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Based upon observation and staff interview, the facility fails to assure that means of egress are continuously maintained free of all obstructions to full use in case of emergency. The deficient practice reduces the width of the corridor and means of egress, affecting all LTC residents, visitors and staff in 3 of 7 smoke zones. The facility has a capacity of 18 beds in the Hospital with a census of 5 and a capacity of 25 beds in the LTC with a census of 23 at the time of this survey.

Findings include:

During the tour conducted on 06/26/2017, at 4:13 p.m., it is observed that:

-- 1. Furniture in the living room area between resident room corridors extends into both corridors, reducing the width of the egress corridors.

Head of Environmental Services and Maintenance Staff A were present and acknowledged the results of the records review.

NFPA Standard: Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
2012 NFPA 101 18.2.1, 19.2.1, 7.1.10.1

Based upon a review of records and staff interview, the facility fails to assure that emergency lighting of at least 1-1/2-hour duration is automatically provided in accordance with 7.9. The deficient practice could result in a failure to provide illumination in the event of a power failure, affecting all residents, visitors and staff in 7 of 7 smoke zones. The facility has a capacity of 18 beds in the Hospital with a census of 5 and a capacity of 25 in the LTC with a census of 23 at the time of this survey.

Findings include:

During the tour conducted on 06/23/2017, a review of records between 1:00 p.m. and 2:30 p.m., revealed that:

-- 1. Documentation for monthly 30-second functional testing of the emergency lighting units through November 2016 does not include detailed information of each unit that was tested, only a summary that all units were tested.

-- 2. Prior to February 2017, documentation for 30-second functional testing of emergency lighting units indicated that only 3 of 6 units on site were being tested.

-- 3. Documentation of the annual 90-minute testing of the emergency lighting units conducted on 12/30/2016 did not include 3 of the 6 units on site.

Head of Environmental Services and Maintenance Staff A were present and acknowledged the results of the records review.

NFPA Standard: A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 and 1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 2012 NFPA 101, 7.9.3

Based on record review, observation and staff interview, this facility is not maintaining the sprinkler system in accordance with the 2011 edition of NFPA 25 by not providing complete documentation of monthly visual inspections of the automatic, wet-pipe sprinkler system. This deficient practice could compromise the effectiveness of the fire suppression system, affecting all residents, visitors and staff in 7 of 7 smoke zones. The facility has a capacity of 18 beds in the Hospital with a census of 5 and a capacity of 25 beds in the LTC with a census of 23 at the time of this survey.

Findings include:

During the tour conducted on 06/23/2017, between 1:00 p.m. and 2:30 p.m., during a review of records, it is observed:

-- 1. No documented monthly visual inspections of the automatic fire sprinkler system.

Head of Environmental Services and Maintenance Staff A were present and acknowledged the results of the records review.

NFPA Standard: Automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25 per 2012 NFPA 101, 9.7.5.

NFPA Standard: Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. 2012 NFPA 101 4.6.12.1

NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 2012 NFPA 101, 4.6.12.1

Based on observation and staff interview, the facility did not ensure that electrical wiring and equipment is installed and maintained in accordance with NFPA 70, National Electrical Code. This deficient practice does not ensure prevention of an electrical fire or electric shock hazard, affecting no residents and any visitors or staff in 1 of 7 smoke zones. The facility has a capacity of 18 beds in the Hospital with a census of 5 and a capacity of 25 beds in the LTC with a census of 23 at the time of this survey.

Findings include:

During the tour conducted on 06/23/2017 at 4:47 p.m., in the Kitchen, a 15A powerstrip is used to power a commercial mixer (600W-5A), a waffle iron (1200W-10A) and a hand-mixer (200W-1.66A). The items exceed the rated capacity of the powerstrip.

Head of Environmental Services and Maintenance Staff A were present and acknowledged the results of the records review.

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