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Based on staff interview and review of the code foot print, the facility does not have a 2 hour wall separating the different occupancies as required in Life Safety Code 101. The deficient practice would affect all patients, visitors, and staff in 5 of 5 smoke zones. The LTCU and Hospital were both inspected as there is no 2 hour fire wall between the facilities. The LTCU has a capacity of 39 with a census of 39, and the Hospital has a capacity of 21 with a census of 7 at the time of the survey.

Findings include:

During the survey conducted on 6/29/17 the following deficiency is noted:

1. During document review at 1:33 PM it is observed that the code foot print and visual inspection show there is no 2 hour wall separation between the LTCU and the Hospital. There is a current waiver in place.

Maintenance staff was present and acknowledged there was no 2 hour wall separation.

NFPA Standard: Sections of health care facilities shall be permitted to be classified as other occupancies, provided that they meet all of the following conditions: (1) They are not intended to provide services simultaneously for four or more inpatients for purposes of housing, treatment, or customary access by inpatients incapable of self preservation. (2) They are separated from areas of health care occupancies
by construction having a minimum 2-hour fire resistance rating in accordance with Chapter 8. (3) For other than previously approved occupancy separation arrangements, the entire building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. NFPA Life Safety Code 101 19.1.3.3

Based on observation and staff interview the facility fails to properly maintain their means of egress doors and corridors as required in Life Safety Code 101. The deficient practice would affect approximately 15 residents in the LTCU, and all visitors and staff in 1 of 5 smoke zones. The LTCU and Hospital were both inspected as there is no 2 hour fire wall between the facilities. The hospital has a capacity of 21 with a census of 7, and the LTCU has a capacity of 39 with a census of 39 at the time of the survey.

Findings include:

During the survey conducted on 6/29/17 the following deficiency is noted:

1. During the survey at 4:17 PM it is observed that the exit door in the LTCU near room 126 is obstructed by a small table. This was corrected on site.

Maintenance staff was present and acknowledged the obstruction in the means of egress.

NFPA Standard: Life Safety Code 101 2012 7.1.10.2.1 No furnishings, decorations, or other objects shall
obstruct exits or their access thereto, egress therefrom, or visibility thereof. 7.1.10.2.2 No obstruction by railings, barriers, or gates shall divide the means of egress into sections appurtenant to individual
rooms, apartments, or other occupied spaces. Where the authority having jurisdiction finds the required path of travel to be obstructed by furniture or other movable objects, the authority shall be permitted to require that such objects be secured out of the way or shall be permitted to require that railings or other permanent barriers be installed to protect the path of travel against encroachment. Life Safety Code 101 2012.

Based on observation and staff interview the facility fails to properly protect and maintain their hazardous areas in accordance with NFPA 101. The deficient practice would affect approximately no patients or visitors and all staff in 1 of 5 smoke zones. The LTCU and Hospital were both inspected as there is no 2 hour fire wall between the facilities. The LTCU has a capacity of 39 with a census of 39 and the Hospital has a capacity of 21 with a census of 7 at the time of the survey.

Findings include:

During the survey conducted on 6/29/17 the following deficiency is noted:

1. During the survey at 2:58 PM it is observed that the front wall in the boiler room has approximately six 1" unsealed penetrations through the cinderblock from removed devices. This would allow the passage of smoke through the wall.

Maintenance staff was present and acknowledged the unsealed penetrations.

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:
(1) Boiler and fuel-fired heater rooms (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 materials in quantities less than those that would be considered a severe hazard
19.3.2.1.2* Where the sprinkler option of 19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4.

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 no residents or visitors, and staff in 1 of 5 smoke zones. The LTCU and Hospital were both inspected as there is no 2 hour fire wall between the facilities. The LTCU has a capacity of 39 with a census of 39, and the Hospital has a capacity of 21 with a census of 7 at the time of the survey.

Findings include:

During the tour conducted on 6/29/17 the following deficiency is observed:

-- 1. During the survey at 3:21 PM it is observed that the corridor door to the procedure room was held open with a rubber door wedge.

Maintenance staff was present and acknowledged the obstruction to the corridor door.

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 properly maintain their electrical systems in accordance with NFPA 70. The deficient practice would affect approximately no patients or visitors and all staff in 1 of 5 smoke zones. The LTCU and Hospital were both inspected as there is no 2 hour fire wall between the facilities. The LTCU has a capacity of 39 with a census of 39, and the Hospital has a capacity of 21 with a census of 7 at the time of the survey.

Findings include:

During the survey conducted on 6/29/17 the following deficiency is noted:

1. During the survey at 3:41 PM it is observed that there are exposed wires coming out of conduit on the back wall in the basement maintenance work area that are not properly capped and closed in a junction box.

Maintenance staff was present and acknowledged the exposed wires from the conduit.

NFPA Standard: Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2

Based on observation and staff interview, the facility failed to maintain proper usage of space heating appliances within the facility that have heating elements limited to 212 degrees Fahrenheit. The deficient practice would affect no patients and all visitors and staff in 2 of 5 smoke zones. The LTCU and Hospital were both inspected as there is no 2 hour fire wall between the facilities. The LTCU has a capacity of 39 with a census of 39, and the Hospital has a capacity of 21 with a census of 7 at the time of the survey.

Findings include:

During the survey conducted on 6/29/17 the following deficiencies are noted:

1. During the survey at 3:16 PM it is observed that there are 2 radiator space heaters in use in the business office near the lobby. There is no documentation on these heaters not exceeding the 212 degrees limit.

2. During the survey at 3:27 PM it is observed that there is a space heater in use in the laboratory office. There is no documentation that the heater will not exceed the 212 degrees limit.

Maintenance Staff was present and acknowledged the space heaters.

NFPA Standard: Portable space heating devices shall be prohibited in all healthcare occupancies. Unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit. 2012 NFPA 101, 18/19.7.8

Based on staff interview and observation, the facility fails to maintain their electrical systems in accordance with NFPA 70. The deficient practice would affect no patients, and all visitors and staff in 1 of 5 smoke zones. The LTCU and Hospital were both inspected as there is no 2 hour fire wall between the facilities. The LTCU has a capacity of 39 with a census of 39, and the Hospital has a capacity of 21 with a census of 7 at the time of the survey.

Findings include:

During the survey conducted on 6/29/17 the following deficiency is noted:

1. During the survey at 3:56 PM it is observed that there is power strip powering several devices that is hanging along the wall, over a metal support beam, in the OT Office.

Maintenance staff was present and acknowledged the hanging power strip.

NFPA Standard: Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction. 2012 NFPA 101, 9.1.2

Based on observation and staff interview, the facility failed to properly protect and store compressed gasses as required by NFPA 99. The deficient practice would affect approximately 15 residents and all visitors and staff in 1 of 5 smoke zones. The LTCU and Hospital were both inspected as there is no 2 hour fire wall between the facilities. The LTCU has a capacity of 39 with a census of 39, and the Hospital has a capacity of 21 with a census of 7 at the time of the survey.

Findings include:

During the survey conducted on 6/29/17 the following deficiency is noted:

1. During the survey at 4:04 PM it is observed that there is an unsecured e size O2 cylinder standing in the corridor unsecured near room 126 in the LTCU. This was corrected on site.

Maintenance staff was present and acknowledged the unsecured cylinder in the corridor.

NFPA Standard: NFPA 99 2012 11.3.2.8 Cylinder valve protection caps shall comply with 11.6.2.3 11.6.2.3 Cylinders shall be protected from damage by means of the following specific procedures: (1) Oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device. (2) Oxygen cylinders shall not be stored near elevators or gangways or in locations where heavy moving objects will strike them or fall on them. (3) Cylinders shall be protected from tampering by unauthorized individuals. (4) Cylinders or cylinder valves shall not be repaired, painted, or altered. (5) Safety relief devices in valves or cylinders shall not be tampered with. (6) Valve outlets clogged with ice shall be thawed with warm - not boiling - water. (7) A torch flame shall not be permitted, under any circumstances, to come in contact with a cylinder, cylinder valve, or safety device. (8) Sparks and flame shall be kept away from cylinders. (9) Even if they are considered to be empty, cylinders shall not be used as rollers, supports, or for any purpose other than that for which the supplier intended them. (10) Large cylinders (exceeding size E) and containers larger than 45 kg (100 lb) weight shall be transported on a proper hand truck or cart complying with 11.4.3.1. (11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart. (12) Cylinders shall not be supported by radiators, steam pipes, or heat ducts.