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The facility failed to meet the minimum construction requirements in accordance with NFPA 101, 19.1.6 Minimum Construction Requirements. This deficient practice could affect all residents, staff and visitors should fire occur within the facility. This STANDARD is not met as evidenced by:

During the tour of the facility it was determined the facility is a two-story Type II (000) structure. (see initial comments under tag K000). In accordance with NFPA 101, 19.1.6.2, Construction Type limitation, a facility found to be a Type II (000) structure must be protected throughout by an automatic sprinkler system, and may be no more than two(2) stories in height.
The Director of Maintenance acknowledge the automatic sprinkler system requirements throughout the building during the tour of the facility.
Life Safety Code Section 19.1.6 Health Care occupancies shall be limited to the construction types specified in Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7

One hour fire rated construction (with ¾ hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protects hazardous areas. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors. Doors shell be self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. 19.3.2.1 This STANDARD is not met as evidenced by:

Based on observation and staff interview during the survey, it was determined that the facility failed to maintain sprinkler protected hazardous areas in accordance with Life Safety Section 19.3.2.1. This deficient practice could affect all residents and staff in the main smoke compartment (includes the main lobby, main dining room, and kitchen areas) should there be smoke and heat transfer between the hazard area and other portions of the building.
This was evidence by the following.


A. The facility removed the self-closing devices form the doors to the main kitchen and staff/visitors dining area. This room is over fifty square feet in area, does not have automatic sprinkler system protection.

B. The housekeeping storage room was not equipped with a self-closing device. This storage area was over fifty-square-feet in area and contained quantities of combustible materials and is considered as a hazardous area.

The Director of Maintenance acknowledged the hazardous area enclosures and door condition during a tour of the facility.
Life Safety Code Section 19.3.2.1 requires that sprinkler protected hazardous areas be separated from other spaces by smoke-resisting construction. Doors installed to protect hazardous areas must be self-closing or automatic closing.

K-0046
Based on record review and staff interviews of the emergency lighting, the battery-powered emergency lights have not been monthly and annually tested in accordance with 7.9.3 and 19.2.9.1. This deficient practice could affect all residents and staff throughout the facility in the event of the loss of primary power.
This was evidenced by the following:
1. No documentation was available during record review of the facility required annual testing of the battery-powered emergency lighting system at 30 day intervals for not less than 30 seconds.

2. No documentation was available during record review of the facility required annual testing of the battery-powered emergency lighting system for not less than 1 ½ hours

3. The facility failed to maintain the battery-powered emergency lighting in the CT room.
The emergency light would not illuminate when the test button was depressed.

The Director of Maintenance acknowledge the required testing of the emergency lighting during the tour of the facility.

7.9.3 Periodic Testing of Emergency Lighting Equipment. 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 ½ hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Based on observation, during the tour of the facility, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13 and Standard 25. This deficient practice could affect all residents, staff and visitors should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant maintenance. This was evidence by the following.

Located in the basement storage room a pendent sprinkler head was obstructed by an air-condition unit and will not allow proper coverage to this area.
The Director of Maintenance acknowledge the sprinkler obstruction deficiency during the tour of the facility.
NFPA 101Life Safety Code Standards required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

Based on observation and staff interview it was determined that the facility failed to maintain fire safe environment in the Administration Offices. This deficient practice could affect all patients, staff and visitors should a fire occur by the non-rated space heaters. This was evidence by the following.

Non- documented space heaters were located in the following areas.
A. Nurses station (2)
B. BT Office (1)
C. Medical Records Office (1)

The Hospital CEO and Director of Maintenance acknowledge the deficiency of the prohibited space heaters during the facility tour.
Life Safety Code, Section 19.7.8. Portable space-heating devices shall be prohibited in all heath care occupancies. Exception: Portable space-heating devices shall be permitted to be used in non-sleeping staff and employee ' s areas where the heating elements of such devices do not exceed 212° F (100° C).

Through observation during the survey, June 28, 2016, it was determined that the facility failed to provide emergency lighting of at least 1-1/2-hour duration at the transfer switches. This deficient practice could affect all residents and staff throughout the facility in the event of the loss of primary power. This was evidenced by the following:
During the walk through of the facility, with the staff, the room which housed the transfer switches for the emergency lighting system and the housing unit of the generator was not equipped with a battery powered emergency light fixture. This battery light is required to be on the secondary side, of the transfer switch, (powered from the emergency panel).

The Director of Maintenance acknowledge the lack of emergency lighting deficiency during the tour of the facility.
NFPA 110 Chapter 5 Section 5-3. Level 1 or Level 2 EPS equipment locations shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

Based on observation during the course testing the transfer switch on the generator it was determined that the facility failed to maintain emergency power systems in accordance with section 19.2.9.1 of the Life safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems Chapter 6 This deficient practice has the potential to affect all residents, staff and visitors in the event of power loss.

This was evidenced by the following.

The diesel fueled emergency generator failed to start, several attempts to start the generator were made by the Director of Maintenance unsuccessfully.


The emergency power supply system deficiency item was discussed with the Director of Maintenance during the survey and again during the exit conference with the Hospital CEO.

NFPA 110, Section 6-4.1 Level I and Level EPSSs, including all appurtenant components, shall be inspected and shall be exercised under load at least monthly.