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Based on observation and interview, the facility failed to provide separation of a hazardous area from other compartments. This deficient practice would allow fire and smoke to migrate out of the hazard area. The facility census was 12.
Findings are:
Observations on 9-12-12 between 11:25 am and 12:20 pm revealed:
1. A conduit in the electrical room that penetrated the wall.
2. The door for the kitchen storage failed to close and latch within the doorframe.
3. The door for housekeeping failed to close and latch within the doorframe and was propped open by a block.
4. The door for the cafeteria failed to close and latch within the doorframe.
5. The storage room #228 failed to provide a self-closing door.
6. The OB storage room had missing ceiling tile.

During an interview on 9-12-12 between 11:25 am and 12:20 pm revealed, Maintenance A confirmed all the findings.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Based on observation and interview, the facility failed to provide emergency lighting of 1? hour duration, in accordance with NFPA 101, 7.9. The lack of illumination would delay evacuation during an emergency. The facility census was 12.

Findings are:
Observations on 9-12-12 at 11:28 am revealed the emergency light in the boiler failed to light when test button was depressed.

During an interview on 9-12-12 at 11:28 am, Maintenance A confirmed the emergency lights failed to operate.

During record review of the facility's maintenance records on 9-12-12 at 1:15 pm revealed that there was no documentation regarding the monthly and annual testing of the emergency battery lighting system.

During an interview on 9-12-12 at 1:15 pm Maintenance A confirmed emergency lighting were failed to be tested.

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. NFPA 101, 7.9.3

Based on observation and staff interview, the facility failed to maintain the fire alarm system in accordance with the National Fire Protection Association, 72. This condition would delay the fire alarm system activation which would delay response time from personnel. Facility census was 12.

Findings are:

Observation and staff interview on 9-12-12 at 12:58 pm revealed a supervisory alarm on the fire alarm panel. The alarm indicated the PIV tamper switch was in trouble.

During an interview on 9-12-12 at 12:58 pm, Administrator A confirmed that the fire alarm panel was in in trouble.

Based on observation and staff interview, the facility failed to use electrical wiring and equipment in accordance with the National Fire Protection Association, 70. This failure increased the probability of electrical equipment and wiring causing an electrical fire or shock. Facility census was 12.

Findings Include:

Observations on 9-12-12 between 11:45 am and 12:42 pm revealed:

1. The use of four unapproved surge protector multi strip at the nurse ' s station.
2. The use of an unapproved surge protector multi strip in the triage room.
3. The use of an unapproved surge protector multi strip in the PFT room.

During an interview on 9-12-12 between 11:45 am and 12:42 pm, Maintenance A confirmed the confirmed all the findings


NFPA Standard:
Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8
NE State Fire Marshal Official Interpretation: Relocatable power taps are not permitted in areas of health care occupancies regularly occupied by patients. This includes general patient care areas and critical patient care areas. General care areas include patient bedrooms, examining rooms, treatment rooms, clinics and similar areas where it is intended that the patient will come in contact with ordinary appliances such as nurse call systems, electrical beds, examining lamps, telephones and entertainment devices such as radios, televisions and computers. This will also include common spaces such as corridors, lounges, dining rooms and similarly occupied spaces where electrical appliances noted above may be found. Critical patient care areas are: intensive care units, coronary care units, angiography labs, cardiac catheterization labs, delivery rooms, operating rooms, post anesthesia recovery rooms and emergency rooms. In areas not occupied by patients, properly listed portable power taps are permitted. This can include business offices and staff lounges and similar spaces.

Based on observation and interview, the facility failed to provide separation of a hazardous area from other compartments. This deficient practice would allow fire and smoke to migrate out of the hazard area. The facility census was 12.
Findings are:
Observations on 9-12-12 between 11:25 am and 12:20 pm revealed:
1. A conduit in the electrical room that penetrated the wall.
2. The door for the kitchen storage failed to close and latch within the doorframe.
3. The door for housekeeping failed to close and latch within the doorframe and was propped open by a block.
4. The door for the cafeteria failed to close and latch within the doorframe.
5. The storage room #228 failed to provide a self-closing door.
6. The OB storage room had missing ceiling tile.

During an interview on 9-12-12 between 11:25 am and 12:20 pm revealed, Maintenance A confirmed all the findings.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Based on observation and interview, the facility failed to provide emergency lighting of 1? hour duration, in accordance with NFPA 101, 7.9. The lack of illumination would delay evacuation during an emergency. The facility census was 12.

Findings are:
Observations on 9-12-12 at 11:28 am revealed the emergency light in the boiler failed to light when test button was depressed.

During an interview on 9-12-12 at 11:28 am, Maintenance A confirmed the emergency lights failed to operate.

During record review of the facility's maintenance records on 9-12-12 at 1:15 pm revealed that there was no documentation regarding the monthly and annual testing of the emergency battery lighting system.

During an interview on 9-12-12 at 1:15 pm Maintenance A confirmed emergency lighting were failed to be tested.

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. NFPA 101, 7.9.3

Based on observation and staff interview, the facility failed to maintain the fire alarm system in accordance with the National Fire Protection Association, 72. This condition would delay the fire alarm system activation which would delay response time from personnel. Facility census was 12.

Findings are:

Observation and staff interview on 9-12-12 at 12:58 pm revealed a supervisory alarm on the fire alarm panel. The alarm indicated the PIV tamper switch was in trouble.

During an interview on 9-12-12 at 12:58 pm, Administrator A confirmed that the fire alarm panel was in in trouble.

Based on observation and staff interview, the facility failed to use electrical wiring and equipment in accordance with the National Fire Protection Association, 70. This failure increased the probability of electrical equipment and wiring causing an electrical fire or shock. Facility census was 12.

Findings Include:

Observations on 9-12-12 between 11:45 am and 12:42 pm revealed:

1. The use of four unapproved surge protector multi strip at the nurse ' s station.
2. The use of an unapproved surge protector multi strip in the triage room.
3. The use of an unapproved surge protector multi strip in the PFT room.

During an interview on 9-12-12 between 11:45 am and 12:42 pm, Maintenance A confirmed the confirmed all the findings


NFPA Standard:
Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8
NE State Fire Marshal Official Interpretation: Relocatable power taps are not permitted in areas of health care occupancies regularly occupied by patients. This includes general patient care areas and critical patient care areas. General care areas include patient bedrooms, examining rooms, treatment rooms, clinics and similar areas where it is intended that the patient will come in contact with ordinary appliances such as nurse call systems, electrical beds, examining lamps, telephones and entertainment devices such as radios, televisions and computers. This will also include common spaces such as corridors, lounges, dining rooms and similarly occupied spaces where electrical appliances noted above may be found. Critical patient care areas are: intensive care units, coronary care units, angiography labs, cardiac catheterization labs, delivery rooms, operating rooms, post anesthesia recovery rooms and emergency rooms. In areas not occupied by patients, properly listed portable power taps are permitted. This can include business offices and staff lounges and similar spaces.