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Based on observations and staff interview, the facility failed to maintain all 2 hour rated walls in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 19.1.3.5 and 8.2.1.3. The deficient practice affects 2 out of 10 smoke zones, including 50 out of 71 residents. The facility has a capacity of 78 with a census of 71 residents.

Findings include:

Observation and staff interview on 9/3/20, between 9:45 a.m. and 2:45 p.m., revealed the following deficiencies:

1. There was a hole, (approximately 1 foot by 1 foot square), in the 2 hour rated wall by the Dietician Office.
2. There was an open conduit, (approximately 4 inches), with communications lines through it, extending thorough the 2 hour rated wall by the Dietician Office.
3. There was a penetration, (approximately 1/2 inch), around three communications lines, extending through the 2 hour rated wall to the Sleep Lab Corridor.
4. There was a penetration, (approximately 1/2 inch), around 2 communications lines, extending through the 2 hour rated wall to the Sleep Lab Corridor.
5. There were two penetrations, (both approximately 1/2 inch), around communications lines, extending through the Accounting Corridor two hour rated wall.
6. The fire door in the two hour wall separating the Rural Health Clinic from the Ambulance Garage was not equipped with an automatic closure device as required.

Maintenance Staff verified observations during the survey process.

Based on observations and staff interview, the facility failed to provide the fire alarm system in accordance with National Fire Protection Association, NFPA 72, 2010 edition. The primary power supply for the fire alarm system shall be mechanically protected. The facility has a capacity of 25 with a census of 6 patients.

Findings include:

Observations and staff interview on 9/3/20, between 9:45 a.m. and 2:45 p.m., revealed the following deficiencies:

1. There was a smoke detector installed near an air supply or return ventilation duct in the Basement Corridor by the Loading Dock.
2. There was a smoke detector installed near an air supply or return ventilation duct in the Basement Corridor by the Cafeteria Entrance.
3. There was a smoke detector installed near an air supply or return ventilation duct at the Surgery
Nurses Station.

Maintenance Staff verified observations during the survey process.

Based on record review and staff interview, the facility failed to provide a policy regarding the procedures to be taken in the event the fire alarm system is out of service for more than four hours in any twenty-four hour period in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 9.6.1.6. The facility has a capacity of 25 with a census of 6 patients.

Findings include:

Record review and staff interview on 9/3/20 at 1:07 p.m., revealed the fire alarm outage policy did not contain all required language and information as follows:

"When the fire alarm system is out of service for more than 4 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 outage.
b) An approved fire watch. The fire watch is continuous and all portions of the facility will be checked at least once every 30 minutes."

Maintenance Staff verified record review during the survey process.

Based on record review and staff interview, the facility failed to provide a policy regarding the procedures to be taken in the event the sprinkler system is out of service for more than 10 hours in any twenty-four hour period in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 9.7.6. and National Fire Protection Association, NFPA 25, 2011 edition. The facility has a capacity of 25 with a census of 6 patients.

Findings include:

Record review and staff interview on 9/3/20 at 1:07 p.m., revealed the sprinkler system outage policy did not contain all required information as follows:

1. The policy did not contain language indicating that the extent and expected duration of the impairment has been determined.
2. The policy did not contain language indicating that the areas or buildings involved have been inspected and increased risks determined.
3. The policy did not contain language indicating that recommendations have been submitted to management or the property owner.
4. The policy did not contain notification of the insurance carrier.
5. The policy did not contain language indicating that the supervisors in the areas to be affected have been notified.
6. The policy did not contain language indicating that a tag impairment system has been implemented.
7. The policy did not contain language indicating that all necessary tools and materials have been assembled on the impairment site.
8. The policy did not address all of the following conditions: System leakage. Interruption of water supply. Ruptured piping. Equipment failure.
9. The policy did not contain all of the following required language: "When the sprinkler 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 outage.
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."

Maintenance Staff verified record review during the survey process.

Based on observations and staff interview, this facility is not assuring that all smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 19.3.7.3. The facility has a capacity of 25 with a census of 6 patients.

Findings include:

Observations and staff interview on 9/3/20 at 10:19 a.m., revealed the following deficiencies:

1. There were two penetrations, (both approximately 1/2 inch), around two conduit extending through the Basement Cafeteria Smoke Barrier Wall.
2. There was an open conduit, (approximately 1/2 inch), with communications lines through it, extending through the Basement Cafeteria Smoke Barrier Wall.
3. There was a hole, (approximately 1 inch), extending through the Basement Cafeteria Smoke Barrier Wall.

Maintenance Staff verified observations during the survey process.

Based on observation and staff interview, the facility failed to maintain the building's electrical system in accordance with National Fire Protection Association, NFPA 70, 2010 Edition. The facility has a capacity of 25 with a census of 6 patients.

Findings include:

Observation and staff interview on 9/3/20 at 11:28 a.m., revealed an open electrical junction box above the ceiling tiles in the corridor by the Gift Shop. Maintenance Staff verified observations during the survey process.

Based on record review and staff interview, the facility failed to provide emergency plans and procedures as required by National Fire Protection Association, NFPA 101, 2012 Edition, 19.7.2.2. The facility has a capacity of 25 with a census of 6 patients.

Findings include:

Record review and staff interview on 9/3/20 at 1:24 p.m., revealed the fire emergency plan and procedures policy did not contain all required information as follows:

1. The policy did not contain the use of all types of fire extinguishers in the facility.
2. The policy did not contain the use of the Kitchen Hood and Duct Extinguishment System.

Maintenance Staff verified record review during the survey process.

Based on observations and staff , the facility did not store compressed gas cylinders in accordance with National Fire Protection Association (NFPA) Standard 99, Health Care Facilities Code, 2012 edition, 11.6.2.3, by ensuring tanks were adequately secured to prevent them from accidental damage or dislocation. The facility has a capacity of 25 with a census of 6 patients.

Findings include:

Observations and staff interview on 9/3/20 at 10:51 a.m., revealed 4 large compressed gas cylinders that were not properly secured in the Emergency Department Ambulance Garage. Maintenance Staff verified observations during the survey process.