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Based on observation and interview, it was determined the facility failed to maintain discharge from exits in accordance with National Fire Protection Association (NFPA) standards. The deficient practice had the potential to affect two (2) of three (3) smoke compartments, staff, and all patients.

The findings include:

Observation, during the building inspection tour on 01/18/2024 between 1:51 PM and 2:02 PM, revealed the exit discharge outside the emergency exit for Hope Unit and Faith Unit did not have an all-weather travel surface to the public way. The Hope Unit had a concrete sidewalk that turned the corner and terminated in grass. The Faith Unit had a four (4) foot by 10-foot concrete sidewalk that terminated to grass. Both exit discharges were located outside changing to grass between the concrete pad and the public way.

Interview, on 01/18/2024 at 2:02 PM with the Director of Plant Operations, revealed the facility was unaware of the requirements for maintaining exit discharges.

The finding was verified by the Director of Physical Plant Operations at the time of observation and the Vice President at the exit conference on 01/18/2024.

Reference: NFPA 101 (2012 edition)

7.1.6.2 Changes in Elevation. Abrupt changes in elevation of walking surfaces shall not exceed 1/4 in. (6.3 mm). Changes in elevation exceeding 1/4 in. (6.3 mm), but not exceeding 1/2 in. (13 mm), shall be beveled with a slope of 1 in 2. Changes in
elevation exceeding 1/2 in. (13 mm) shall be considered a change in level and shall be subject to the requirements of 7.1.7.
7.1.6.3 Level. Walking surfaces shall comply with all of the following:
(1) Walking surfaces shall be nominally level.
(2) The slope of a walking surface in the direction of travel shall not exceed 1 in 20, unless the ramp requirements of 7.2.5 are met.
(3) The slope perpendicular to the direction of travel shall not exceed 1 in 48.

Discharge from Exits Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface in accordance with CMS Survey and Certification Letter 05-38. 18.2.7, 19.2.7,

S&C 05-38

Based on observation and interview, it was determined the facility failed to ensure smoke barriers could restrict the transfer of smoke in accordance with National Fire Protection Association (NFPA) Standards. The deficient practice affected two (2) of three (3) smoke compartments, staff, and 20 residents. The facility had the capacity of 40 beds with a census of eight (8) on the day of survey.

The findings include:

1.Observation, during the building inspection tour on 01/18/2024 at 12:58 PM, revealed two (2), two (2) inch penetrations and an unsealed pipe brace located above the ceiling of Outpatient Services that would not resist the passage of smoke. Interview, on 01/18/2024 at 12:59 PM with the Director of Physical Plant Operations, stated the facility was not aware of the penetrations of the smoke barrier.
2. Observation, during the building inspection tour on 01/18/2024 at 1:16 PM, revealed the smoke barrier wall located above room 110 had a four (4) foot by three (3) foot missing drywall that would not resist the passage of smoke. Interview, on 01/18/2024 at 1:17 PM with the Director of Physical Plant Operations, stated the facility was not aware of the missing drywall penetration of the smoke barrier.

The finding was verified by the Director of Physical Plant Operations at the time of observation and the Vice President at the exit conference on 01/18/2024.

Actual NFPA Standard: NFPA 101 Life Safety Code (2012), 18.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1-hour fire resistance rating, unless otherwise permitted by one of the following: (1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply: (a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c). (b) Not less than two separate smoke compartments shall be provided on each floor. (2)*Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems

8.5.6.2 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.

Based on observation and interview, the facility failed to ensure portable space heaters used in the facility were in accordance with National Fire Protection Association (NFPA) standards. The deficient practice affected one (1) of three (3) smoke compartments, staff, and 2 residents. The facility had the capacity for 40 beds with a census of eight (8) on the day of survey.

Findings include:

Observation, during the building inspection tour on 01/18/2024 between 1:22 PM and 1:35 PM, revealed the facility failed to provide documentation that a heat producing portable heater had a heating element that did not exceed 212 degrees Fahrenheit, located in the Reception Office, Admissions Office, and Intake Bull Pen.

Interview, on 01/18/2024 at 1:36 PM with the Director of Physical Plant Operations, stated the facility was aware of the requirements for portable heaters but was not aware the heaters had been brought into the facility.

The finding was verified by the Director of Physical Plant Operations at the time of observation and the Vice President at the exit conference on 01/18/2024.

Actual NFPA Standard: NFPA 101 Life Safety Code (2012)
18.7.8 Portable Space-Heating Devices. Portable space heating devices shall be prohibited in all health care occupancies, unless both of the following criteria are met:
(1) Such devices are used only in nonsleeping staff and employee areas.
(2) The heating elements of such devices do not exceed 212°F (100°C).