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Based on observation and staff interview the facility failed to maintain a separation wall as described the Life Safety Code (NFPA 101) 2012 edition section 19.1.3.2. This deficient practice could allow for the spread of fire and smoke affecting all patients staff and visitors.

Findings include:

On the facility tour between 9:00 am to 12:00 pm on 07/23/2018 observations revealed:
1) the separation wall did not extend to the roof deck along the Fire Barrier at the clinic waiting room.
2) Fire Barrier Wall is not complete to the ceiling above the staff entrance.
3)

This deficient conditions was confirmed by the Enviromental Services Manager.

Based on observations and staff interview the facility failed to install the smoke detection in accordance with NFPA 101 Life Safety Code (2012) section 19.3.4.1, 9.6.1.3 and NFPA 72 National Fire Alarm Code (2010) section 17.7.4.1. This deficient practice could affect the ability of the alarm system to sound in a timely manner during a fire event which could affect 15 of the 15 patients and an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 9:00 am to 12:00 pm on 07/23/2018 observations and staff interview revealed a smoke detector with 36 inches of an HVAC diffuser in the folling areas:
1) Nurses station
2) Rooms 102 and 103
3) In CT and corridor by CT


This deficient conditions was confirmed by the Enviromental Services Manager.

Based on observations and staff interview the facility failed to install the smoke detection in accordance with NFPA 101 Life Safety Code, (2012) section 19.3.6.1 & 9.6.2.10 and NFPA 72 National Fire Alarm Code (2010) section 17.6.3.1.1 This deficient practice could affect the ability of the alarm system to sound in a timely manner during a fire event which could affect 15 of the 15 patients and an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 9:00 am to 12:00 pm on 07/23/2018 , observation and staff interview revealed:
1) Missing smoke detector in the sleeping room in X-Ray.

This deficient conditions was confirmed by the Enviromental Services Manager.

Based on observation and staff interview the facility failed to install the sprinkler system in accordance with the 2012 edition of the Life Safety Code (NFPA 101) sections 19.3.5.1, 9.7.1.1 and the 2010 edition of NFPA 13, 7.2.6.2.1, The Standard for the Installation of Sprinkler Systems. This deficient practice could cause a delay in extinguishing a fire affecting the safety of 15 of the 15 patients and an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 9:00 am to 12:00 pm on 07/23/2018, observations and staff interview revealed:

1) The air compressor was plugged into the dry system and not hardwired as required.
2) There were multiple sprinkler heads that were too close to each other in the Medical Records Room

This deficient conditions was confirmed by the Environmental Services Manager.

Based on observation and staff interview, the facility failed to maintain the sprinkler system in accordance with the 2012 Life Safety Code (NFPA 101) and NFPA 25 section 5.3.2 & 14.2. The standard for testing and maintenance of sprinkler systems. This deficient condition could cause the sprinkler system not to function properly and allow for the spread of fire. This could affect all of the 15 patients and an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 9:00 am to 12:00 pm on 07/23/2018 observations revealed the following:
1. The escutcheon in the housekeeping closet is missing in the main corridor.
2. The escutcheon in X-Ray is missing.
3. There is a 2 1/2 inch hole in the ceiling tile in the Procedure room, RM 101, X-Ray.

This deficient conditions was confirmed by the Environmental Services Manager.

Based on record review and staff interview the facility failed to fire drills at least quarterly on each shift as required by the Life Safety Code (NFPA 101) 2012 edition, section 19.7.1.4 to 19.7.1.7. This deficient practice could reduce the ability of staff to conduct a safe and timely response to a fire emergency, which would affect all 15 patients and an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 9:00 am to 12:00 pm on 07/23/2018 record review and staff interview revealed the following fire drills were missed in the past 12 months.
1) 1st Quarter 2nd Shift 2018
2) 2nd Quarter 2nd Shift 2018
3) 3rd Quarter 3rd Shift 2017/2018
4) 4th Quarter 2nd Shift 2017

This deficient conditions was confirmed by the Environmental Services Manager.

Based on documentation review and staff interview, the facility failed to inspect the building systems are designed to meet Category 1 through 4 requirements as detailed in NFPA 99. Categories are determined by a formal and documented risk assessment procedure performed by qualified personnel. The deficient practice could affect all patients.

Findings include:

On the facility tour between 9:00 am to 12:00 pm on 07/23/2018 , documentation review and staff interview revealed the required risk assessment NFPA 99 had not been started at the time of the survey.

This deficient conditions was confirmed by the Environmental Services Manager.

Based on record review and staff interview the facility failed to provide test documentation in accordance with the 2012 edition of the Life Safety Code (NFPA 101) section 9.1.3.1 and the 2010 edition of NFPA 110 the Standard for Emergency and Standby Power Systems. This deficient practice could affect the safety of all 15 patients and an undetermined amount of staff and visitors if the generator failed to operate during a power outage.

Findings include:

On the facility tour between 9:00 am to 12:00 pm on 07/23/2018 record review and staff interview revealed:
1) The monthly generator log did not address the required testing data.
2) Annual load bank test was not performed.

This deficient conditions was confirmed by the Environmental Services Manager.

Based on observation and staff interview the facility failed to store oxygen tanks in accordance with NFPA 99 (Health Care Facilities Code) 2012 edition section 11.6.2.3 item 11. This deficient practice could create confusion for staff who handle the bottles. This condition could affect an undetermined amount of patients, staff and visitors.

Findings include:

On the facility tour between 9:00 am to 12:00 pm on 07/23/2018 observations revealed oxygen bottles in the oxygen storage room were not properly labeled as full or empty and they were not separated.

This deficient conditions was confirmed by the Environmental Services Manager.