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Based upon observation and staff interview, the facility fails to assure that fire barrier doors are held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout. The deficient practice would not prevent products of fire or smoke from passing to other areas of the building affecting all patients, visitors and staff in 1 of 4 smoke zones and the medical clinic. The facility has a capacity of 25 with a census of 11 at the time of this survey.

Findings include:

1) It was observed at 9:17 AM on February 19th, 2019 the fire door in the 2 hr. separation between the hospital and the medical clinic is not tied into the alarm system and is being held open.

Staff MD 1 and MS 1 were present and acknowledged the findings.

NFPA Standard: Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Based on observation and staff interview the facility failed to provide task orientated emergency lighting. This deficiency affects patients, visitors and staff in 2 of 4 smoke zones. The facility has a capacity of 25 with a census of 11 at the time of survey.

Findings include:

During the survey on February 19th, 2019 the following observations were made:

1) It was observed at 10:26 AM in ER 1 the emergency light failed to illuminate.
2) It was observed at 10:30 AM in the pharmacy the emergency light failed to illuminate.
3) It was observed at 10:49 AM in the PT room the north emergency light failed to illuminate.

Staff MS 1 was present at the time of the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: Emergency lighting shall be provided in accordance with Section 7.9. 2012 NFPA 101, 19.2.9.1

Review of the following NFPA Standard revealed: Emergency illumination shall be provided for a minimum of 1 ½ 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 ft-candle (l0.8 lux) and, at any point, not less than 0.1 ft-candle (1.1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6.5 lux) and, at any point, not less than 0.06 ft-candle (0.65 lux) at the end of 1 ½ hours. A maximum-to minimum illumination uniformity ratio of 40 to 1 shall not be exceeded. 2012 NFPA 101, 7.9.2.1

Based on staff interview and observation, the facility fails to install and maintain their Alcohol Based Hand Rub dispensers in accordance with NFPA 101. This deficient practice affects patients, staff and visitors in 1 of 4 smoke zones. The facility has a capacity of 25 and a census of 11.

Findings include:

During the survey on February 19th, 2019 the following observations were made.

1) It was observed at 10:50 AM in the PT room there is an alcohol-based hand rub dispenser installed over a power outlet.

Staff MS 1 was present and acknowledged the findings.

NFPA Standard: Life Safety Code 101 2012 19.3.2.6* Alcohol-Based Hand-Rub Dispensers. Alcohol-based hand-rub dispensers shall be protected in accordance with 8.7.3.1, unless all of the following conditions are met: (8) Dispensers shall not be installed in the following locations: (a) Above an ignition source within a 1 in. (25 mm) horizontal distance from each side of the ignition source (b) To the side of an ignition source within a 1 in. (25mm) horizontal distance from the ignition source (c) Beneath an ignition source within a 1 in. (25 mm) vertical distance from the ignition source.

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 all patients, staff, and visitors in all smoke zones. The facility has a capacity of 25 and a census of 11 at the time of this survey.

Findings include:

During the survey on February 19th, 2019 the following observations were made.

It was observed at 8:30 AM during documentation review revealed that the annual inspection, testing, and maintenance of the fire alarm system is past due. The last inspection of the system was completed on 1/27/17.

Staff MD 1 and MS 1 were present and acknowledged the results of the records review.

NFPA Standard: A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. 2012 NFPA 101, 9.6.1.3

Based on observation and staff interview, the facility did not ensure that electrical wiring and equipment is installed and maintained in accordance with NAPA 70, National Electrical Code. This deficient practice does not ensure prevention of an electrical fire or electric shock hazard, affecting residents, visitors and staff in 1 of 4 smoke zones. The facility has a capacity of 25 with a census of 11 at the time of this survey.

Findings include:

During the survey on February 19th, 2019 the following was observed:
1) It was observed at 11:14 AM in the kitchen above the freezer an open junction box with exposed wiring.
Review of the following NAPA Standard revealed: Electrical wiring and equipment shall be in accordance with NAPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. 2012 NAPA 101, 9.1.2

Based upon interview and record review, the facility fails to provide a written plan and train the staff on basic response, the fire safety plan and for the evacuation of the building's smoke zones directly affected by fire. The deficient practice affects all patients, staff and visitors in 4 of 4 smoke zones. The facility has a capacity of 25 with a census of 11 at the time of this survey.

Findings include:

During the survey on February 18th, 2019 the following observations were made:

1) It was observed at 1:30 PM during the records review, it is revealed that the facility does not have a complete smoke zone evacuation plan. The staff is not being trained annually on basic response, the fire safety plan and for the evacuation of the building's smoke zones directly affected by fire.

Staff MS 1 was present and acknowledged 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 required by 19.7.1.1. A copy of the plan required by 19.7.1.1 shall be readily available at all times in the telephone operator ' s location or at the security center. 2012. NFPA 101, 18/19.7.1.1

NFPA Standard: A written health care occupancy fire safety plan shall provide for all of the following: (1) use of alarms; (2) transmission of alarms to fire department; (3) emergency phone call to fire department; (4) response to alarms; (5) isolation of fire; (6) evacuation of immediate area; (7) evacuation of smoke compartment; (8) preparation of floors and building for evacuation; (9) extinguishment of fire. 2012 NFPA 101 18/19.7.2.2

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 patients, staff and visitors in all 4 smoke zones. The facility has a capacity of 25 and a census of 11.

Findings include:

During the survey on February 18th, 2019 the following observations were made.

1) It was observed at 12:15 PM during documentation review of the previous five quarters of fire drills no 2nd shift fire drill was performed in 2018 during the first quarter.2) It was observed at 12:20 PM during the documentation review of the previous five quarters of fire drills the fire alarm system was not activated with the following fire drills: 5/30/18, 7/31/18, 8/29/18 and 10/30/18.3) It was observed at 12:25 PM during the documentation review of the previous five quarters of fire drills the facility failed to test the fire alarm system following a silent fire drill on 12/26/18 at 10:45 PM.
4) It was observed at 12:30 PM during the documentation review of the previous five quarters of fire drills staff performed fire drills during the last week of the month on the following drills: 1/31/18, 4/30/18, 5/30/18, 6/26/18, 7/31/18, 8/29/18, 9/25/18, 10/30/18 and 12/26/18.


Staff MD 1 and MS 1 were present and acknowledged the findings.

Review of the following NFPA Standard revealed: 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 required by 19.7.1.1. A copy of the plan required by 19.7.1.1 shall be readily available at all times in the telephone operator's location or at the security center. Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 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. and
6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms. Employees of health care occupancies shall be instructed in life safety procedures and devices. 2012 NFPA 101, 19.7.1.1-8

Based upon a review of records and staff interview the facility is not inspecting and maintaining fire-rated door assemblies in compliance with NFPA 80. This deficient practice could prevent the ability of the facility to properly confine smoke and prevent fire from spreading to other areas of the building. 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 11 at the time of this survey.


Findings include:


During the survey conducted on February 18th, 2019 the following deficiency is noted:


1) It was observed at 11:45 AM there was no documented records of inspections on the fire-rated door assemblies by a trained individual.


Staff MS 1 was present and acknowledged the findings.


NFPA Standard: NFPA 80 2010 5.2.1 Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ. 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing. 5.2.4.2 As a minimum, the following items shall be verified: (1) No open holes or breaks exist in the surfaces of either the door or frame. (2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped. (3) The door, frame, hinges, hardware, and non combustible threshold are secured, aligned, and in working order with no visible signs of damage. (4) No parts are missing or broken. (5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7 (6) The self-closing device is operational; that is, the active door completely closes when operated from the open position. (7) If a coordinator is installed, the inactive leaf closes before the active leaf. (8) Latching hardware operates and secures the door when it is in the closed position. (9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame. (10) No field modifications to the door assembly have been performed that void the label. (11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity. 3.3.95 Qualified Person. A person who, by possession of a recognized degree, certificate, professional standing, or skill, and who by knowledge, training, and experience, has demonstrated the ability to deal with the subject matter, the work, or the project.

Based on staff interview and document review, the facility failed to maintain and test their electrical receptacles and systems in accordance with NFPA 99. This deficient practice would affect all patients, visitors, and staff in 4 of 4 smoke zones. The facility has a capacity of 25 and a census of 11 at the time of this survey.
Findings include:
During the survey on February 18th, 2019 the following observations were made.
1) It was observed at 2:30 PM there is no documented annual receptacle testing.
Staff MS 1 was present and acknowledged the results of the records review.

NFPA Standard: NFPA 99 2012 6.3.3.2 Receptacle Testing in Patient Care Rooms 6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection. 6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified. 6.3.3.2.3 correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. 6.3.4.1 Maintenance and testing of Electrical System 6.3.4.1. 1 Where hospital-grade receptacles are required at patient bed location and in location where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device. 6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data. 6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months. 6.3.4.1.4 The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch (see 6.3.2.6.3.6). For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators. 6.3.4.1.5 After any repair or renovation to an electrical distribution system, the LIM circuit shall be tested in accordance with 6.3.3.3.2 6.4.4.1.2.1* Circuit Breakers. Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer ' s recommendations. 6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modification. 6.3.4.2.1.2 At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter. 6.3.4.2.2 Isolated Power System (Where Installed). A permanent record shall be kept of the results of each of the tests.

Based on observation and staff interview, the facility did not ensure that electrical wiring and equipment is installed and maintained in accordance with NFPA 99, Health Care Facility Code. This deficient practice does not ensure prevention of an electrical fire or electric shock hazard, affecting patients in 4 of 4 smoke zones. This facility has a capacity of 25 with a census of 11 at the time of this survey.

Findings include:


During the survey conducted on February 19th, 2019 it was observed:

1) It was observed at 8:10 AM the facility does not have a policy in place to assure that assessments of power strips are conducted on a yearly basis.
2) It was observed at 11:21 am in the OR recovery room there are 2 medical carts with non-rated power strips in use within 6 ft of patient bed.

Staff MS 1 was present and acknowledged the findings.

NFPA Standard: 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

NFPA Standard: Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

NFPA Standard: NFPA 70 2011, 400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following: (1) As a substitute for the fixed wiring of a structure (2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors (3) Where run through doorways, windows, or similar openings (4) Where attached to building surfaces Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B) (5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings (6) Where installed in raceways, except as otherwise permitted in this Code (7) Where subject to physical damage.