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Based on observation and staff interview, the facility fails to provide means of egress that are maintained free of all obstructions or impediments to a full instant use in case of fire or other emergency. The deficient practice would prevent these exits from being arranged so that they are readily available and accessible, affecting all occupants and all patients in 2 of 5 smoke zones. The facility has a capacity of 25 and a census of 9 at the time of the survey.

Findings Include:

During the tour conducted on 3/19/2014, it is observed:

1. At 1:00 p.m., that the North and East delayed egress doors leading from the acute care area to other parts of the hospital do not have signage indicating that by pushing on the doors they can be opened within 15 seconds.

2. At 1:15 p.m., that the exit discharge path from the West exit of the acute care area does not have a hard surface to the public way.

The Chief Nursing Officer and Maintenance Engineer were present and acknowledged the findings.

NFPA Standard: Exits shall terminate directly at a public way or an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. 2000 NFPA 101, 7.7.1.

NFPA Standard: Approved, listed, delayed-egress locks shall be permitted to be installed on doors serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7, provided that the following criteria are met: doors shall unlock upon actuation of an approved, supervised automatic sprinkler system or any heat detector or activation of not more than two smoke detectors of an approved, supervised automatic fire detection system; the doors shall unlock upon loss of power; an irreversible process shall release the lock within 15 seconds upon application of a force not to exceed 15 pounds nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only; on the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 inch high and not less than 1/8 inch wide on a contrasting background that reads as follows: PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS. 2000 NFPA 101, 7.2.1.6.1.

Based on record review and staff interview, the facility fails to assure that fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all patients, staff, and visitors in the event of a fire. The deficiency affects all occupants and all patients in 5 of 5 smoke zones. The facility has a capacity of 25 and a census of 9 at the time of the survey.

Findings Include:

During the tour conducted 3/19/2014, at 10:40 a.m. during record review, it is observed that when silent drills are being performed on the 3rd shift the alarm system is not being transmitted the immediate day before or after the drill.

The Chief Nursing Office and Maintenance Engineer were present and acknowledged the findings.

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, 18.7.1.2

Based upon a review of records and staff interview, the facility fails to assure that the automatic sprinkler system is inspected, tested, and maintained in accordance with NFPA 25. The deficient practice could result in the unexpected failure of the automatic fire sprinkler system, affecting all occupants and all patients in 5 of 5 smoke zones. The facility has a capacity of 25 and a census of 9 at the time of the survey.

Findings include:

During the tour conducted on 3/19/2014, at 11:20 a.m. during record review, it is observed that it has been over 12 months since that last annual sprinkler system inspection.

The Chief Nursing Officer and Maintenance Engineer were present and acknowledged the finding. .

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

Based on observation and staff interview, the facility fails to provide means of egress that are maintained free of all obstructions or impediments to a full instant use in case of fire or other emergency. The deficient practice would prevent these exits from being arranged so that they are readily available and accessible, affecting all occupants and all patients in 2 of 5 smoke zones. The facility has a capacity of 25 and a census of 9 at the time of the survey.

Findings Include:

During the tour conducted on 3/19/2014, it is observed:

1. At 1:00 p.m., that the North and East delayed egress doors leading from the acute care area to other parts of the hospital do not have signage indicating that by pushing on the doors they can be opened within 15 seconds.

2. At 1:15 p.m., that the exit discharge path from the West exit of the acute care area does not have a hard surface to the public way.

The Chief Nursing Officer and Maintenance Engineer were present and acknowledged the findings.

NFPA Standard: Exits shall terminate directly at a public way or an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. 2000 NFPA 101, 7.7.1.

NFPA Standard: Approved, listed, delayed-egress locks shall be permitted to be installed on doors serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7, provided that the following criteria are met: doors shall unlock upon actuation of an approved, supervised automatic sprinkler system or any heat detector or activation of not more than two smoke detectors of an approved, supervised automatic fire detection system; the doors shall unlock upon loss of power; an irreversible process shall release the lock within 15 seconds upon application of a force not to exceed 15 pounds nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only; on the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 inch high and not less than 1/8 inch wide on a contrasting background that reads as follows: PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS. 2000 NFPA 101, 7.2.1.6.1.

Based on record review and staff interview, the facility fails to assure that fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all patients, staff, and visitors in the event of a fire. The deficiency affects all occupants and all patients in 5 of 5 smoke zones. The facility has a capacity of 25 and a census of 9 at the time of the survey.

Findings Include:

During the tour conducted 3/19/2014, at 10:40 a.m. during record review, it is observed that when silent drills are being performed on the 3rd shift the alarm system is not being transmitted the immediate day before or after the drill.

The Chief Nursing Office and Maintenance Engineer were present and acknowledged the findings.

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, 18.7.1.2

Based upon a review of records and staff interview, the facility fails to assure that the automatic sprinkler system is inspected, tested, and maintained in accordance with NFPA 25. The deficient practice could result in the unexpected failure of the automatic fire sprinkler system, affecting all occupants and all patients in 5 of 5 smoke zones. The facility has a capacity of 25 and a census of 9 at the time of the survey.

Findings include:

During the tour conducted on 3/19/2014, at 11:20 a.m. during record review, it is observed that it has been over 12 months since that last annual sprinkler system inspection.

The Chief Nursing Officer and Maintenance Engineer were present and acknowledged the finding. .

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