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Based on document review and staff interview, the facility fails to conduct fire drills as required by Life Safety Code NFPA 101. This deficient practice would affect all patients, visitors, and staff in 4 of 4 smoke zones. The facility has a capacity of 25 with a census of 8 at the time of the survey.

Findings Include:

During the survey on 12/21/18 the following deficiencies are noted:

1. During document review at 1:10 PM, it is observed that three of the last four fire drills on 1st shift occurred between the hours of 2:07 and 3:02 PM.
2. During document review at 1:10 PM, it is observed that three of the last four fire drills on 2nd shift occurred between 4:00 and 4:45 AM.

Staff A was present and acknowledged findings.

NFPA Standard: NFPA 101 2012 19.7.1.4* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 19.7.1.5 Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 19.7.1.6 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. 19.7.1.7 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.

Based on observation and staff interview, the facility failed to properly protect and store compressed gasses as required by NFPA 99. The deficient practice would affect no patients, and all visitors and staff in 1 of 4 smoke zones. The facility has a capacity of 25 with a census of 8 at the time of the survey.

Findings include:

During the survey conducted on 12/21/18 the following deficiency is noted:

1. During the survey at 2:10 PM, it is observed that there is an unsecured O2 cylinder in the emergency room soiled utility room.

Staff A was present and acknowledged the finding.

NFPA Standard: NFPA 99 2012 11.3.2.8 Cylinder valve protection caps shall comply with 11.6.2.3 11.6.2.3 Cylinders shall be protected from damage by means of the following specific procedures: (1) Oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device. (2) Oxygen cylinders shall not be stored near elevators or gangways or in locations where heavy moving objects will strike them or fall on them. (3) Cylinders shall be protected from tampering by unauthorized individuals. (4) Cylinders or cylinder valves shall not be repaired,
painted, or altered. (5) Safety relief devices in valves or cylinders shall not be tampered with. (6) Valve outlets clogged with ice shall be thawed with warm - not boiling - water. (7) A torch flame shall not be permitted, under any circumstances, to come in contact with a cylinder, cylinder valve, or safety device. (8) Sparks and flame shall be kept away from cylinders. (9) Even if they are considered to be empty, cylinders shall not be used as rollers, supports, or for any purpose other than that for which the supplier intended them. (10) Large cylinders (exceeding size E) and containers larger than 45 kg (100 lb) weight shall be transported on a proper hand truck or cart complying with 11.4.3.1. (11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart. (12) Cylinders shall not be supported by radiators, steam pipes, or heat ducts.