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Based upon a review of records and staff interview, the facility fails to assure that emergency lighting of at least 1-1/2-hour duration is automatically provided in accordance with 7.9. The deficient practice could result in a failure to provide illumination in the event of a power failure. This deficient practice can affect all patients, visitors and staff in 4 of 4 smoke zones. The facility has a capacity of 10 with a census of 1 at the time of this survey.

Findings include:


During the survey conducted on 02/08/2019, the following deficiency is noted:


1. At approximately 02:49 PM, In the med room you can switch off the lights preventing the room from being illuminated during an emergency.


Staff A was present and acknowledged the finding.


NFPA 99 2012 edition:
NFPA Standard: 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)

Sprinkler System Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
This REQUIREMENT is not met as evidenced by:

Based on record review, observation and staff interview, this facility is not maintaining the sprinkler system in accordance with the 2011 edition of NFPA 25, and the 2010 edition of NFPA 13 regular maintenance and testing. This deficient practice can compromise the effectiveness of the fire suppression system, affecting all patients, visitors and staff in 4 of 4 smoke zones. The facility has a capacity of 10 with a census of 1 at the time of this survey.

Findings include:

During the review of documentation on 2/08/2019 between 10:00 AM and 12:30 PM the following is observed:

1.) No documentation available for the 2nd quarter flow testing on the fire sprinkler system.

Staff A was present and acknowledged the finding.

NFPA Standard: Automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25 per 2012 NFPA 101, 9.7.5.

NFPA Standard: Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. 2012 NFPA 101 4.6.12.1

NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 2012 NFPA 101, 4.6.12.1

NFPA Standard: Obstructions shall not prevent sprinkler discharge from reaching the protected area. Continuous or non-continuous obstructions that interrupt the water discharge in a horizontal plane more than 18 inches below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with this section. The requirements of this section shall also apply to obstructions 18 in. or less below the sprinkler for light and ordinary hazard occupancies per NFPA 13, 5 6.5.3.

Based on observation and staff interview, the facility fails to maintain their smoke barrier walls as required by Life Safety Code NFPA 101. This deficient practice can affect all patients, visitors and staff in 1 of 4 smoke zones. The facility has a capacity of 10 with a census of 1 at the time of this survey.

Findings Include:

During the tour conducted on 2/08/2019, the following is observed:

1.) At approximately 2:52 PM, in the Telecom room on the west wall beside the duct work, there is a penetration near electrical conduit.

Staff A was present and acknowledged the finding.

NFPA Standard: NFPA 101 2012 19.3.7.3 Any required smoke barrier shall be constructed in
accordance with Section 8.5 and shall have a minimum 1?2-hour fire resistance rating, unless otherwise permitted by one of the following: (1) This requirement shall not apply where an atrium is used,
and both of the following criteria also shall apply: (a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c). (b) Not less than two separate smoke compartments shall be provided on each floor. (2)*Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier. 8.5.6.2 Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed
as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke.

Based on record review and staff interview, the facility is not conducting fire drills as required. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency. This deficient practice can affect all patients, visitors and staff in 4 of 4 smoke zones. The facility has a capacity of 10 with a census of 1 at the time of this survey.


Findings include:

During the review of documentation on 2/08/2019 between 10:00 AM and 12:30 PM the following is observed:

2.) Fire drills conducted on 02/12/18, at 8:15 PM, and 9/24/2018, at 7:30 PM, is documented as a "silent" drill. The time of the drill is outside of the time frame permitted for silent drills.

Staff A was present and acknowledged the finding.

NFPA Standard: Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 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. 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. NFPA 101 2012 19.7.1*

Maintenance, Inspection & Testing Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non rated doors, including corridor doors to patient rooms and smoke barrier doors, are
routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)
This REQUIREMENT is not met as evidenced by:
Based upon a review of records and staff interview the facility is not inspecting and maintaining fire 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 areas of the building. This deficient practice can affect all patients, visitors and staff in 4 of 4 smoke zones. The facility has a capacity of 10 with a census of 1 at the time of this survey.


Findings include:

During the review of documentation on 2/08/2019 between 10:00 AM and 12:30 PM the following is observed:

1.) The facility was unable to provide documentation of an annual inspection program of fire door assemblies as required.

Staff A was present and acknowledged the findings.
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.