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Based on observation and interview, the facility failed to provide unobstructed egress in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-7.2.1.5.10), 2012 Edition. This deficient practice affects approximately 3 staff in 1 of 5 smoke zones. This facility has a capacity of 19 and a census of 2.
Findings include:
Observation and interview on 05/07/19 at 10:00 a.m., revealed that the corridor side of the Recycling Room door contained a hasp type lock. If this hasp were to be locked, it could prevent egress from the Recycling Room. The Director of Facilities verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to provide exit signage in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-7.10.1.2.1), 2012 Edition. This deficient practice affects approximately 8 residents, staff, and visitors in 2 of 5 smoke zones. This facility has a capacity of 19 and a census of 2.

Findings include:

1. Observation and interview on 05/07/19 at 10:02 a.m., revealed that the east end of the Kitchen Corridor did not contain an exit sign.

2. Observation and interview on 05/07/19 at 11:04 a.m., revealed that the north end of the Main Entrance Corridor did not contain an exit sign.

3. Observation and interview on 05/07/19 at 11:15 a.m., revealed that the illumination of the exits signs at each end of the corridor near the New Ambulance Garage were controlled by a motion sensor and not continuously illuminated. The Director of Facilities verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to install fire alarm notification devices in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-9.6.3.1), 2012 Edition. This deficient practice affects approximately 8 residents, staff, and visitors in 1 of 5 smoke zones. This facility has a capacity of 19 and a census of 2.
Findings include:
1. Observation and interview on 05/07/19 at 11:12 a.m., revealed the Emergency Department Public Restroom did not contain a visible fire alarm notification device.
2. Observation and interview on 05/07/19 at 11/17 a.m., revealed the Emergency Department Public Restroom near the Specialty Clinic did not contain a visible fire alarm notification device. The Director of Facilities verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to maintain smoke detection in accordance with National Fire Protection Association (NFPA) 72, National Fire Alarm and Signaling Code (Section-17.7.4.1), 2010 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 19 and a census of 2.

Findings include:

1. Observation and interview on 05/07/19 at 10:44 a.m., revealed that the Family Room contained a smoke detector that was installed within 3 feet of an HVAC (Heating, ventilation, and air-conditioning) opening.

2. Observation and interview on 05/07/19 at 10:45 a.m., revealed that the corridor near the Family Room contained a smoke detector that was installed within 3 feet of an HVAC opening.

3. Observation and interview on 05/07/19 at 10:50 a.m., revealed that the Med Surgical Clean Linen Room contained a smoke detector that was installed within 3 feet of an HVAC opening.

4. Observation and interview on 05/07/19 at 11:05 a.m., revealed that the Main Entrance near the registration desk contained a smoke detector that was installed within 3 feet of an HVAC opening. The Director of Facilities verified these observations at the time of the survey process.

Based on record review and interview, the facility failed to provide an adequate fire watch policy for the fire alarm system being out of service in accordance with National Fire Protection Association (NFPA 101), Life Safety Code (Section-9.6.1.6), 2012 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 19 and a census of 2.

Findings include:

Record review and interview on 05/07/19 at 11:29 a.m., revealed that the provided Fire Watch Policy for the fire alarm system being out of service for 4 or more hours in a 24 hour period was last revised in 2010. The policy did not include contact numbers for the State Fire Marshal, The Department of Inspections and Appeals or the local Fire Department. The policy did not state that these entities are to be contacted at the beginning and end of a fire watch. The policy also did not define that the fire watch is to be continuous and in every room at least every 30 minutes. The policy did not define that the designee conducting the fire watch is to have no other responsibilities except for the fire watch. The Director of Facilities verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain sprinklers in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-9.7.5), 2012 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 19 and a census of 2.
Findings include:
1. Observation and interview on 05/07/19 at 10:26 a.m., revealed that the CT Scan Room contained 4 sprinklers. 1 of the 4 sprinklers was missing the escutcheon ring.
2. Observation and interview on 05/07/19 at 11:16 a.m., revealed that the Emergency Department Specialty Clinic Office contained 1 sprinkler. The sprinkler was missing the escutcheon ring. The Director of Facilities verified these observations at the time of the survey process.

Based on record review and interview, the facility was unable to provide an impairment policy for the sprinkler system being out of service in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (Section-15.1.1), 2011 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 19 and a census of 2.

Findings include:

Record review and interview on 05/07/19 at 11:27 a.m., revealed the facility was unable to provide an impairment policy for the Sprinkler System being out of service for 10 or more hours in a 24 hour period. To include pre-planned and emergency impairments. The Director of Facilities verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to inspect portable fire extinguishers in accordance with National Fire Protection Association (NFPA) 10, Standard for Portable Fire Extinguishers (Section-7.2.1.2), 2010 Edition. This deficient practice affects approximately 15 residents, staff, and visitors in 2 of 5 smoke zones. This facility has a capacity of 19 and a census of 2.

Findings include:

1. Record review and interview on 05/07/19 at 10:15 a.m., revealed the portable fire extinguisher located in the corridor near the Pharmacy was not documented as being inspected for the month of November 2018.

2. Record review and interview on 05/07/19 at 11:01 a.m., revealed the portable fire extinguisher located in the Outpatient Area was not documented as being inspected for the month's of November and December 2018.

3. Record review and interview on 05/07/19 at 11:07 a.m., revealed the portable fire extinguisher located in the Main Entrance Lobby was not documented as being inspected for the month of December 2018. The Director of Facilities verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to ensure that smoke barriers are free of penetrations which would prevent the passage of smoke to an adjacent smoke compartment in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-8.5.6.2), 2012 Edition. This deficient practice affects approximately 20 residents, staff, and visitors in 3 of 5 smoke zones. This facility has a capacity of 19 and a census of 2.

Findings include:

1. Observation and interview on 05/07/19 at 10:05 a.m., revealed that above the lay-in ceiling tile at the smoke barrier near Janitor Closet #135 there was an approximate 1/4 inch gap around a 3/4 inch conduit that penetrated the barrier.

2. Observation and interview on 05/07/19 at 10:05 a.m., revealed that above the lay-in ceiling tile at the smoke barrier near Janitor Closet #135 there were 3 open to the center 3/4 inch conduits that penetrated the barrier.

3. Observation and interview on 05/07/19 at 10:17 a.m., revealed that above the lay-in ceiling tile at the smoke barrier near the Human Resources Office there was a 3/4 inch open to the center conduit that penetrated the barrier.

4. Observation and interview on 05/07/19 at 10:18 a.m., revealed that above the lay-in ceiling tile at the smoke barrier near the Human Resources Office there was an approximate 2 inch gap around a 2 inch PVC pipe that penetrated the barrier. The Director of Facilities verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to install proper electrical receptacles in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-9.1.2), 2012 Edition and National Fire Protection Association (NFPA) 70, National Electrical Code, 2011 Edition. This deficient practice affects approximately 3 residents, staff, and visitors in 1 of 5 smoke zones. This facility has a capacity of 19 and a census of 2.

Findings include:

Observation and interview on 05/07/19 at 11:10 a.m., revealed the Emergency Department Pixis Room contained an electrical receptacle that was installed within 6 feet of the sink that was not GFCI (Ground Fault Circuit Interrupter) protected. The Director of Facilities verified this observation at the time of the survey process.

Based on record review and interview, the facility was unable to provide a fire safety plan in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.7.2.2), 2012 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 19 and a census of 2.

Findings include:

Record review and interview on 05/07/19 at 11:56 a.m., revealed the facility was unable to provide a Fire Safety Plan to include the use of alarms, transmission of alarms to the fire department, emergency phone call to the fire department, response to alarms, isolation of fire, evacuation of immediate area, evacuation of smoke compartments, preparation of floors and building for evacuation, and extinguishment of fire to include the use of the ansul system and the different types of portable fire extinguishers in the facility. The Director of Facilities verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to inspect and test the emergency generator in accordance with National Fire Protection Association (NFPA) 110, Standard for Emergency and Standby Power Systems (Section-8.3.8, Section-8.4.1, Section-8.4.9, and Section-8.4.9.2), 2010 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 19 and a census of 2.

Findings include:

1. Record review and interview on 05/07/19 at 10:19 a.m., revealed the facility was unable to provide documentation for annual testing of fuel quality for the facility's diesel powered emergency generator.

2. Record review and interview on 05/07/19 at 9:50 a.m., revealed the facility is not documenting weekly inspections of the fan and alternator belt and the condition of flexible hoses and connections for the facility's diesel powered emergency generator.

3. Record review and interview on 05/07/19 at 9:59 a.m., revealed the facility was unable to provide documentation for weekly visual inspections of the facility's diesel powered emergency generator for the 2nd week of February 2019, the 4th week of December 2018, and the 3rd week of October 2018.

4. Record review and interview on 05/07/19 at 10:19 a.m., revealed the facility was unable to provide documentation for 4-hour continuous under load testing within the past 36 months for the facility's diesel powered Level 1 emergency generator. The Director of Facilities verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to maintain proper storage of oxygen cylinders in accordance with National Fire Protection Association (NFPA) 99, Health Care Facilities Code (Section-5.1.3.3.2 (7)), 2012 Edition. This deficient practice affects approximately 1 staff in 1 of 5 smoke zones. This facility has a capacity of 19 and a census of 2.

Findings include:

Observation and interview on 05/07/19 at 10:10 a.m., revealed the HME Oxygen Storage Room contained 8 small oxygen cylinders that were not secured so as to prevent them from falling over. The Director of Facilities verified this observation at the time of the survey process.