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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 18.


1. Observation on 4/16/18, during the facility tour, showed the following;

-designated medical surge exit requires patients, staff and visitors to walk 50 feet to a hard surface. 50 feet of path to hardpath consists of unleveled grass surface.

-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 area designated for resident use.

During an interview on 4/16/18 at 12:13 P.M., the Facilities 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 staff interview, the facility staff failed to ensure all designated exits were marked by exit signs. The facility census was 18.

Observation on 4/16/18, during the facility tour showed the medical surge wing, outside the conference room, did not have exit signs at either end of the exit discharge areas.

Observation on 4/16/18, during the facility tour, showed the obstetrics hall did not have exit signs at either end of the exit discharge areas.

During an interview on 4/16/18 at 12:50 P.M., the facilities director confirmed the observations.

NFPA 101, 2012 edition, section 7.10.1.5.1 states "Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants.

Based on observation and interview, the facility failed to install a sprinkler system in accordance with the National Fire Protection Association 13, Standards for the Installation of Sprinkler Systems. These deficient practices affects all patients in the facility. The facility census was 18.

1. Observation on 4/16/18, during the facility tour, showed the elevator in the 1993 section did not have sprinkler coverage in the hoistway pits. Observation showed the elevator employed a hydraulic elevator lift mechanism that uses a petroleum-based hydraulic fluid, which is combustible.

During an interview on 4/16/18 at 1:38 P.M., the facilities director confirmed the observation.

Section 8.15.5.1* of NFPA 13 states: " Sidewall spray sprinklers shall be installed at the bottom of each elevator hoistway not more than 2 ft (0.61 m) above the floor of the pit.

* The sprinklers in the pit are intended to protect against fires caused by debris, which can accumulate over time. Ideally, the sprinklers should be located near the side of the pit below the elevator doors, where most debris accumulates. However, care should be taken that the sprinkler location does not interfere with the elevator toe guard, which extends below the face of the door opening.
ASME A17.1, Safety Code for Elevators and Escalators, allow the sprinklers within 2 ft (0.65 m) of the bottom of the pit to be exempted from the special arrangements of inhibiting waterflow until elevator recall has occurred.

Based on observation and facility staff interview, the facility staff failed to ensure the building ventilation system was installed according to NFPA 90B, Standard for the Installation of Warm Heating and Air-Conditioning and Ventilating Systems, 2012 edition and NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems, 2012 edition. The census was 18.

Observation on 4/16/18, during the building tour, showed a stand-alone room air conditioner in the chemistry room. Additional observation showed the warm air exhaust flexible duct penetrated the suspended ceiling and exhausted the air into the interstitial space between the ceiling and the roof.

During an interview on 4/16/18 at 11:55 A.M., the Facilities Director confirmed the observation.

NFPA 101, 2012 edition, Section 19.5.2 states:

"19.5.2 Heating, Ventilating, and Air-Conditioning.
19.5.2.1 Heating, ventilating, and air-conditioning shall comply
with the provisions of Section 9.2 and shall be installed in
accordance with the manufacturer ' s specifications, unless otherwise
modified by 19.5.2.2."

9.2 Heating, Ventilating, and Air-Conditioning.
9.2.1 Air-Conditioning, Heating, Ventilating Ductwork, and
Related Equipment. Air-conditioning, heating, ventilating
ductwork, and related equipment shall be in accordance with
NFPA 90A, Standard for the Installation of Air-Conditioning and
Ventilating Systems, or NFPA 90B, Standard for the Installation of
Warm Air Heating and Air-Conditioning Systems, as applicable, unless
such installations are approved existing installations,
which shall be permitted to be continued in service.

Refer to NFPA 90A, Standard for the Installation of Air-Conditioning and
Ventilating Systems, 2012 edition, Section 4.2.4 thru 4.2.4.2 and Section 4.3.3.1 for additional information.

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 18.

1. Record review on 4/16/18 of the facility fire drill records, showed no documentation for the following fire drills:

- no fire drills for the second shift (3:00 P.M., to 11:00 P.M.) for the second quarter of 2017.
- no fire drills for the third shift (11:00 P.M., to 7:00 A.M.) for the first quarter of 2018 and the second and fourth quarter of 2017.


During an interview on 4/16/18 at 4:16 P.M., the facilities director confirmed the missing fire drills.

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 record review and interview, the facility failed to ensure that all building systems had been assigned a risk assessment category. The facility census was 18.

1. Review of the facility documents for fire safety, building system tests, and policies showed no assessment of which systems were critical for patient safety.

During an interview on 4/16/18 at 3:35 P.M. the facilities director said the facility did not have a risk categorical assessment.

NFPA 99 2012 - chapter four Fundamentals, 4.1-4.3

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 18.

Observation on 4/16 /18, during the facility tour, of the facility emergency generators showed the manual stop switches located on the generator.

During an interview on 4/16/18, at 12:28 P.M., the Facilities Director confirmed the observation.
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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."