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Based on observation and staff interview, the facility failed to provide egress door locks that will unlock with a single motion. This deficient practice affects all patients and staff. This facility has a capacity of 21 with a census of 6 at the time of this survey.

Findings include:

During the survey on December 20th, 2018 the following is observed:

1) It was observed at 8:20 AM in the east exit out the dining room the marked exit door requires a key to unlock the door.

Staff ED 1 and MD 1 were 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 upon observation and staff interview, the facility fails to assure that hazardous areas are separated from other spaces by smoke resisting partitions and doors. The deficient practice fails to provide solid, smoke resisting walls or ceiling in hazardous areas which would not stop the spread of smoke, affecting all residents or patients and any visitors or staff. The facility has a capacity of 21 with a census of 6 at the time of this survey.

Findings include:

During the survey on December 20th, 2018 it is observed:

1) It was observed at 8:13 AM in the laundry room there is a 1-inch hole in the wall behind the door.

2) It was observed at 9:58 AM in the laundry room above the desk in the ceiling there is a 2-inch hole with a copper pipe passing through it that is unsealed.

3) It was observed at 10:03 AM in the soiled utility room the sprinkler pipe in the west wall is unsealed.

Staff ED 1 and MD 1 were present during the survey and acknowledged the findings.

NFPA Standard: Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4-hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. 2012 NFPA 101 19.3.2.1

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 all patients, visitors and staff. The facility has a capacity of 21 and census of 6 at the time of the survey.

Findings include:

During the survey on December 20th, 2018 the following observations were made:

1) It was observed at 8:50 am in the ambulance garage electrical panel the circuit breaker for the fire alarm control panel (FACP) is not identified as "FIRE ALARM CIRCUIT" and have a red marking and not restricted to use by authorized personnel.

Staff ED 1 and MD 1 were present 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 and staff interview, the facility is not conducting fire drills properly. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency. The facility has a capacity of 21 and a census of 6.

Findings include:

During the survey on December 19th, 2018 the following observations were made

1) It was observed at 12:15 PM during the documentation review of the previous five quarters of fire drills. It was noted that the fire drills have been held at the last of the month as follows: 10/31/17, 11/30/17, 12/29/17, 1/30/18, 2/28/18, 3,29/18, 5/30/18, 7/24/18, 9/28/18 and 11/28/18.


Staff ED 1 and MD 1 were 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 101, 19.7.1.1-8

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 all patients, visitors, and staff. The facility has a capacity of 21 with a census of 6 at the time of this survey.


Findings include:


During the survey conducted on December 19th, 2018 the following deficiency is noted:


1) It was observed at 1:00 PM during documentation review the facility is not annually inspecting fire-rated door assemblies and documenting as required.


Staff ED 1 and MD 1 were 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 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. This facility has a capacity of 21 and a census of 6.

Findings include:

During the survey on December 20th, 2018 the following observations were made:

1) It was observed at 9:08 AM in the boiler room on the north wall 2 power strips being powered by extension cords.

Staff ED 1 and MD 1 were present during the survey and acknowledged the findings.

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Based on observation the facility fails to segregate full and empty oxygen cylinders, provide the appropriate signs on the oxygen storage room door and provide appropriate spacing between combustibles and oxygen cylinders. This deficient practice affects all patents, visitors and staff. The facility has a capacity of 21 and census of 6 at the time of the survey.

Findings include:

During the survey on December 20th, 2018 the following is observed:

1) It was observed at 9:04 AM the door to the oxygen storage room down stairs does not have sign on the door that is visible from 5 feet that says CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.

Staff ED 1 and MD 1 were present and acknowledged the findings.

Review of the following NFPA standard revealed: Storage shall be planned so that cylinders can be used in the order in which they are received from the supplier. If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders. When the facility employs cylinders with integral pressure gauge, it shall establish the threshold pressure at which a cylinder is considered empty. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner. (NFPA 99), 11.4

Review of the following NFPA standard revealed: Containers shall be stored, used, and operated in accordance with the manufacturer's instructions and labeling. Containers shall not be placed in the following areas: (1) Where they can be tipped over by the movement of a door (2) Where they interfere with foot traffic (3) Where they are subject to damage from falling objects (4) Where exposed to open flames and high-temperature. (NFPA 99), 11.7.3

Review of the following NFPA standard revealed: A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum: CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING. (NFPA 99), 11.4
Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following: (1) Minimum distance of 6.1 m (20 ft) (2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems (3) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1?2 hour. (NFPA 99) 11.3.2.3