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Based on observation and staff interview the facility failed to provide continuous illumination of medication preparation rooms to values of at least 1 ft candle (10 lux) measured at the floor. This deficient practice does not insure that the working areas will be illuminated continuously and will delay medication dispensing, affecting 5 of 5 smoke zones. The facility has a capacity of 36 with a census of 8 at the time of survey.

Findings Include:

During the tour from 1/17/17 to 1/18/17 it is noted that:

1. At 1:37 PM on 1/17/17 the medication rooms for the 100 and 200 halls and C-section recovery area are not provided with emergency lighting.
2. At 2:45 PM on 1/17/17 the ER medication room lighting is controlled by a switch and no additional emergency lighting is provided.

The maintenance director was present during the findings.

NFPA Standard: Delayed-Automatic Connections to Equipment Branch. The following equipment shall be permitted to be connected to the equipment branch and shall be arranged for delayed-automatic connection to the alternate power source:
(1) Task illumination and select receptacles in the following:
(a) Patient care rooms
(b) Medication preparation areas
(c) Pharmacy dispensing areas
(d) Nurses ' stations (unless adequately lighted by corridor luminaires)
(2) Supply, return, and exhaust ventilating systems for airborne infectious isolation rooms
(3) Sump pumps and other equipment required to operate for the safety of major apparatus and associated control
systems and alarms
(4) Smoke control and stair pressurization systems
(5) Kitchen hood supply or exhaust systems, or both, if required to operate during a fire in or under the hood 2012 NFPA 99 SECTION, 6.5.2.2.3.3

NFPA Standard: Emergency illumination shall be provided for not less than 11/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 foot-candle. 2012 NFPA 101, 7.9.2.1
NFPA Standard: The emergency lighting system shall be arranged to provide the required illumination automatically in the event of the interruption of normal lighting, opening of a circuit breaker, or a manual act, including accidental opening of a switch controlling normal lighting facilities. 2012 NFPA 101, 7.9.2.3

Based on observation and staff interview, the facility did not assure that the relative humidity was monitored for the operating rooms that utilize anesthesia as required by code. This deficient practice affects both operating rooms in 1 of 5 smoke zones. The facility has a capacity of 36 with a census of 8 at the time of survey.

Findings Include:
During the tour from 1/17/17 to 1/18/17 it is noted that:

1. At 3:54 PM on 1/17/17 No humidity log documentation available for review before December 2016.

The maintenance director was present during the findings.

NFPA Standard: Anesthetizing locations shall be in accordance with Section 8.7 and the provisions of NFPA 99, Health Care Facilities Code, applicable to administration, maintenance, and testing. 2012 NFPA 101, 19.3.2.3


NFPA Standard: Heating, cooling, ventilating, and process systems serving spaces or providing health care functions covered by this code or listed within ASHRAE 170, Ventilation of Health Care Facilities,shall be provided in accordance with ASHRAE 170. 2012 NFPA 99, 9.3.1.1

Based on observation, interview and record review, the facility failed to provide and maintain documentation of annual inspection and testing of the fire alarm system as required by NFPA 72. The absence of complete, verifiable documented maintenance and repair history on the fire alarm system fails to ensure reliability of the alarm system in the event of an emergency, affecting 5 of 5 smoke zones. The facility has a capacity of 36 with a census of 8 at the time of survey.

Findings Include:

During the tour from 1/17/17 to 1/18/17 it is noted that:

1. At 11:43 AM on 1/17/17 the last documented sensitivity tests were performed in 2009 and 2013 however no nuisance alarm records were available for review.


The maintenance director was present during the findings.
NFPA Standard: Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 14.3.1. 2010 NFPA 72, 14.3.1.

NFPA Standard: A permanent record of all inspections, testing, and maintenance shall be maintained that includes periodic tests and applicable information, per 2010 NFPA 72, 14.6.2.4 and figure 14.6.2.4; A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70. 2012 NFPA 101, 9.6.1.5.

NFPA Standard: If the frequency is extended, records of nuisance alarms and subsequent trends of these alarms shall be maintained. , 2010 NFPA 72, 14.4.5.3.3.1

Based on observation, record review and interview the facility does not assure a fire watch procedure and policy is written and available for implementation when fire alarm system is out of service for more than 4 hours in a 24 hour period. This deficient practice would allow facility exposure to undetected smoke and/or fire without an automatic detection compensatory provision when it occurred, and without appropriately prepared staff response, affecting 5 of 5 smoke zones. The facility has a capacity of 36 with a census of 8 at the time of survey.

Findings Include:
During the tour from 1/17/17 to 1/18/17 it is noted that:

1. At 12:26 PM on 1/17/17 fire watch policy did not provide the details of how emergency services will be contacted in the event a fire is found during the watch, there are no frequency details on how often the facility is to be inspected.

The maintenance director was present during the findings.


NFPA Standard: When a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the AHJ shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties until the fire alarm system has been returned to service. A fire watch should consist of trained personnel who continuously patrol the affected area, with ready access to fire extinguishers and the ability to promptly notify the fire department. During the patrol of the area, the person should look for fire, and that other fire protection features of the building such as egress routes and alarm systems are available and functioning properly. 2012 NFPA 101, 9.6.1.6. and A.9.6.1.6.

Based on observation and staff interviews, the facility does not assure that the automatic fire sprinkler system is tested and maintained properly. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting 5 of 5 smoke zones. The facility has a capacity of 36 with a census of 8 at the time of survey.

Findings Include:

During the tour from 1/17/17 to 1/18/17 it is noted that:

1. At 12:08 PM on 1/17/17 quarterly sprinkler inspection documentation information did not indicate if the hydraulic nameplate is attached the system.
2. At 2:00 PM on 1/17/17 the sprinkler riser #1 in the boiler room gauges are overdue for replacement.

The maintenance director was present during the findings.


NFPA Standard: 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. 2012 NFPA 101, 4.6.12.1.

NFPA Standard: All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2012 NFPA 101, 9.7.5.
NFPA Standard: Testing the waterflow alarms on wet pipe systems shall be accomplished by opening the inspector ' s test connection. Fire pumps shall not be turned off during testing unless all impairment procedures contained in Chapter 15 are followed.
NFPA Standard: Hydraulic Design Information Sign. The hydraulic design information sign for hydraulically designed systems shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible. 2011 NFPA 25, 5.2.6

Based on observation and staff interview the facility is not ensuring that room doors resist the passage of smoke. This deficient practice prevents the ability of the facility to properly confine fire and smoke products and to properly defend occupants in place, affecting 1 of 5 smoke zones. The facility has a capacity of 36 with a census of 8 at the time of survey.

Findings Include:
During the tour from 1/17/17 to 1/18/17 it is noted that:

1. At 3:13 PM on 1/17/16 an unrated sliding window observed installed the old cashier corridor door that is not designed to prevent the passage of smoke.

The maintenance director was present during the findings.


NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2012 NFPA 101, 19.3.6.3.1 and A.19.3.6.3.10.

Based on observation and staff interview the facility fails to maintain smoke barriers to at least one half hour fire resistance and ensure that all penetrations are properly sealed. This deficient practice would prevent containment of fire and smoke, affecting 5 of 5 smoke zones. The facility has a capacity of 36 with a census of 8 at the time of survey.

Findings Include:

During the tour from 1/17/17 to 1/18/17 it is noted that:

1. At 9:04 AM on 1/18/17 a 2 " x 8 ' gap between the roof deck and concrete crossbeam along the 200 hall main entryway along the west side of the barrier wall visible above ceiling level.
2. At 9:51 AM on 1/18/17 a 3 " hole around a black cable in the north side of room #107 smoke barrier wall visible above ceiling level.
3. At 9:57 AM on 1/18/17 an ¼ " unsealed gap around the access panel in the east side of the smoke barrier wall above the restroom in room #107 visible above ceiling level.
4. At 10:18 AM on 1/18/17 an unsealed 3 " gap between the drywall and the ceiling member above the nurses station entrance to the recovery area.
5. At 10:24 AM on 1/18/17 an unsealed 8 " x 12 " gap around piping above the nurses station work room along the east side of the smoke barrier wall visible above ceiling level.

The maintenance director was present during the findings.

NFPA Standard: Requires smoke walls to have a fire resistance rating of at least a half hour and to be continuous from floor to roof deck and from outside wall to outside wall. 2012 NFPA 101, 8.5.2.1, 19.3.7.3.
NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.5.2.2. Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke. 2012 NFPA 101, 8.5.6.2.

Based on observation, record review and staff interview the facility failed to provide a written fire safety plan that addresses the required aspects of an evacuation plan. The deficient practice may prevent the staff in identifying the need to evacuate occupants beyond the compartment of origin to another smoke compartment, affecting 5 of 5 smoke zones. The facility has a capacity of 36 with a census of 8 at the time of survey.

Findings Include:

During the tour from 1/17/17 to 1/18/17 it is noted that:

1. At 12:29 PM on 1/17/17 the evacuation plan addressed that the room of origin should be evacuated and then to proceed to evacuate based on ambulation status instead of by proximity to the fire. There is no procedure to identify rooms that have been evacuated. There is no secondary procedure for notifying the fire department of a fire (other than activation of the fire alarm). The place instructs employees to attempt to extinguish a fire, there is no training information available providing instruction on the different types of extinguishers and usage.

The maintenance director was present during the findings.

NFPA Standard: The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator ' s position or at the security center. The provisions of 19.7.1.1 through 19.7.2.3 shall apply. 2012 NFPA 101, Section 19.7.1

NFPA Standard: For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy ' s fire safety plan. 2012 NFPA 101, Section 19.7.2.1.2.

NFPA Standard: A written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
2012 NFPA 101, Section 19.7.2.2.

Based on record review and staff interview, the facility is not conducting fire drills as required quarterly on each shift 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 5 of 5 smoke zones. The facility has a capacity of 36 with a census of 8 at the time of survey.

Findings Include:

During the tour from 1/17/17 to 1/18/17 it is noted that:

1. At 11:07 AM on 1/17/17 no record of fire alarm testing for the drill recorded on 2/4/16.
2. At 11:08 AM on 1/17/17 the drill recorded on 6/17/16 at 7:15 PM was conducted as a silent drill.
3. At 11:09 AM on 1/17/17 no record of signal received for the drill conducted on 12/1/16.

The maintenance director was present during the findings.

NFPA Standard: Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 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.
When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 2012 NFPA 101, 19.7.1.5.

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, affecting 1 of 5 smoke zones. The facility has a capacity of 36 with a census of 8 at the time of survey.

FINDINGS INCLUDE:

During the tour from 1/17/17 to 1/18/17 it is noted that:

1. At 3:09 PM an extension cord observed installed through the floor powering a sump pump in the MAMO file storage room.

The maintenance director was present during the findings.

NFPA 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; where subject to physical damage. 2012 NFPA 70, 400.8

Based on record review and staff interview the facility fails to assure that training has been conducted for the individuals responsible for transferring Oxygen into cylinders. This deficient practice affects the ability of the facility to ensure proper procedures are followed to provide Oxygen to all patients using such services, affecting 4 of 5 smoke zones. The facility has a capacity of 36 with a census of 8 at the time of survey.

Findings include:
During the tour from 1/17/17 to 1/18/17 it is noted that:

1. At 4:00 PM on 1/17/17 no training documentation available for individuals responsible for transfilling.

The maintenance director was present during the findings.

NFPA Standard: Transfilling to liquid oxygen base reservoir containers or to liquid oxygen portable containers over 344.74 kPa (50 psi) shall include the following:
(1) A designated area separated from any portion of a facility wherein patients are housed, examined, or treated by a fire barrier of 1 hour fire-resistive construction. (2) The area is mechanically ventilated, is sprinklered, and has ceramic or concrete flooring.
(3) The area is posted with signs indicating that transfilling is occurring and that smoking in the immediate area is not permitted.
(4) The individual transfilling the container(s) has been properly trained in the transfilling procedures. 2012 NFPA 99, 11.5.2.3.1