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Based on observation and staff interview the facility failed to provide emergency lighting and testing of emergency lighting as required for exit access and discharge paths. The deficient practice could leave the operating room without emergency lighting sufficient enough to terminate procedures during a disruption of normal or emergency power and leave the exit paths without illumination during a disruption of normal power. This deficiency affects eight patients in two of two smoke zones. The facility has a capacity of eight with a census of zero at the time of survey.

Findings include:

During the survey on July 18th, 2017 the following observation was made:

There is no documentation the battery backup emergency lights are being inspected for 30 seconds monthly for the months of April, May and June 2017.

During the survey on July 19th, 2017 the following observation was made:

11:25 a.m. It was observed in operating room 1 there is no battery operated emergency light.

The maintenance director was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: Emergency lighting shall be provided in accordance with Section 7.9. 2012 NFPA 101, 19.2.9.1

Review of the following NFPA Standard revealed: Emergency illumination shall be provided for a minimum of 1 ½ hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 ft candle (l0.8 lux) and, at any point, not less than 0.1 ft candle (1.1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft candle (6.5 lux) and, at any point, not less than 0.06 ft candle (0.65 lux) at the end of 1 ½ hours. A maximum to minimum illumination uniformity ratio of 40 to 1 shall not be exceeded. 2012 NFPA 101, 7.9.2.1.

Based on observation and record review the facility failed to test the emergency power supplies for the exit signs where provided monthly for 30 seconds. The deficient practice of not testing the power supply and assuring the exit signs are working where provided may prevent the occupants of the building from being directed to the exit path and delay egress affecting all residents and staff in two of two smoke zones. The facility has a capacity of eight with a census of zero at the time of survey.

Findings include:

During the survey on July 18th, 2017 the following observation was made:

Based on interview and observation on July 18th, 2017 during documentation review there is no documentation the exit signs are being monthly inspected.

The maintenance director was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. (2012) NFPA 101 18.2.10.1

Review of the following NFPA Standard revealed: Means of egress shall have signs in accordance with Section 7.10, unless otherwise permitted by 18.2.10.3 or 18.2.10.4. Where the path of egress travel is obvious, signs shall not be required at gates in outside secured areas.

Access to exits within rooms or sleeping suites shall not be required to be marked where staff is responsible for relocating or evacuating occupants. Illumination of required exit and directional signs in buildings equipped with, or in which patients use, lifesupport systems (see 18.5.1.3) shall be provided as follows: (1) Illumination shall be supplied by the life safety branch of the electrical system as described in NFPA 99, Health Care Facilities Code. (2) Self-luminous exit signs complying with 7.10.4 shall be permitted.

Review of the following NFPA Standard revealed: Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days or shall be periodically monitored in accordance with 7.9.3.l.3. 2012 NFPA 101, 7.10.9.1
Review of the following NFPA Standard revealed: Exit signs connected to, or provided with, a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3. 2012 NFPA 101, 7.10.9.2

Based on observation and staff interview, the facility failed to provide walls and ceilings in the hazardous rooms free from holes and penetrations. This deficient practice would allow smoke and fire products to travel from the room or origin to adjacent rooms and the attic affecting all residents and staff in two of two smoke zones. The facility has a capacity of eight and census of zero at the time of the survey.

Findings include:

During the survey on July 19th, 2017 the following observation was made:

11:44 a.m. The southwest corner of the medical gas room up at the the ceiling above the steel beam there is a penetration hole above it approximately 1 inch by 10 inches.

The maintenance director was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Health Care Facilities Code. 18.3.2.4 Medical Gas.

Review of the following NFPA Standard revealed: Hazardous Areas. Any hazardous areas shall be protected in accordance with Section 8.7, and the areas described in Table 18.3.2.1. by a 1 hour fire rated wall.

Based on observation and staff interview the facility is not ensuring that doors to a corridor close and latch properly. This deficient practice of not ensuring that room doors latch properly prevents the ability of the facility to properly confine fire and smoke products and to properly defend occupants in place, affecting one patient in one of two smoke zones. The facility has a capacity of eight and census of zero at the time of the survey.

Findings include:

During the survey on July 19th, 2017 the following observation was made:

11:08 a.m. It was observed in the physical therapy room the southeast corridor door has a pulley system attached to the top of the door that prevents the corridor door from closing.

The maintenance director was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: Doors protecting corridor openings shall be constructed to resist the passage of smoke, and the following also shall apply: (1) Compliance with NFPA80, Standard for Fire Doors and Other Opening Protectives, shall not be required. (2) A clearance between the bottom of the door and the floor covering not exceeding 1 in. (25 mm) shall be permitted for corridor doors. (3) Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible material shall not be required to be constructed to resist the passage of smoke. (2012) NFPA 101 18.3.6.3.1
Review of the following NFPA Standard revealed: Doors shall be self-latching and provided with positive latching hardware. Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials shall not be required to meet the latching requirements. (2012) NFPA 101 18.3.6.3.6

Based on observation and staff interview the facility fails to maintain smoke barriers to at least one hour smoke resistance. This deficient practice would prevent containment of fire and smoke, affecting eight patients and staff in two of two smoke zones. The facility has a capacity of eight and census of zero at the time of the survey.

Findings include:

During the survey on July 19th, 2017 the following observations were made:

10:02 a.m. It was observed in the east mechanical room in the east patient hallway there are multiple penetrations in the north and west walls of the room around conduit pipes and the ends of the conduit pipes. It is observed there is a five inch diameter hole in the west wall near the north wall and ceiling that is not sealed. It was also observed there is a two inch diameter penetration hole with a one inch pipe in the center that is not sealed around.

10:52 a.m. It was observed in electrical room east of the kitchen the north wall is a smoke barrier wall that has multiple penetration through the wall that are around conduit that are not sealed.

12:42 p.m. It was observed in the kitchen above the dishwasher and ceiling there is a hole in the north side of the one hour smoke barrier approximately 3" by 3 ".

The maintenance director was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: 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. (2012) NFPA 101 18.3.7.3

Review of the following NFPA Standard revealed: Materials and methods of construction used for required smoke barriers shall not reduce the required fire resistance rating. (2012) NFPA 101 18.3.7.4

Based on observation and staff interview the facility fails to provide doors that will close properly in a smoke barrier. The deficient practice of not providing properly closing doors in a smoke barrier would prevent the door from closing as required allowing smoke and fire product to spread beyond the smoke barrier more rapidly, affecting staff only in one of two smoke zones. The facility has a capacity of eight and census of zero at the time of the survey.

Findings include:

During the survey on July 19th, 2017 the following observation was made:

9:52 a.m. It was observed in the center hallway by the conference room when tested the south leaf of the smoke barrier doors will not close. It stops 6 inches short of going closed.

The maintenance director was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: Doors in smoke barriers shall be substantial doors, such as 13?4 in. (44 mm) thick, solid-bonded wood- core doors, or shall be of construction that resists fire for a minimum of 20 minutes, and shall meet the following requirements: (1) Nonrated factory- or field-applied protective plates, unlimited in height, shall be permitted. (2) Cross-corridor openings in smoke barriers shall be protected by a pair of swinging doors or a horizontal-sliding door complying with 7.2.1.14, unless otherwise permitted by 18.3.7.7. (3) The swinging doors addressed by 18.3.7.6(2) shall be arranged so that each door swings in a direction opposite from the other.

Review of the following NFPA Standard revealed: 18.3.7.7 Cross-corridor openings in smoke barriers that are not in required means of egress from a health care space shall be permitted to be protected by a single-leaf door. (2012) NFPA 101 18.3.7.7

Review of the following NFPA Standard revealed: Doors in smoke barriers shall comply with 8.5.4 and all of the following: (1) The doors shall be self-closing or automatic-closing in accordance with 18.2.2.2.7. (2) Latching hardware shall not be required. Stops shall be required at the head and sides of door frames. (4) Rabbets, bevels, or astragals shall be required at the meeting edges of pairs of doors. (5) Center mullions shall be prohibited. (2012) NFPA 101

Based on observation and staff interview, the facility did not ensure that electrical equipment is protected 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 patients in one of two smoke zones. The facility has a capacity of eight and census of zero at the time of the survey.

Findings Include:

During the survey on July 19th, 2017 the following observation was made:

11:35 a.m. It was observed in the electrical room inside the boiler room on the north wall electrical panel EQH1 has an open space exposing electrical components.

The maintenance director was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. 2012 NFPA 101, 9.1.2

Review of the following NFPA Standard revealed: Permissible Loads. In no case shall the load exceed the branch circuit ampere rating. An individual branch circuit shall be permitted to supply any load for which it is rated. A branch circuit supplying two or more outlets or receptacles shall supply only the loads specified according to its size as specified in 210.23(A) through (D) and as summarized in 210.24 and Table 210.24. 2011 NFPA 70, 210.23

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 one patient and staff in one of two smoke zones. This facility has a capacity of eight and a census of zero.

Findings include:

During the survey on July 19th, 2017 the following observation was made:

11:01 a.m. It was observed in the physical therapy department there is a 20 foot extension cord running around the southwest corner of the room to a patient physical therapy bed. The cord is being used in place of a receptacle.

The maintenance director was present during the survey and acknowledged the finding.

Review of the following NFPA Standard revealed: Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following: (1) As a substitute for the fixed wiring of a structure (2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors (3) Where run through doorways, windows, or similar openings (4) Where attached to building surfaces Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B) (5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings (6) Where installed in raceways, except as otherwise permitted in this Code (7) Where subject to physical damage. NFPA 70 2011, 400.8