survey.

Findings include:

During the tour conducted on 7/12/12, a review of records from 1:00 p.m. to 3:00 p.m. revealed that there is no documentation available for review proving that hood duct work in the kitchen has ever been cleaned.

Maintenance Staff A was present and acknowledged the findings.

NFPA Standard: Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s). 1998 NFPA 96, 8-3.1

Based on observation and staff interview, the facility is not assuring that soiled linen containers in excess of 32 gallons in size are located within a hazardous area. This deficient practice of allowing excessive capacity soiled linen containers to remain outside of a hazard area exposes the occupants to a greater danger to exposure of fire and smoke products, affecting 1 of 7 smoke zones. This facility has a capacity of 25 and a census of 6 residents.

Findings Include:

During the tour conducted on 7/12/12 at 3:30 p.m., it is observed that a trash container of 44 gallon capacity is in the soiled linen room of the OB Hall which is not protected as a hazardous area.

Maintenance Staff A was present and acknowledged the deficiency.


NFPA Standard: Soiled linen or trash collection receptacles shall not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gal/ft2 (20.4 L/m2). A capacity of 32 gal (121 L) shall not be exceeded within any 64-ft2 (5.9-m2) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) shall be located in a room protected as a hazardous area when not attended.

Exception: Container size and density shall not be limited in hazardous areas. 2000 NFPA 101, Section 19.7.5.5.

Based upon observation and staff interview, the facility fails to assure that flexible cords are not used as a substitute for fixed wiring of a structure. The deficient practice could result in a electrical short resulting in a fire, affecting 1 of 7 smoke zones. The facility has a capacity of 25 with a census of 6 at the time of this survey.

Findings Include:

During the tour conducted on 7/12/12, at 3:40 p.m. it is observed that there is an extension cord plugged into an outlet in the A wing utility room that is transferred through the wall into the adjacent patient room via conduit made of pvc.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8

Based on observation and staff interview, the facility fails to assure that communicating openings in fire barriers are permitted only in corridors. The deficient practice compromises the fire resistance rating of the 2 hour wall, affecting 1 of 7 smoke zones. The facility has a capacity of 25 with a census of 6 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 7/12/12, at 1:00 p.m., it is observed that the fire barrier wall separating the Hospital and the Clinic has two existing doors that are not located in connecting corridors. They connect the dining room and the small board room, and the Hospital and Clinic outpatient waiting room. The doors are 3 hour fire rated and automatic closing.

Maintenance Staff A was present and acknowledged the findings.

NFPA Standard: Additions shall be separated from any existing structure notconforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition. Communicating openings in the fire barriers shall be permitted only in corridors and protected by approved self-closing fire doors. 2000 NFPA 101, 18/19.1.1.4.1 and 18/19.1.1.4.2

Based upon a review of records and staff interview, the facility fails to assure that emergency lighting of at least 1? hour duration is provided in accordance with 7.9. The deficient practice could result in a failure to illuminate exit pathways in the event of an emergency or loss of power, affecting 7 of 7 smoke zones. The facility has a capacity of 25 with a census of 6 at the time of this survey.

Findings include:

During the tour conducted on 7/12/12, a review of records from 1:00 p.m. to 3:00 p.m. revealed that there is no record of a 90 minute annual emergency light test since 3/3/10.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Emergency illumination shall be provided for not less than 1? hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 foot-candle. 2000 NFPA 101, 7.9.2

Based upon a review of records and staff interview, the facility fails to assure that fire drills are held at unexpected times, under varying conditions and at least once per shift per quarter. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all residents, staff and visitors in the event of a fire, affecting 7 of 7 smoke zones. The facility has a capacity 25 of with a census of 6 at the time of the survey.

Findings include:

During the tour conducted on 7/12/12, a review of records between 1:00 p.m. and 3:00 p.m. for the last 5 quarters revealed the following:

--1. The drills for the 2nd, 3rd and 4th quarter of 2011 on the 1st shift were all held between 7:25 a.m. and 7:38 a.m..

--2. The drills for the 1st and 2nd quarter of 2012 and 2nd quarter of 2011 were all held between 6:00 p.m. and 6:22 p.m..

Maintenance Staff A was present and acknowledged the results of the record review.

NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 19.7.1.2

Based upon a review of records and staff interview, the facility fails to assure that the hood duct work is cleaned to bare metal at frequent intervals. The deficient practice could result in a fire in the kitchen hood system, affecting 1 of 7 smoke zones. The facility has a capacity of 25 with a census of 6 at the time of the survey.

Findings include:

During the tour conducted on 7/12/12, a review of records from 1:00 p.m. to 3:00 p.m. revealed that there is no documentation available for review proving that hood duct work in the kitchen has ever been cleaned.

Maintenance Staff A was present and acknowledged the findings.

NFPA Standard: Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s). 1998 NFPA 96, 8-3.1

Based on observation and staff interview, the facility is not assuring that soiled linen containers in excess of 32 gallons in size are located within a hazardous area. This deficient practice of allowing excessive capacity soiled linen containers to remain outside of a hazard area exposes the occupants to a greater danger to exposure of fire and smoke products, affecting 1 of 7 smoke zones. This facility has a capacity of 25 and a census of 6 residents.

Findings Include:

During the tour conducted on 7/12/12 at 3:30 p.m., it is observed that a trash container of 44 gallon capacity is in the soiled linen room of the OB Hall which is not protected as a hazardous area.

Maintenance Staff A was present and acknowledged the deficiency.


NFPA Standard: Soiled linen or trash collection receptacles shall not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gal/ft2 (20.4 L/m2). A capacity of 32 gal (121 L) shall not be exceeded within any 64-ft2 (5.9-m2) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) shall be located in a room protected as a hazardous area when not attended.

Exception: Container size and density shall not be limited in hazardous areas. 2000 NFPA 101, Section 19.7.5.5.

Based upon observation and staff interview, the facility fails to assure that flexible cords are not used as a substitute for fixed wiring of a structure. The deficient practice could result in a electrical short resulting in a fire, affecting 1 of 7 smoke zones. The facility has a capacity of 25 with a census of 6 at the time of this survey.

Findings Include:

During the tour conducted on 7/12/12, at 3:40 p.m. it is observed that there is an extension cord plugged into an outlet in the A wing utility room that is transferred through the wall into the adjacent patient room via conduit made of pvc.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8