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Based on observation, interview and record review, facility staff failed to inspect, test and maintain the fire egress doors in accordance with the 2010 Editions of NFPA 80 (Standard for Fire Doors and Other Opening Protectives) and NFPA 105 (Standard for Fire Doors and Other Opening Protectives). Facility staff failed to conduct an annual inspection of the fire egress doors. The facility census was two.

1. Review of the facility's inspection, testing and maintenance records for the 2017 year showed the records did not contain documentation of an annual inspection of the fire egress doors during the 12-month period.

During an interview on 3/7/18 at 1:00 P.M., the Maintenance Director said he/she did not know of the requirement to conduct annual inspections of the egress doors.


Review of NFPA 101, 2012 Edition showed the following:
-7.1.10.2.1 showed no furnishings, decorations, or other objects shall obstruct exits or their access thereto, egress therefrom, or visibility thereof.
-19.2.2.2.1 Doors complying with 7.2.1 shall be permitted.
-7.2.1.15.1* Where required by Chapters 11 through 43, the following door assemblies shall be inspected and tested not less than annually in accordance with 7.2.1.15.2 through 7.2.1.15.8:
(1) Door leaves equipped with panic hardware or fire exit hardware in accordance with 7.2.1.7;
(2) Door assemblies in exit enclosures;
(3) Electrically controlled egress doors;
(4) Door assemblies with special locking arrangements subject to 7.2.1.6.
-7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives.
-7.2.1.15.3 The inspection and testing interval for fire-rated and nonrated door assemblies shall be permitted to exceed 12 months under a written performance-based program in accordance with 5.2.2 of NFPA 80, Standard for Fire Doors and Other Opening Protectives.
-7.2.1.15.4 A written record of the inspections and testing shall be signed and kept for inspection by the authority having jurisdiction.

Based on observation, staff interview, and record review, the facility staff failed to provide continuously maintained exit ways free of all obstructions or impediments continuous to a public way such as a parking lot. This deficient practice has the potential to affect all patients, staff and visitors in the facility. The facility census was two.


1. Observation on 3/7/18, during the facility tour, showed the following;

-designated business office exit requires patients, staff and visitors to walk 16 feet to a hard surface. Sixteen feet of path to hardpath consists of dirt and gravel.

-outpatient north exit requires patients, staff and visitors to walk 25 feet to a hard surface. Twenty five feet of path to hardpath consists of grass.

Record review of the facility layout showed the exit discharge areas designated for resident use.

During an interview on 3/7/18 at 12:13 P.M., the Maintenance Director confirmed the observations.


The National Fire Protection Association 101, Life Safety Code 2012 Edition, section 7.7 states:
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7.7 Discharge from Exits.

7.7.1* Exit Termination. Exits shall terminate directly, at a
public way or at an exterior exit discharge, unless otherwise
provided in 7.7.1.2 through 7.7.1.4.

Based on observation and facility staff interview, facility staff failed to ensure emergency lighting was provided for outside exit discharge areas. The facility census was two.

1. Observations on 3/7/18 , during the Life Safety Code (LCS) tour, showed the business office hallway exit discharge did not have emergency lighting.

Observation on 3/7/18, during the LSC tour, showed the south hallway exit discharge did not have emergency lighting.

During an interview on 3/7/18 at 12:13 P.M., the Maintenance Director said that the two exit discharge areas did not have emergency lighting. The Maintenance Director said that the light fixtures located in the exit discharge areas are not connected to the generator. The Maintenance Director said both exits can be accessed by patients and visitors.

NFPA 101, 2012 edition, Section 7.9.2.7 states: "7.9.2.7 The emergency lighting system shall be either continuously in operation or shall be capable of repeated automatic
operation without manual intervention."

NFPA 99, 2012 edition, section 6.4.2.2.4.2 states:

"6.4.2.2.4.2 The critical branch shall supply power for task illumination,
fixed equipment, select receptacles, and select power
circuits serving the following areas and functions related to patient
care:
(1) Critical care areas that utilize anesthetizing gases, task illumination,
select receptacles, and fixed equipment
(2) Isolated power systems in special environments
(3) Task illumination and select receptacles in the following:
/(a) Patient care r/ooms, including infant nurseries, selected
acute nursing areas, psychiatric bed areas (omit receptacles),
and ward treatment rooms
(b) Medication preparation areas
(c) Pharmacy dispensing areas
(d) Nurses ' stations (unless adequately lighted by corridor
luminaires)
(4) Additional specialized patient care task illumination and
receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7)*Telephone equipment rooms and closets
(8) Task illumination, select receptacles, and select power circuits
for the following areas:
(a) General care beds with at least one duplex receptacle
per patient bedroom, and task illumination as required
by the governing body of the health care facility
(b) Angiographic labs
(c) Cardiac catheterization labs
(d) Coronary care units
(e) Hemodialysis rooms or areas
(f) Emergency room treatment areas (select)
(g) Human physiology labs
(h) Intensive care units
(i) Postoperative recovery rooms (select)
(9) Additional task illumination, receptacles, and select power
circuits needed for effective facility operation, including
single-phase fractional horsepower motors, which are permitted
to be connected to the critical branch"



7.9.2.6* Existing battery-operated emergency lights shall use
only reliable types of rechargeable batteries provided with suitable
facilities for maintaining them in properly charged condition.
Batteries used in such lights or units shall be approved
for their intended use and shall comply with NFPA 70, National
Electrical Code.

7.9.2.7 The emergency lighting system shall be either continuously
in operation or shall be capable of repeated automatic
operation without manual intervention.

7.9.3 Periodic Testing of Emergency Lighting Equipment.

7.9.3.1 Required emergency lighting systems shall be tested in
accordance with one of the three options offered by 7.9.3.1.1,
7.9.3.1.2, or 7.9.3.1.3.

7.9.3.1.1 Testing of required emergency lighting systems
shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a
minimum of 3 weeks and a maximum of 5 weeks between
tests, for not less than 30 seconds, except as otherwise
permitted by 7.9.3.1.1(2).
(2)*The test interval shall be permitted to be extended beyond
30 days with the approval of the authority having
jurisdiction.
(3) Functional testing shall be conducted annually for a minimum
of 11.2 hours if the emergency lighting system is battery
powered.
(4) The emergency lighting equipment shall be fully operational
for the duration of the tests required by 7.9.3.1.1(1)
and (3).
(5) Written records of visual inspections and tests shall be
kept by the owner for inspection by the authority having
jurisdiction.

7.9.3.1.2 Testing of required emergency lighting systems
shall be permitted to be conducted as follows:
(1) Self-testing/self-diagnostic battery-operated emergency
lighting equipment shall be provided.
(2) Not less than once every 30 days, self-testing/self-diagnostic
battery-operated emergency lighting equipment shall automatically
perform a test with a duration of a minimum of
30 seconds and a diagnostic routine.
(3) Self-testing/self-diagnostic battery-operated emergency
lighting equipment shall indicate failures by a status indicator.
(4) A visual inspection shall be performed at intervals not exceeding
30 days.
(5) Functional testing shall be conducted annually for a minimum
of 11.2 hours.
(6) Self-testing/self-diagnostic battery-operated emergency
lighting equipment shall be fully operational for the duration
of the 11.2-hour test.
(7) Written records of visual inspections and tests shall be
kept by the owner for inspection by the authority having
jurisdiction."

Based on observation and interview, facility staff failed to separate designated exit corridors from hazardous areas. The facility census was two.

1. Observation on 3/7/18, during the Life Safety Code (LSC) tour, showed the laundry department doors did not have self closing devices. Observation showed the area contained large quantities of soiled linen and a gas fired dryer.

During an interview on 3/7/18 at 11:23 A.M., the Maintenance Director confirmed the observation.

2. Observation on 3/7/18, during the LSC tour, showed a soiled linen barrel stored in radiology unit corridor room. Observation showed the room did not have a door.

During an interview on 3/7/18 at 12:08 P.M., the Maintenance Director said staff store soiled linen in the room. The Maintenance Director said the room did not have a door.

19.3.2.1.5 Hazardous areas shall include, but shall not be restricted
to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Rooms with soiled linen in volume exceeding 64 gal (242 L)
(6) Rooms with collected trash in volume exceeding 64 gal
(242 L)
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including
repair shops, used for storage of combustible supplies and
equipment in quantities deemed hazardous by the authority
having jurisdiction

Based on observation and facility staff interview, the facility staff failed to provide and maintain one of one kitchen range hood in accordance with National Fire Protection Association (NFPA) 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition requirements. The facility census was two.

1. Observation on 3/7/18, during the facility tour, showed the range hood did not have a an enclosed metal container to collect grease from the drip tray.

During an interview on 3/7/18 at 11:37 A.M., The Maintenance Director confirmed the observation.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition, section 6.2.4.1 states: "Grease filters shall be equipped with a grease drip-tray beneath their lower edges.

Based on record review and facility staff interview, facility staff did not ensure all devices connected to the fire alarm system were inspected and tested per NFPA 72, National Fire Alarm and Signaling Code, 2010 edition. The facility census was two.

Record review of the annual fire alarm inspection dated did not show inspections and connection function tests for the following:

-smoke detector sensitivity testing

Record review of the annual fire alarm inspections for 2016 and 2017did not show smoke detector sensitivity testing for the facility smoke detectors.

During an interview on 3/7/18, at 12:36 P.M., the Maintenance Director confirmed the record review.

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, Table 14.3.1, Table 14.4.2.2, Table 14.4.5, sections 14.4.5, 14.4.5.3.1 through section 14.4.5.4 for additional testing information.

Based on interview and record review facility staff failed to maintain an out of service policy for the fire alarm system. The facility census was two.

1. Record review on 3/7/18 of the facility records did not show an out of service policy for the fire alarm system.

During an interview on 3/7/18 at 2:00 P.M.,., the Maintenance Director confirmed that the facility did not have an out of service policy for the fire alarm system.


NFPA Standard: 2012 NFPA 101, 9.6.1.6 Where a required fire alarm is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated, or an approved fire watch shall be provided for all /parties left unprotected by the shutdown until the fire alarm system has been returned to service. /

Based on observation and facility staff interview, facility staff failed to ensure areas open to the corridor contain smoke detection per NFPA 72, National Fire Alarm and Signaling Code. The facility census was two.

Observations on 3/7/18, during the facility tour, showed the staff kitchen open to the designated exit corridor. Observation showed the room did not have smoke detector coverage.

During an interview on 3/7/18 at 1:13 P.M., the Maintenance Director confirmed the observation.

19.3.4.1 General. Health care occupancies shall be provided
with a fire alarm system in accordance with Section 9.6.

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, sections 17.6.3 Location and Spacing and 17.6.3.3.1 Spacing for additional information.

Based on observation and facility staff interview, facility staff failed to ensure the building sprinkler system met NFPA 13, Standard For The Installation Of Sprinkler Systems, 2010 edition installation requirements. The facility census was two.

1. Observation on 3/7/18, during the facility tour, showed a sprinkler sprig extending five feet without lateral support bracing.

During an interview on 3/7/18 at 12:01 P.M., the Maintenance Director confirmed the observation.

NFPA 13, 2010 edition, section 9.2.3.7

9.2.3.7 Sprigs. Sprigs 4 ft (1.2 m) or longer shall be restrained
against lateral movement.

Refer to NFPA 101, 2012 edition, Table 19.1.6.1 Construction Type Limitations for information regarding complete sprinkler coverage for Type II (000) construction types.

Please refer to NFPA 13, 2010 edition, Sections 8.15.10, 8.15.10.1, 8.15.10.2 and 8.15.10.3 for sprinkler requirements in electrical rooms.

2. Observation on 3/7/18, during the facility tour, showed the lab draw room and attached restroom did not have sprinkler coverage.

Observation showed the building type as type II (000) which requires the building to be completely sprinklered.

During an interview on 3/7/18, at 12:25 P.M., the Maintenance Director confirmed the observation.

Based on staff interview and record review, facility staff failed to inspect and test the one wet sprinkler systems per NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition. The facility census was two.

Record review on 3/7/18 did not show the 5 year internal pipe inspections & gauge replacements/calibrations for the one wet sprinkler systems. In addition, record review did not show monthly or quarterly tests on the wet sprinkler system

During an interview on 3/7/18 at 12:37 P.M., the Maintenance Director said the sprinkler inspections and tests were missed.

Refer to NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition, Chapters 5, 13 and 14 for additional information.

Based on interview and record review facility staff failed to maintain an out of service policy for the sprinkler system. The facility census was two..

1. Record review on 3/7/18 of the facility records did not show an out of service policy for the sprinkler system.

During an interview on 3/7/18 at 2:00 P.M., the Maintenance Director confirmed that the facility did not have an out of service policy for the sprinkler system.

Review of the National Fire Protection Association (NFPA) 25 (Inspection, Testing and Maintenance of Water-Based Fire Protection Systems), 2011 Edition, showed:

-4.1.9.1 Where an impairment to a water-based fire protection system occurs, the procedures outlined in Chapter 15 of this standard shall be followed, including the attachment of a tag to the impaired system;
-15.2.1 The property owner or designated representative shall assign an impairment coordinator to comply with the requirements of this chapter;
-15.2.3 Where the lease, written use agreement, or management contract specifically grants the authority for inspection, testing, and maintenance of the fire protection system(s) to the tenant, management firm, or managing individual, the tenant, management firm, or managing individual shall assign a person as impairment coordinator;
-15.3.1* A tag shall be used to indicate that a system, or part thereof, has been removed from service;
-15.3.2* The tag shall be posted at each fire department connection and the system control valve, and other locations required by the authority having jurisdiction, indicating which system, or part thereof, has been removed from service;
-15.5.1 All preplanned impairments shall be authorized by the impairment coordinator;
-15.5.2 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;
-*A.15.3.1 A clearly visible tag alerts building occupants and the fire department that all or part of the water-based fire protection system is out of service. The tag should be weather resistant, plainly visible, and of sufficient size [typically 4 in. × 6 in. (100 mm × 150 mm)]. The tag should identify which system is impaired, the date and time impairment began, and the person responsible;
-*A.15.5.2(4)(b) A fire watch should consist of trained personnel
who continuously patrol the affected area. Ready access to fire extinguishers and the ability to promptly notify the fire department are important items to consider. During the patrol of the area, the person should not only be looking for fire, but making sure that the other fire protection features of the building such as egress routes and alarm systems are available and functioning properly;
-*A.15.5.2(4)(c) Temporary water supplies are possible from a number of sources, including use of a large-diameter hose from a fire hydrant to a fire department connection, use of a portable tank and a portable pump, or use of a standby fire department pumper and/or tanker.
-15.6.1 Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping and equipment failure;
-15.6.2 When emergency impairments occur, emergency action shall be taken to minimize potential injury and damage;
-15.6.3 The coordinator shall implement the steps outlined in Section 15.5;
-15.7 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 the 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.

Based on staff interview and record review, facility staff failed to conduct fire drills for four of four quarters reviewed. This deficient practice has the potential to effect all facility residents. Failure to hold drills could effect facility staff response in a fire or other emergency. The facility census was two.

1. Record review on 3/7/18 of the facility fire drill records, showed no documentation for the following fire drills:

- no fire drills for the second shift (7:00 P.M., to 7:00 A.M.) for the entire year of 2017.
- no fire drills for the 1st and 2nd second quarters of the first shift (7:00 A.M., to 7:00 P.M.) of 2017.


During an interview on 3/7/18 at 2:50 P.M., the Emergency Management Director said he/she did not have documentation that the drills were conducted.The National Fire Protection Association 101 Life Safety Code, 2012 edition, Section 19.7.1 states:

19.7.1 Evacuation and Relocation Plan and Fire Drills.

19.7.1.4* Fire drills in health care occupancies shall include
the transmission of a fire alarm signal and simulation of emergency
fire conditions.

19.7.1.5 Infirm or bedridden patients shall not be required
to be moved during drills to safe areas or to the exterior of the
building.

19.7.1.6 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.

19.7.1.7 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.

Based on observation and interview the facility failed to provide window blinds that were flame resistant in accordance with provisions of NFPA 101, 10.3. The facility census was two.

1. Observations on 3/7/18, during the Life Safety Code tour, showed all of the window treatments in resident rooms did not have identification that showed them as being flame retardant.

NFPA Standard: Draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as /demonstrated by testing in accordance with NFPA 701. 2012 NFPA 101.

Based on interview and record review the facility failed to develop a maintenance program for the medical gas, vacuum, WAGD (Waste Anesthetic Gas Disposal), or support gas system within the facility . The facility census was two.

1. Review of the facility maintenance program documentation, conducted on the afternoon of 3/7/18, showed the facility did not have a program in place which includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets, and an inspection and maintenance schedule for this system.

During an interview on 3/7/18 at 1:57 P.M, the Maintenance Director stated did not have a maintenance program for the system.

Section 5.1.14.2.2.1 of the National Fire Protection Association (NFPA 99) states: Health care facilities with installed medical gas, vacuum, WAGD, or medical support gas systems, or combinations thereof, shall develop and document periodic maintenance programs for these systems and their subcomponents as appropriate to the equipment installed.

Based on record review and interview the facility failed to operate the emergency generators for a minimum of 30 minutes under load at least 12 times a year. In addition, facility staff failed to perform weekly visual inspections of the generator. The facility census was two.

1. Review of the generator operating records, showed facility staff did not conduct weekly visual inspection of the generator. Further review showed facility staff did not run the generators monthly under load.

During an interview on 3/7/18 at 12:50 P.M., the Maintenance Director said only an annual inspection is conducted on the generator.

NFPA Standard: Level 1 and level 2 Emergency Power Supply Sources (EPSS)s, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes using one of the following methods: Under operating temperature conditions or at not less than 30% of the EPS nameplate rating or loading that maintains the minimum exhaust temperatures as recommended by the manufacturer. 1999 NFPA 110, 6-4.1 and 6-4.2

NFPA Standard: A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. 1999 NFPA 99, 3-4.4.2

NFPA Standard: Level 1 and level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes using one of the following methods: under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating or loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. 1999 NFPA 110, 6.4.1 and 6.4.2

NFPA Standard: Generator sets or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function, serve to detect causes of malfunction and to train personnel in operating procedures. 1999 NFPA 99, 3-4.4.1.1

Based on observation and facility staff interview, the facility failed to maintain their emergency power generator in accordance with the National Fire Protection Association (NFPA) 110, 2010 edition. The generator did not have an emergency stop switch remotely located away from the generator location. The facility census was two.

Observation on 3/7/18, during the facility tour, of the facility emergency generator showed the uncovered manual stop switch located on the generator.

During an interview on 3/7/18, at 12:57 P.M., the Maintenance Director confirmed the observation.
/
NFPA 110 "Emergency and Standby Power Systems", 2010 edition, section 5.6.5.6 states: "5.6.5.6* All installations shall have a remote manual stop station
of a type to prevent inadvertent or unintentional operation located
outside the room housing the prime mover, where so installed,
or elsewhere on the premises where the prime mover is
located outside the building.

5.6.5.6.1 The remote manual stop station shall be labeled."

Based on observation and staff interview, facility staff failed to store liquid oxygen containers in accordance with the National Fire Protection Association (NFPA), 99 2012 edition. The facility census was two.

1. Observation on 3/7/18, during the Life Safety Code tour, showed three liquid oxygen containers in a room located in the supply area. Observation showed each liquid oxygen tank contained 160 liters of compressed oxygen. Observation showed an unrated door to the room. Further observation showed an 18 inch by 18 inch hole in the ceiling of the room. Observation showed the hole exposed the roof deck of the building.

Observation showed the building type as type II (000).

During an interview on 3/7/18 at 11:32 A.M., the Maintenance Director confirmed the observations.

NFPA 99, Health Care Facilities Code, 2012 edition, section 11.7.4 states:"The maximum total quantity of liquid oxygen permitted in storage and in use in a patient bed location or patient care room shall be 120 L (31.6 gal), provided that the patient bed location or patient care room, or both, are separated from the remainder of the facility by fire barriers and horizontal assemblies having a minimum fire resistance rating of 1 hour in accordance with the adopted building code".