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Based on observation and staff interview, the facility failed to properly inspect and maintain the smoke barrier doors in accordance with NFPA 101. This deficient practice could affect no patients and all visitors and staff in 3 of 12 smoke zones. The hospital has a capacity of 49 with a census of 6 patients at the time of the survey.
Findings include:

During the survey conducted on 10/13/16 the following deficiencies are noted:

1. During the survey at approximately 9:55 AM it is observed that the smoke barrier doors near the Ultrasound Office on the 2nd floor did not completely close when tested.
2. During the survey at approximately 10:05 AM it is observed that the smoke barrier doors near the Stiz Bath on the 2nd floor did not completely close when tested.

The Director and Maintenance Staff were present and acknowledged that the smoke barrier doors completely closing.
NFPA Standard: Requires doors in smoke barriers to be self-closing and have at least a 20-minute rating, 2000 NFPA 101, 19.3.7.6

Based on observation and staff interview, the facility failed to test and maintain the emergency lights to provide a means of illumination at each exit discharge, so that failure of normal lighting would not leave the area to public way in darkness. This deficient practice could affect all patients, visitors, and staff in 12 of 12 smoke zones. The facility has a capacity of 49 with a census of 6 residents at the time of the survey.
Findings include:


During the survey conducted on 10/12/13 and 10/13/16 the following deficiencies are noted:


1. During document review on 10/12/13 between 1:00 PM and 4:00 PM it is observed that there is no documentation available at the time of survey for an annual 90 minute test of the emergency lights.
2. During the survey on 10/13/16 at approximately 10:25 AM it is observed that the emergency lights in the Pharmacy did not function when tested and that the batteries are dead.

The Director and Maintenance Staff were present and acknowledged the missing documentation for an annual 90 minute test of the emergency lights and the failed emergency lights in the pharmacy.

NFPA Standard: A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 and 1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 2000 NFPA 101, 7.9.3

Based on record review and staff interview, the facility is not conducting fire drills at least quarterly on each shift in accordance with NFPA 101. The lack of fire drills could affect the abilities of the staff to respond in the event of an actual emergency. This deficient practice could affect all patients, visitors, and staff in 12 of 12 smoke zones. The facility has a capacity of 49 with a census of 6 at the time of survey.
Findings include:

During the survey conducted on 10/12/16 the following deficiencies are noted:

1. During document review between 1:00 PM and 4:00 PM it is observed that the fire drills held on 2nd shift in the last five quarters did not include any scenarios.
2. During document review between 1:00 PM and 4:00 PM it is observed that the fire drills held on 2nd shift in the last four quarters were all held between 19:00 and 20:00.
3. During document review between 1:00 PM and 4:00 PM it is observed that the fire drills held on 1st shift in the last five quarters did not include any scenarios.

The Director and Maintenance Staff were present and acknowledged the fire drills with no scenarios and the routine time frames of the drills.

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. The fire alarm shall be transmitted the day before or the day after the coded drill. 2000 NFPA 101, 19.7.1.2

Based on observation, document review, and staff interview, the facility failed to properly inspect and maintain the sprinkler system in accordance with NFPA 25. This deficient practice could affect all patients, visitors, and staff in 12 of 12 smoke zones. The facility has a capacity of 49 and a census of 6 at the time of the survey.

Findings include:

During the survey conducted on 10/12/16 and 10/13/16 the following deficiencies are noted:

1. During document review on 10/12/16 between 1:00 PM and 4:00 PM it is observed that there is no documentation for any monthly inspections of the sprinkler system at the time of survey.
2. During document review on 10/12/16 between 1:00 PM and 4:00 PM it is observed that there is no documentation for a quarterly inspection of the sprinkler system in the 3rd quarter of 2016.
3. During the survey on 10/13/16 at approximately 11:30 AM it is observed that there is an escutcheon ring and an escutcheon plate that are not flush with the ceiling tiles near the front lobby desk.

The Director and Maintenance Staff were present and acknowledged the missed monthly inspections and the escutcheon ring and plate that were not flush with the ceiling tiles.

NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. 1999 NFPA 13, 12.1
NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1
NFPA Standard: The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor. 1998 NFPA 25, 1-4.4

Based on observation and staff interview, the facility fails to inspect and maintain the hood system in accordance with NFPA 17A. This deficient practice may cause the hood to improperly function in the event of a fire, affecting no patients or visitors and all staff in 1 of 12 smoke zones. The facility has a capacity of 49 with a census of 6 at the time of survey.
Findings include:


During the survey conducted on 10/13/16 the following deficiency is noted:


1. During the survey at approximately 10:45 AM it is observed that there have not been any monthly inspections of the hood system.

The Director and Maintenance Staff were present and acknowledged the missed monthly inspections on the hood system.

NFPA Standard: Owner ' s Inspection
" Inspection shall be conducted on a monthly basis in accordance with the manufacturer ' s listed installation and maintenance manual or the owner ' s manual ...and shall include the following:
(1) The extinguishing system is in its proper location. (2) The manual actuators are unobstructed. (3) The tamper indicators and seals are intact. (4) The maintenance tag or certificate is in place. (5) No obvious physical damage or condition exists that might prevent operation. (6) The pressure gauge(s), if provided, is in operable range. (7) The nozzle blow-off caps are intact and undamaged. (8) The hood, duct, and protected cooking appliances have not been replaced, modified, or relocated.
If any deficiencies are found, appropriate corrective action shall be taken immediately. The date the inspection is performed and the initials of the person performing the inspection shall be recorded. The records shall be retained for the period between the semi-annual maintenance inspections. NFPA 17A - 7.2

Based on observation, staff interview and record review, the facility is not storing oxygen cylinders in accordance with NFPA 99, by ensuring that tanks were adequately secured to prevent them from accidental damage or dislocation. This deficient would affect no patients or visitors and all staff in 1 of 12 smoke zones. This facility has a capacity of 49 and a census of 6 residents at the time of survey.

Findings include:

During the survey conducted on 10/13/16 the following deficiency is noted:

1. During the survey at approximately 10:20 AM it is observed that there are three O2 cylinders in the Soiled Room in the ER that are not properly secured.

The Director and Maintenance Staff were present and acknowledged the unsecured O2 cylinders.
NFPA Standard: Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation. 1999 NFPA 99, 4.3.1.1.2

Based on observation, document review, and staff interview, the facility failed to properly inspect and document the maintenance of the fire dampers in accordance with NFPA 80. This deficient practice could affect all patients, visitors, and staff in 12 of 12 smoke zones. The facility has a capacity of 49 and a census of 6 at the time of the survey.

Findings include:

During the survey conducted on 10/12/16 the following deficiency is noted:

1. During document review on 10/12/16 at between 1:00 PM and 4:00 PM it is observed that there is no documentation for any inspections or maintenance of the fire dampers at the time of survey.

The Director and Maintenance Staff were present and acknowledged the missing documentation of the fire dampers.

NFPA Standard: Each damper shall be inspected and tested 1 year after installation. NFPA 80-19.4. Periodic Inspection and Testing 19.4.1. 19.4.1.1. The test and inspection frequency shall be every 4 years, except in hospitals, where the frequency shall be every 6 years. NFPA 80 19.4.1.1. NFPA 105-6.5 Periodic Inspection and Testing 6.5.2 Each damper shall be tested and inspected one year after installation. The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years. . NFPA 105-6.5 Periodic Inspection and Testing 6.5.2

Based on staff interview and record review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice would affect all patients, visitors, and staff in 12 of 12 smoke zones. The facility has a capacity of 49 with a census of 6 residents at the time of the survey.
Findings include:

During the survey conducted on 10/12/16 and 10/13/16 the following deficiencies are noted:

1. During document review on 10/12/16 between 1:00 PM and 4:00 PM it is observed that there is no documentation for any weekly inspections of the generator at the time of survey.
2. During the survey on 10/13/16 at approximately 11:15 AM it is observed that there is no remote shutoff for the generator.

The Director and Maintenance Staff were present and acknowledged the missed weekly tests of the generator and that there is no remote shutoff.

NFPA Standard: All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.

NFPA Standard: Level 1 and level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes. 1999 NFPA 110, 6.4.1 and 6.4.2

Based on observation and staff interviews, the facility failed to assure that the electrical system is installed and maintained in accordance with the NFPA 70. This deficient practice increases the risk of an electrical fire, affecting no patients or visitors and all staff in 1 of 12 smoke zones. This facility has a capacity of 49 and a census of 6 at the time of survey.

Findings Include:


During the survey conducted on 10/13/16 the following deficiency is noted:


1) During the survey at approximately 9:30 AM it is observed that in the 3rd floor pantry clean utility room there is a power outlet within 6 feet of the sink that is not GFCI protected.


The Director and Maintenance Staff were present and acknowledged the needed GFCI outlet.

NFPA Standard: Ground-fault circuit-interrupter protection for personnel shall be provided as required in 210.8(A) through (D). The ground-fault circuit- interrupter shall be installed in a readily accessible location. Dwelling Units: (7) Sinks - where receptacles are installed within 6 feet of the outside edge of the sink. NFPA 70 210.8 (A) (7)
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 properly inspect and maintain the smoke barrier doors in accordance with NFPA 101. This deficient practice could affect no patients and all visitors and staff in 3 of 12 smoke zones. The hospital has a capacity of 49 with a census of 6 patients at the time of the survey.
Findings include:

During the survey conducted on 10/13/16 the following deficiencies are noted:

1. During the survey at approximately 9:55 AM it is observed that the smoke barrier doors near the Ultrasound Office on the 2nd floor did not completely close when tested.
2. During the survey at approximately 10:05 AM it is observed that the smoke barrier doors near the Stiz Bath on the 2nd floor did not completely close when tested.

The Director and Maintenance Staff were present and acknowledged that the smoke barrier doors completely closing.
NFPA Standard: Requires doors in smoke barriers to be self-closing and have at least a 20-minute rating, 2000 NFPA 101, 19.3.7.6

Based on observation and staff interview, the facility failed to test and maintain the emergency lights to provide a means of illumination at each exit discharge, so that failure of normal lighting would not leave the area to public way in darkness. This deficient practice could affect all patients, visitors, and staff in 12 of 12 smoke zones. The facility has a capacity of 49 with a census of 6 residents at the time of the survey.
Findings include:


During the survey conducted on 10/12/13 and 10/13/16 the following deficiencies are noted:


1. During document review on 10/12/13 between 1:00 PM and 4:00 PM it is observed that there is no documentation available at the time of survey for an annual 90 minute test of the emergency lights.
2. During the survey on 10/13/16 at approximately 10:25 AM it is observed that the emergency lights in the Pharmacy did not function when tested and that the batteries are dead.

The Director and Maintenance Staff were present and acknowledged the missing documentation for an annual 90 minute test of the emergency lights and the failed emergency lights in the pharmacy.

NFPA Standard: A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 and 1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 2000 NFPA 101, 7.9.3

Based on record review and staff interview, the facility is not conducting fire drills at least quarterly on each shift in accordance with NFPA 101. The lack of fire drills could affect the abilities of the staff to respond in the event of an actual emergency. This deficient practice could affect all patients, visitors, and staff in 12 of 12 smoke zones. The facility has a capacity of 49 with a census of 6 at the time of survey.
Findings include:

During the survey conducted on 10/12/16 the following deficiencies are noted:

1. During document review between 1:00 PM and 4:00 PM it is observed that the fire drills held on 2nd shift in the last five quarters did not include any scenarios.
2. During document review between 1:00 PM and 4:00 PM it is observed that the fire drills held on 2nd shift in the last four quarters were all held between 19:00 and 20:00.
3. During document review between 1:00 PM and 4:00 PM it is observed that the fire drills held on 1st shift in the last five quarters did not include any scenarios.

The Director and Maintenance Staff were present and acknowledged the fire drills with no scenarios and the routine time frames of the drills.

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. The fire alarm shall be transmitted the day before or the day after the coded drill. 2000 NFPA 101, 19.7.1.2

Based on observation, document review, and staff interview, the facility failed to properly inspect and maintain the sprinkler system in accordance with NFPA 25. This deficient practice could affect all patients, visitors, and staff in 12 of 12 smoke zones. The facility has a capacity of 49 and a census of 6 at the time of the survey.

Findings include:

During the survey conducted on 10/12/16 and 10/13/16 the following deficiencies are noted:

1. During document review on 10/12/16 between 1:00 PM and 4:00 PM it is observed that there is no documentation for any monthly inspections of the sprinkler system at the time of survey.
2. During document review on 10/12/16 between 1:00 PM and 4:00 PM it is observed that there is no documentation for a quarterly inspection of the sprinkler system in the 3rd quarter of 2016.
3. During the survey on 10/13/16 at approximately 11:30 AM it is observed that there is an escutcheon ring and an escutcheon plate that are not flush with the ceiling tiles near the front lobby desk.

The Director and Maintenance Staff were present and acknowledged the missed monthly inspections and the escutcheon ring and plate that were not flush with the ceiling tiles.

NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. 1999 NFPA 13, 12.1
NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1
NFPA Standard: The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor. 1998 NFPA 25, 1-4.4

Based on observation and staff interview, the facility fails to inspect and maintain the hood system in accordance with NFPA 17A. This deficient practice may cause the hood to improperly function in the event of a fire, affecting no patients or visitors and all staff in 1 of 12 smoke zones. The facility has a capacity of 49 with a census of 6 at the time of survey.
Findings include:


During the survey conducted on 10/13/16 the following deficiency is noted:


1. During the survey at approximately 10:45 AM it is observed that there have not been any monthly inspections of the hood system.

The Director and Maintenance Staff were present and acknowledged the missed monthly inspections on the hood system.

NFPA Standard: Owner ' s Inspection
" Inspection shall be conducted on a monthly basis in accordance with the manufacturer ' s listed installation and maintenance manual or the owner ' s manual ...and shall include the following:
(1) The extinguishing system is in its proper location. (2) The manual actuators are unobstructed. (3) The tamper indicators and seals are intact. (4) The maintenance tag or certificate is in place. (5) No obvious physical damage or condition exists that might prevent operation. (6) The pressure gauge(s), if provided, is in operable range. (7) The nozzle blow-off caps are intact and undamaged. (8) The hood, duct, and protected cooking appliances have not been replaced, modified, or relocated.
If any deficiencies are found, appropriate corrective action shall be taken immediately. The date the inspection is performed and the initials of the person performing the inspection shall be recorded. The records shall be retained for the period between the semi-annual maintenance inspections. NFPA 17A - 7.2

Based on observation, staff interview and record review, the facility is not storing oxygen cylinders in accordance with NFPA 99, by ensuring that tanks were adequately secured to prevent them from accidental damage or dislocation. This deficient would affect no patients or visitors and all staff in 1 of 12 smoke zones. This facility has a capacity of 49 and a census of 6 residents at the time of survey.

Findings include:

During the survey conducted on 10/13/16 the following deficiency is noted:

1. During the survey at approximately 10:20 AM it is observed that there are three O2 cylinders in the Soiled Room in the ER that are not properly secured.

The Director and Maintenance Staff were present and acknowledged the unsecured O2 cylinders.
NFPA Standard: Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation. 1999 NFPA 99, 4.3.1.1.2

Based on observation, document review, and staff interview, the facility failed to properly inspect and document the maintenance of the fire dampers in accordance with NFPA 80. This deficient practice could affect all patients, visitors, and staff in 12 of 12 smoke zones. The facility has a capacity of 49 and a census of 6 at the time of the survey.

Findings include:

During the survey conducted on 10/12/16 the following deficiency is noted:

1. During document review on 10/12/16 at between 1:00 PM and 4:00 PM it is observed that there is no documentation for any inspections or maintenance of the fire dampers at the time of survey.

The Director and Maintenance Staff were present and acknowledged the missing documentation of the fire dampers.

NFPA Standard: Each damper shall be inspected and tested 1 year after installation. NFPA 80-19.4. Periodic Inspection and Testing 19.4.1. 19.4.1.1. The test and inspection frequency shall be every 4 years, except in hospitals, where the frequency shall be every 6 years. NFPA 80 19.4.1.1. NFPA 105-6.5 Periodic Inspection and Testing 6.5.2 Each damper shall be tested and inspected one year after installation. The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years. . NFPA 105-6.5 Periodic Inspection and Testing 6.5.2

Based on staff interview and record review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice would affect all patients, visitors, and staff in 12 of 12 smoke zones. The facility has a capacity of 49 with a census of 6 residents at the time of the survey.
Findings include:

During the survey conducted on 10/12/16 and 10/13/16 the following deficiencies are noted:

1. During document review on 10/12/16 between 1:00 PM and 4:00 PM it is observed that there is no documentation for any weekly inspections of the generator at the time of survey.
2. During the survey on 10/13/16 at approximately 11:15 AM it is observed that there is no remote shutoff for the generator.

The Director and Maintenance Staff were present and acknowledged the missed weekly tests of the generator and that there is no remote shutoff.

NFPA Standard: All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.

NFPA Standard: Level 1 and level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes. 1999 NFPA 110, 6.4.1 and 6.4.2

Based on observation and staff interviews, the facility failed to assure that the electrical system is installed and maintained in accordance with the NFPA 70. This deficient practice increases the risk of an electrical fire, affecting no patients or visitors and all staff in 1 of 12 smoke zones. This facility has a capacity of 49 and a census of 6 at the time of survey.

Findings Include:


During the survey conducted on 10/13/16 the following deficiency is noted:


1) During the survey at approximately 9:30 AM it is observed that in the 3rd floor pantry clean utility room there is a power outlet within 6 feet of the sink that is not GFCI protected.


The Director and Maintenance Staff were present and acknowledged the needed GFCI outlet.

NFPA Standard: Ground-fault circuit-interrupter protection for personnel shall be provided as required in 210.8(A) through (D). The ground-fault circuit- interrupter shall be installed in a readily accessible location. Dwelling Units: (7) Sinks - where receptacles are installed within 6 feet of the outside edge of the sink. NFPA 70 210.8 (A) (7)
NFPA Standard: Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2