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Based on observation and staff interview, the facility failed to assure that the 2 hour wall separating the hospital from the Business offices is properly sealed, failing to provide the proper fire resistance rating. This deficient practice of allowing improperly sealed penetrations in a 2 hour separation wall affect patients and staff in 2 of 4 smoke zones. The facility has a capacity of 25 and a census of 7 at the time of survey.

Findings include:

During the survey on August 10, 2017, the following is observed:

1.At 2:30 pm that the 2-hour fire barrier wall from hospital to business and pool therapy area above Ebrle Conference room door, has penetration from cables above suspended ceiling.
.

The Maintenance Director was present and acknowledged the findings.


Review of the following NFPA Standard revealed: Sections of health care facilities shall be permitted to
be classified as other occupancies, provided that they meet all
of the following conditions:

(1) They are not intended to provide services simultaneously for four or more inpatients for purposes of housing, treatment, or customary access by inpatients incapable of self preservation.

(2) They are separated from areas of health care occupancies by construction having a minimum 2 hour fire resistance rating in accordance with Chapter 8.

(3) For other than previously approved occupancy separation arrangements, the entire building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
2012 NFPA 101, 19.1.3.3

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other spaces. The area of deficient practice would provide a path for smoke and fire to travel into the adjacent area, affecting patients and staff in 1 of 4 smoke zones. The facility has a capacity of 25 with a census of 7 at the time of survey.

Findings include:

During the survey on August 10 2017, the following is observed:

At 12:35 pm is observed that the door to the clean linen room by nurse's station did not self close and latch.

The Maintenance Director was present during the survey and acknowledged the findings.


Review of the following NFPA Standard revealed: Any hazardous areas shall be safeguarded by a fire barrier having a 1 hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. 2012 NFPA 101, 19.3.2.1

Review of the following NFPA Standard revealed: An automatic extinguishing system, where used in hazardous areas, shall be permitted to be in accordance with 19.3.5.9. 2012 NFPA 101, 19.3.2.1.1

Review of the following NFPA Standard revealed: Where the sprinkler option of19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4. 2012 NFPA 101, 19.3.2.1.2

Based on observation, staff interview and record review, the facility failed to clean the kitchen range hood, grease removal devices, fans, ducts, and other appurtenances at intervals prior to surfaces becoming heavily contaminated with grease or oily sludge in compliance with NFPA 96. The deficient practice provides fuel for cooking equipment to ignite, affecting all patients and staff in 1 of 4 smoke zones, including the main dining room. The facility has a capacity of 25 with a census of 7 at the time of the survey.

Findings include:

During record review on August 10, 2017 between 9:00 am and 11:30 am it is noted that documentation indicate that only one cleaning of the kitchen exhaust hood system has been performed in the past year

The Administrator and Maintenance Director were present and acknowledged the findings.


Review of the following NFPA Standard revealed: Inspection for Grease Buildup. The entire exhaust system
shall be inspected for grease buildup by a properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction and in accordance with Table 11.4
2011 NFPA 96,11.4

Based on observation and interviews, the facility fails to ensure that the facility's automatic sprinkler system is installed in accordance with NFPA 13 and maintained in accordance with NFPA 25. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting all patient and staff in 1 of the 4 smoke zones. The facility has a capacity of 25 with a census of 7 at the time of survey.

During the tour on August 10, 2017 the following is observed:

At 1:50 pm an extension cord is found to be wire tied to the sprinkler pipe in the EMS bay.

The Maintenance Director was present during the survey and acknowledged the findings.


Review of the following NFPA Standard revealed: Responsibility for Inspection, Testing, Maintenance, and Impairment. The property owner or designated representative shall be responsible for properly maintaining a water based fire protection system.). 2011 NFPA 25,4.1.1


Review of the following NFPA Standard revealed: Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall). 2011 NFPA 25, 5.2.1.1.1

Based on observation, record review and interview the facility does not assure a fire watch procedure and policy is written as required for implementation when the fire sprinkler system is out of service for more than 10 hours in a 24 hour period and fire alarm more than 4 hours in a 24 hour period. This deficient practice would prevent proper notification of insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction as required, affecting all patient and staff in all 4 smoke zones. The facility has a capacity of 25 and a census of 7 at the time of survey.

Findings include:

During record review on August 10, 2017, the following is observed: Between 9:00 am and 11:30 am it is revealed that the facility did not have in the written fire watch policy the phone number of the local fire dept. And other contact information that is required by 2011 NFPA 25, 15.5.2

The Maintenance Director was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: Sprinkler System Impairments. Sprinkler impairment procedures shall comply with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water Based Fire Protection Systems. 2012 NFPA 101, 9.7.6

Review of the following NFPA Standard revealed: All preplanned impairments shall be authorized by the impairment coordinator. 2011 NFPA 25, 15.5.1

Review of the following NFPA Standard revealed: Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented:

1) The extent and expected duration of the impairment have been determined.
(2) The areas or buildings involved have been inspected and the increased risks determined.
(3) Recommendations have been submitted to management or the property owner or designated representative.
(4) Where a required fire protection system is out of service for more than 10 hours in a 24 hour period, the impairment coordinator shall arrange for one of the following:
(a) Evacuation of the building or portion of the building affected by the system out of service
(b) An approved fire watch
(c) Establishment of a temporary water supply
(d) Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire
(5) The fire department has been notified.
(6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified.
(7) The supervisors in the areas to be affected have been notified.
(8) A tag impairment system has been implemented. (See Section 15.3.)
(9) All necessary tools and materials have been assembled on the impairment site. 2011 NFPA 25, 15.5.2

Review of the following NFPA Standard revealed: Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure. When emergency impairments occur, emergency action shall be taken to minimize potential injury and damage.

The coordinator shall implement the steps outlined in Section 15.5. 2011 NFPA 25, 15.6.1, 15.6.2 & 15.6.3

Review of the following NFPA Standard revealed: Restoring Systems to Service. When all impaired equipment is restored to normal working order, the impairment coordinator shall verify that the following procedures have been implemented:
(1) Any necessary inspections and tests have been conducted to verify that affected systems are operational. The appropriate chapter of this standard shall be consulted for guidance on the type of inspection and test required.
(2) Supervisors have been advised that protection is restored.
(3) The fire department has been advised that protection is restored.
(4) The property owner or designated representative, insurance carrier, Alarm Company, and other authorities having jurisdiction have been advised that protection is restored.
(5) The impairment tag has been removed 2011 NFPA 25, 15.7

Based on observation and staff interview the facility failed to ensure that portable fire extinguishers are not mounted 3.5 inches above the floor surface. This deficient practice may prevent the portable fire extinguisher from being readily accessible due to difficulty in retrieving it without a bracket, affecting patient and staff 1 of 4 smoke zones. This facility has a capacity of 25 and a census of 7.

Findings include:

During the tour on August 10, 2017 the following is observed:

1.At 1:40 pm the portable fire extinguisher in the X-ray department is found to be setting on the floor

. The Maintenance Director was present during the survey and acknowledged the findings.


Review of the following NFPA Standard revealed: Where required by the provisions of another section
of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 2012 101,9.7.4.1

Review of the following NFPA Standard revealed: Portable fire extinguishers having a gross weight of not exceeding 40 pounds shall be installed so that the top is not more than 5 feet above the floor. Extinguishers having a gross weight exceeding 40 pounds shall be installed so that the top is not more than 3.5 feet above the bottom not less than 4 inches above floor. 2010 NFPA 10

Based on record review and staff interview, the facility is not conducting fire drills as required and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency, affecting all patients and staff in all 4 smoke zones. The facility has a capacity of 25 with a census of 7 at the time of survey.

Findings include:

1. Review of the facility's fire drill records for the previous 12 months revealed that fire drills conducted on the 1st shift during the last four quarters, revealed that 2 of the 4 occurred within an hour of each other between 6:30 AM on 6/27/17 and 7:04 AM on 12/28/16

2. Review of the facility's fire drill records for the previous 12 months revealed that fire drills conducted on the 1st shift during the last four quarters, revealed that 2 of the 4 occurred within an hour of each other between 7:04 AM on 12/28/16 and 7:40 AM on 9/29/16.

3. Review of the facility's fire drill records for the previous 12 months revealed that fire drills conducted on the 2nd shift in September, revealed that no date or time is recorded when the silent drill was performed. Documentation revealed that a transmission for the fire alarm on the next day was completed

The Maintenance Director was present during the survey and record review and acknowledged the findings.


Review of the following NFPA Standard revealed: 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
Review of the following NFPA Standard revealed: 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. 2012 NFPA 101, 19.7.1.6

Based on observation and staff interview, the facility fails to assure that all electrical wiring and equipment is installed and maintained in accordance with the requirements NFPA 70. This deficient practice increases the risk of an electrical fire. The deficient practice could affect staff and patients in 1 of 4 smoke zones. The facility has a capacity of 25 with a census of 7 at the time of the survey.

Findings include:

During the tour conducted on August 10, 2017, at 1:30 p.m., it is observed that 5 power-strips are piggy-backed in to APC units for the office computers in the facility's health information management office area.

The Maintenance Director was present and acknowledged the findings.



Review of the following NFPA Standard revealed: Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction. 2012 NFPA 101, 9.1.2

Review of the following NFPA Standard revealed: Unless specifically permitted, flexible cords and cable shall not be used as a substitute for fixed wiring of a structure. 2011 NFPA 70, 4000-8

Review of the following NFPA Standard revealed: In no case, shall the load exceed the branch-circuit ampere rating. An individual branch circuit shall be permitted to supply any load for which it is rated. A branch circuit supplying two or more outlets or receptacles shall supply only the loads specified according to its size as specified in (a) through (d) and as summarized in Section 210-24. A 15- or 20-ampere branch circuit shall be permitted to supply lighting units or other utilization equipment, or a combination of both. The rating of any one cord- and plug-connected utilization equipment shall not exceed 80 percent of the branch-circuit ampere rating. The total rating of utilization equipment fastened in place, other than lighting fixtures, shall not exceed 50 percent of the branch-circuit ampere rating where lighting units, cord- and plug-connected utilization equipment not fastened in place, or both, are also supplied.2011 NFPA 70, 210-23

Based on staff interview and document review the facility fails to properly train and document their staff on the proper handling of gas equipment in accordance with NFPA 99. The deficient practice would affect all patients, and staff in all 4 smoke zones. The facility has a capacity of 25 with a census of 7 at the time of the survey.
Findings include:

During record review conducted on August 10, 2017 the following deficiency is noted:

1.During document review Between 9:00 am and 11:30 am it is observed that there is no documentation available for the education or training of facility staff on the risk, safety guidelines, and usage requirements of medical gas equipment at the time of survey.

The Maintenance Director was present and acknowledged the findings.

Review of the following NFPA Standard Revealed Gases in Cylinders and Liquefied Gases in Containers.2012 NFPA 99 11.5.2

Review of the following NFPA Standard Revealed Qualification and Training of Personnel.2012 NFPA 99 11.5.2.1

Review of the following NFPA Standard Revealed Personnel concerned with the application and maintenance of medical gases and others who handle medical gases and the cylinders that contain the medical gases shall be trained on the risks associated with their handling and use. 2012 NFPA 99 11.5.2.1.1*

Review of the following NFPA Standard Revealed Health care facilities shall provide programs of continuing education for their personnel. 2012 NFPA 99 11.5.2.1.2

Review of the following NFPA Standard revealed Continuing education programs shall include periodic review of safety guidelines and usage requirements for medical gases and their cylinders. 2012 NFPA 99 11.5.2.1.3

Review of the following NFPA Standard Revealed Equipment shall be serviced only by personnel trained in the maintenance and operation of the equipment. 2012 NFPA 99 11.5.2.1.4

Review of the following NFPA Standard revealed If a bulk cryogenic system is present, the supplier shall provide annual training on its operation. 2012 NFPA 99 11.5.2.1.5