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Based on observation and staff interview, the facility failed to provide egress door locks that will unlock without the use of a key or tool. This deficient practice affects staff in 1 of 3 smoke zones. This facility has a capacity of 25 with a census of 5 at the time of this survey.

Findings include:

During the survey on 12/16/2021 the following is observed:

1. It was observed at 9:57 AM the Medical Supply room requires the use of key to exit when the door is locked.

The Facilities Director was present during the survey and acknowledged the findings.

Egress Doors
Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:
CLINICAL NEEDS OR SECURITY THREAT LOCKING
Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times.
18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6
SPECIAL NEEDS LOCKING ARRANGEMENTS
Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation.
18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4
DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted.
18.2.2.2.4, 19.2.2.2.4
ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4

Based on document review and staff interview the facility fails to properly maintain their emergency lights as required by the Life Safety Code. The deficient practice would affect all patients, visitors, and staff in all smoke zones. The facility has a capacity of 25 with a census of 5 at the time of this survey.
Findings include:
During the survey on 12/15/2021 the following was observed:
1. It was observed at 2:34 PM in the boiler room no emergency light is installed to illuminate the generator transfer switch during a power outage.
The Facilities Director was present and acknowledged the findings:
Emergency illumination shall be provided for a minimum of 1 1/2 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 ft-candle (10.8 lux) and, at any point, not less than 0.1 ft-candle (1.1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6.5 lux) and, at any point, not less than 0.06 ft candle (0.65 lux) at the end of 11.2 hours. A maximum-to minimum illumination uniformity ratio of 40 to 1 shall not be exceeded.

The Level 1 or Level 2 EPS equipment location(s) shall be provided with battery-powered emergency lighting. This
requirement shall not apply to units located outdoors in enclosures that do not include walk-in access. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch. The intensity of illumination in the separate building or room housing the EPS equipment for Level 1 shall be 32.3 lux (3.0 ft-candles), unless otherwise specified by a requirement recognized by the authority having jurisdiction.

Based on observation, record review and staff interview the facility fails to provide a fire alarm system installed in accordance with NFPA 72. This deficient practice may result in the fire alarm system not being adequately powered in the emergency power loss mode, affecting patients, visitors, and staff in all smoke zones. The facility has a capacity of 25 with a census of 5 at the time of this survey.

Findings include:

During the survey on 12/15/2021 the following is observed:

1. It was observed at 2:38 PM the dedicated branch circuit disconnecting means is not permanently identified in the boiler room electrical panel. The disconnecting circuit breaker is not identified as "FIRE ALARM CIRCUIT", does not have a red marking, and is not secured against unauthorized personnel from opening it and/or turning off the circuit.

The Facilities Director was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected, or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction. 2012 NFPA 101, 4.6.12.4

Review of the following NFPA Standard revealed: The location of the dedicated branch circuit disconnecting means shall be permanently identified at the control unit. 2010 NFPA 72, 10.5.5.2.1

Review of the following NFPA Standard revealed: For fire alarm systems the circuit disconnecting means shall be identified as "FIRE ALARM CIRCUIT." 2010 NFPA 72, 10.5.5.2.2

Review of the following NFPA Standard revealed: For fire alarm systems the circuit disconnecting means shall have a red marking. 2010 NFPA 72, 10.5.5.2.3

Review of the following NFPA Standard revealed: The circuit disconnecting means shall be accessible only to authorized personnel. 2010 NFPA 72, 10.5.5.2.4

Based on record review, the facility failed to maintain and test the fire alarm system in accordance with National Fire Protection Association (NFPA) 72. Failure to maintain the fire alarm system in accordance with NFPA 72 can prevent the system from working as designed, components and initiating devices from working as designed and delaying notification for rapid evacuation in the event of a fire affecting patients, visitors, and staff in all smoke zones. The facility has a capacity of 25 with a census of 5 at the time of this survey.

Findings include:

During the survey on 12/15/2021 the following was observed:

1. At 1:23 PM during documentation review of the previous 3 years of the fire alarm inspection reports no documentation of semiannual fire alarm testing has been taking place.
2. At 1:34 PM during documentation review of the previous 3 years of the fire alarm inspection reports no technician credentials were included for the individuals completing the inspection of the fire alarm system.

During the survey on 12/16/2021 the following was observed:

3. It was observed at 9:05 AM in the east basement corridor there is sheetrock missing on the ceiling which allow smoke to go above the ceiling and not to the smoke detector.

The Facilities Director was present and acknowledged the findings:

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

NFPA Standard: Service personnel shall be qualified and experienced in the inspection, testing, and maintenance of systems addressed within the scope of this Code. Qualified personnel shall include, but not be limited to, one or more of the following:
(1)*Personnel who are factory trained and certified for the specific type and brand of system being serviced
(2)*Personnel who are certified by a nationally recognized certification organization acceptable to the authority having jurisdiction
(3)*Personnel who are registered, licensed, or certified by a state or local authority to perform service on systems addressed within the scope of this Code
(4) Personnel who are employed and qualified by an organization listed by a nationally recognized testing laboratory for the servicing of systems within the scope of this Code. 2010 NFPA 72 10.4.3.1

NFPA Standard: Evidence of qualifications shall be provided to the authority having jurisdiction upon request. 2010 NFPA 72 10.4.3.2

Based upon record review, and observation the facility fails to ensure that the automatic sprinkler system is installed, maintained, and tested in accordance with National Fire Protection Association (NFPA) 25. This deficient practice fails to ensure that the sprinkler system will be properly prepared in the event of a fire, affecting patients, visitors, and staff in all smoke zones. The facility has a capacity of 25 with a census of 5 at the time of this survey.

Findings include:

During the survey on 12/16/2021 the following was observed:

1 It was observed at 9:00 AM in the purchasing storage room there are medical supplies being stored around the sprinkler riser obstructing the sprinkler system control valves.
2. It was observed at 9:21 AM in the Nurse office the sprinkler head has been painted.
3. It was observed at 9:46 AM in the front lobby there are (2) sprinkler heads that have paint on them.

The Facilities Director was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2012 NFPA 101, 9.7.5 Table 5.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.

Review of the following NFPA Standard revealed: Sprinklers shall be inspected from the floor level annually. 2011 NFPA 25, 5.2.1.1

Based on observation and staff interview, the facility did not ensure that electrical wiring and equipment is installed and maintained in accordance with NFPA 70, National Electrical Code. This deficient practice does not ensure prevention of an electrical fire or electric shock hazard, affecting staff in 1 of 3 smoke zones. The facility has a capacity of 25 with a census of 5 at the time of this survey.
Findings include:
During the survey conducted on 12/16/2021 it is observed:
1. It was observed at 9:33 AM in the nurse station the receptacles on the north wall are within 6 ft. of the sinks and are not protected with Ground Fault Circuit Interrupters (GFCIs).
2. It was observed at 9:35 Am in the nurse kitchen the receptacles on the west wall are within 6 ft. of the sink and are not protected with Ground Fault Circuit Interrupters (CFCIs).

The Facilities Director was present and acknowledged the findings.

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 record review and staff interview, the facility is not conducting fire drills as required and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency, affecting patients, visitors, and staff in all smoke zones. The facility has a capacity of 25 with a census of 5 at the time of this survey.

Findings include:

During the survey on 12/15/2021 the following observations were made:

1. At 12:33 PM during documentation review of the previous (5) quarters of fire drills the coded 2nd shift drill at 2:00 AM on 1/5/2021 was not followed by a fire alarm test by 12:00 PM following that drill.
2. At 12:34 PM during documentation review of the previous (5) quarters of fire drills no 1st and 2nd shift drills were completed during the 4th quarter of 2020 or the 2nd and 3rd quarters of 2021.
3. At 12:40 PM during documentation review of the previous (5) quarters of fire drills no time was documented for the fire drill completed on 7/30/2020. No fire alarm test was completed for this fire drill.

The Facilities Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan required by 19.7.1.1. A copy of the plan required by 19.7.1.1 shall be readily available at all times in the telephone operator's location or at the security center. 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. Employees of health care occupancies shall be instructed in life safety procedures and devices. 2012 NFPA

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 would affect patients, visitors, and staff in all smoke zones. The facility has a capacity of 25 with a census of 5 at the time of this survey.


Findings include:


During the survey conducted on 12/15/2021 the following deficiency is noted:

1. At 2:05 PM during documentation review there is no documentation of inspection of the fire rated doors throughout the facility.

The Facilities Director 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.

Based on record review, the facility fails to maintain and test its electrical receptacles and systems in accordance with National Fire Protection Association (NFPA) 99 and NFPA 70 the National Electrical Code. This deficient practice would affect patients and staff in 2 of 3 smoke zones. The facility has a capacity of 25 with a census of 5 at the time of this survey.

Findings include:

During the survey on 12/15/2021 the following was observed.

1. At 2:12 PM during documentation review there was no documented annual receptacle testing in the patient care rooms, including but not limited to, verifying continuity of the grounding circuit, the correct polarity of the hot and neutral connections, or testing of the retention force of the grounding blade of each electrical receptacle.
The Facilities Director was present and acknowledged the results of the record review.

NFPA Standard: 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. 2012 NFPA 99

Based on record review and staff interview, the facility failed to assure the main and feeder circuit breakers are inspected and tested in accordance with the manufacturer requirements. This deficient practice does not ensure that damage of the emergency power source will occur, affecting patients, visitors, and staff in all smoke zones. The facility has a capacity of 25 with a census of 5 at the time of this survey.

Findings include:

During the survey on 12/15/2021 the following observations were made:

1. At 2:11 PM during documentation review no documented annual inspection of main and feeder circuit breakers nor any evidence of a program for periodically exercising the components according to manufacturer requirements.

The Facilities Director was present during the survey and acknowledged the findings.

Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

A.6.4.4.1.2.1 Main and feeder circuit breakers should be periodically tested under simulated overload trip conditions to ensure reliability.