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Based on document review and staff interview, the facility fails to test and maintain their emergency light systems in accordance with NFPA 101. This deficient practice would affect all patients, visitors, and staff in 2 of 8 smoke zones. The facility has a capacity of 25 with a census of 2 at the time of the survey.

Findings include:

During the survey conducted on July 18th, 2018, the following deficiency is noted:

1) 10:42 a.m. It was observed above the Microbiology Lab Area door emergency light #9 does not illuminate upon test.

2) 10:55 a.m. It was observed in the main lobby the west emergency light closest to the fire panel does not illuminate upon test

3) 1:00 p.m. It was observed in the transfer switch room the emergency light will not illuminate upon test.

Staff member M1 was present and acknowledged the finding.

NFPA Standard: NFPA 101 2012 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.

Based upon observation the facility fails to assure that combustible materials are not stored in hazardous areas. Additionally, this facility fails to provide solid, smoke resisting walls or ceiling in hazardous areas which would not stop the spread of smoke, and doors on hazardous rooms with auto closure devices affecting all patients and any visitors or staff in 2 of 8 smoke zones. The facility has a capacity of 25 with a census of 2 at the time of this survey.

Findings include:


During the survey on July 18th, 2018, it is observed:


1) 12:31 p.m. It was observed in the north elevator equipment room there is combustible materials being stored.


2) 12:32 p.m. It was observed in the north elevator equipment room there is a penetration hole in the ceiling southeast corner.


3) 1:24 p.m. It was observed in patient room 25 it is being used for storage of beds and furniture; there is no auto closure on the door.


Staff Member M1 was present during the survey and acknowledged the findings.

NFPA Standard: Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4-hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. 2012 NFPA 101 19.3.2.1

Based on staff interview and observation, the facility fails to install and maintain their Alcohol Based Hand Rub dispensers in accordance with NFPA 101. The deficient practice would affact all patients, visitors, and all staff in 1 of 8 smoke zones. The facility has a capacity of 35 with a census of 2, at the time of the survey.

Findings include:


During the survey conducted on July 17th and 18th, 2018 the following deficiency is noted:


09:25 am It was observed in the roof top conference room the ABHR is located directly over the light switch.


Staff Member M1 was present and acknowledged the alcohol based hand rub dispenser was mounted over the light switch.

NFPA Standard: Life Safety Code 101 2012 19.3.2.6* Alcohol-Based Hand-Rub Dispensers. Alcohol-based hand-rub dispensers shall be protected in accordance with 8.7.3.1, unless all of the following conditions are met: (8) Dispensers shall not be installed in the following locations: (a) Above an ignition source within a 1 in. (25 mm) horizontal distance from each side of the ignition source (b) To the side of an ignition source within a 1 in. (25mm) horizontal distance from the ignition source (c) Beneath an ignition source within a 1 in. (25 mm) vertical distance from the ignition source.

Based on observation, interview and record review, the facility failed to provide and maintain complete documentation of annual inspection, testing and maintenance of the fire alarm system in accordance with NFPA 72 . The absence of complete, verifiable documented maintenance and repair history on the fire alarm system fails to ensure reliability of the alarm system in the event of an emergency, affecting all residents, visitors and staff in 8 of 8 smoke zones. The facility has a capacity of 25 with a census of 2 at the time of this survey.

Findings include:

During the survey on July 17th and 18th, 2018 the following observations were made:

1) It was observed during documentation review the annual fire alarm report from Simplex Grinnell dated 08-17-2017 notated (5) deficiencies as follows; there is no documentation of repair or replacement.

a) NW ER VESTIBULE - Fire alarm panel - The batteries fail expiration date and need replaced.

b) E. R. STORAGE ROOM NEAR NURSES DESK - Remote power supply - The batteries failed load test and need replaced.

c) NORTH ELEVATOR LOBBY BY EXIT - Horn Strobe -T1 - The audio function of the device failed.

d) BOILER ROOM EAST WALL - Horn Strobe - T1 - The audio function of the device failed.

e) SOUTH ELEVATOR LOBBY - Horn Strobe - T1 - The audio function of the device failed.


Staff Member M1 was present and acknowledged the findings.

NFPA Standard: A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. 2012 NFPA 101, 9.6.1.3

NFPA Standard: A complete record of the tests and operations of each system shall be kept until the next test and for 1 year thereafter. The record shall be available for examination and, if required, reported to the authority having jurisdiction. Archiving of records by any means shall be permitted if hard copies of the records can be provided promptly when requested. If off-premises monitoring is provided, records of all signals, tests, and operations recorded at the supervising station shall be maintained for not less than 1 year. 2010 NFPA 72 10.18.3

NFPA Standard: Smoke detector sensitivity shall be checked within one year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed. 2010 NFPA 72, 14.4.5.3

Based on observation, record review and interview the facility fails to ensure that the facility' automatic sprinkler system is installed, maintained and tested in accordance with NFPA 25. This deficient practice fails to ensure that the sprinkler system will be properly prepared in the event of a fire, affecting all patients in 8 of 8 smoke zones. The facility has a capacity of 25 and census of 2 at the time of the survey.

Findings include:

During the survey on July 17th and 18th, 2018, the following observations were made:

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

2) It was observed there is no documentation of a 2nd quarter 2017 sprinkler testing.

Staff Member M1 was 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 fails to properly maintain their electrical systems in accordance with NFPA 70. The deficient practice would affect staff only in 1 of 8 smoke zones. The facility has a capacity of 25 with a census of 2 at the time of the survey.
Findings include:
During the survey conducted on July 18th, 2018, the following deficiency is noted:

1) 12:40 PM It was observed in the x-ray storage room there is a junction box on the ceiling without a cover plate.

Staff member M1 was present and acknowledged the finding.

NFPA Standard: Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2

Based on observation and staff interview, the facility does not assure that dampers are in accordance with NFPA 72 and 2012 NFPA 101, 8.4.6.2. This deficient practice could affect persons who may need to use areas as a safe zone in the event of an emergency, affecting all patients, visitors and staff in 8 of 8 smoke zones. The facility has a capacity of 25 with a census of 2 at the time of this survey.

Findings include:

During the survey conducted on July 17th and 18th, 2018 the following was observed:

1) No documented testing and maintenance of smoke dampers within the last 6 years.

2) No policy in place to assure that smoke dampers are tested, inspected and maintained. Staff member M1 affirmed that the facility has smoke dampers and that there is no available documentation indicating the number of dampers or their location(s).

NFPA Standard: An approved damper designed to resist the passage of smoke shall be provided for each air transfer opening or duct penetration of a required smoke barrier per NFPA 101, 8.3.5.1. Required smoke dampers in air transfer openings shall close upon detection of smoke by approved smoke detectors in accordance with 2010 NFPA 72 and 2012 NFPA 101, 8.3.5.3

NFPA Standard: Air-transfer openings in smoke partitions shall be provided with approved smoke dampers designed and tested in accordance with the requirements of ANSI/UL 555S, Standard for Smoke Dampers, to limit the transfer of smoke. 2012 NFPA 101 8.4.6.2

Based upon interview and record review, the facility fails to provide a complete written plan for the evacuation of the building's smoke zones directly affected by fire. The deficient practice affects all residents, patients, visitors and staff in 8 of 8 smoke zones. The facility has a capacity of 25 with a census of 2.

Findings include:

During the survey on July 17th & 18th, 2018, the following observations were made:

1) It was observed during the documentation review of the fire procedures policy the procedure does not include staff evacuation of the smoke zones and/or smoke compartments within the hospital. There is no documented plan of how and where to move patients in the event of a fire. Observed there is an overall evacuation plan in place.

2) It was observed during the documentation review there is no documentation of hospital employees and staff receiving periodical instruction of the facilities fire and evacuation plan as well as training on the fire related equipment within the hospital .

Staff Member M1 was present and acknowledged the findings.

NFPA Standard: The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan required by 19.7.1.1. A copy of the plan required by 19.7.1.1 shall be readily available at all times in the telephone operator's location or at the security center. 2012. NFPA 101, 18/19.7.1.1

NFPA Standard: A written health care occupancy fire safety plan shall provide for all of the following: (1) use of alarms; (2) transmission of alarms to fire department; (3) emergency phone call to fire department; (4) response to alarms; (5) isolation of fire; (6) evacuation of immediate area; (7) evacuation of smoke compartment; (8) preparation of floors and building for evacuation; (9) extinguishment of fire. 2012 NFPA 101 18/19.7.2.2

Based on record review and staff interview, the facility is not conducting fire drills as required and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency, affecting all patients in 8 of 8 smoke zones. The facility has a capacity of 25 and a census of 2.

Findings include:

During the survey on July 17th and 18th, 2018, the following observations were made

1) It was observed during documentation review of the previous (5) quarters of fire drill reports there are no documented scenarios on the reports.

2) It was observed during documentation review of the previous (5) quarters of fire drill reports the fire alarm was not tested following the 3rd shift silent fire drill on the following dates:12/27/17, 3/28/18 and 6/21/18.

3) It was observed during documentation review of the previous (5) quarters of fire drill reports there was no fire drill conducted during the 3rd quarter of 2017.

Staff Member M1 was present and acknowledged the findings.

Review of the following NFPA Standard revealed: The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan required by 19.7.1.1. A copy of the plan required by 19.7.1.1 shall be readily available at all times in the telephone operator's location or at the security center. Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 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. 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. Employees of health care occupancies shall be instructed in life safety procedures and devices. 2012 NFPA 101, 19.7.1.1-8

Based upon a review of records and staff interview the facility is not maintaining fire-rated door assemblies in compliance with NFPA 80. This deficient practice could prevent the ability of the facility to properly confine smoke and prevent fire from spreading to other areas of the building. This deficient practice would affect all patients, visitors, and staff in 8 of 8 smoke zones. The facility has a capacity of 25 with a census of 2 at the time of this survey.


Findings include:


During the survey conducted on July 17th & 18th, 2018, the following deficiencies are noted:


1) 57 fire doors throughout the facility were inspected by Fire Door Solutions in December of 2017. Of the 57 fire doors inspected 33 deficiencies were identified. There is no documentation the deficiencies are or have been repaired or replaced.

a) Main Building - Ground Floor - Stairwell door basement - Door 155588 - 90 min door: Excessive Undercut 45min+

b) Main Building - Ground Floor - Cross corridor by purchasing - Door 155590 - 30 min door: Minor damage - delaminated door.

c) Main Building - Ground Floor - Cross corridor by purchasing - Door 155590 - 30 min door - Open/unused Fastener holes.

d) Main Building - Ground Floor - Laundry Room Basement - Door 155591 - Door does not latch closed - closure needs adjusted.

e) Main Building - Ground Floor - Laundry Room Basement - Door 155591 - Open/unused fastener holes.

f) Main Building - Ground Floor - Laundry Door Basement - Door 155592 - Excessive clearance

g) Main Building - Ground Floor - Laundry Door Basement - Door 155592 - Penetrations - Unused fastener holes.

h) Main Building - Ground Floor - Laundry Door Basement - Door 155592 - Open unused fastener holes.

i) Main Building - Ground Floor - Purchasing - Door 155593 - Excessive Clearance.

j) Main Building - Ground Floor - Purchasing - Door 155593 - Open unused fastener holes.

k) Main Building - Ground Floor - Receiving - Door 155594 - Excessive clearance.

l) Main Building - Ground Floor - Receiving - Door 155594 - Excessive undercut 45min+

m) Main Building - Ground Floor - Receiving - Door 155594 - Open unused fastener holes.

n) Main Building - Ground Floor - Dbl doors to air handlers - 90 Min. - Door 155596 - Excessive undercut 45min+

0) Main Building - Ground Floor - Dbl doors to air handlers - 90 Min. - Door 155596 - Open unused fastener holes.

p) Main Building - Ground Floor - Dbl doors to air handlers - 90 min. - Door 155597 - Excessive undercut 45min+

q) Main Building - Ground Floor - Dbl doors to air blower room (White) - 90 min. - Door 155598 - Open unused fastener holes.

r) Main Building - 1st Floor - South stairwell floor 1 - 90 Min. - Door 155550 - Excessive undercut 45min+

s) Main Building - 1st Floor - Cross corridor by insurance - 20 Min - Door 155552 - Excessive clearance.

t) Main Building - 1st Floor - Oxygen Storage and Bathroom - 20 Min. - Door 155554 - Missing filler plates.

u) Main Building - 1st Floor - Cross corridor to OR - 90 min. - Door 155557 - Latch does not engage bottom strike.

v) Main Building - 1st Floor - Cross corridor by Lab - 90 Min. - Door 155559 - Excessive undercut 20min.

w) Main Building - 1st Floor - Old ER Door - Door 155560 - Penetrations - Unused fastener holes.

x) Main Building - 1st Floor - Old ER Door - Door 155560 - Missing filler plates.

y) Main Building - 1st Floor - Old ER Door - Door 155560 - Open unused fastener holes.

z) Main Building - 1st Floor - Cross corridor to new building - 20 Min. - Door 155561 - Door Closer Not Installed. (SB)

aa) Main Building - 1st Floor - Door to Hallway - 90 Min. - Door 155563 - Excessive clearance. (2 Hr.)

bb) Main Building - 1st Floor - Door to Hallway - 90 Min. - Door 155563 - Damaged Smoke Seal. (2 Hr.)

cc) Main Building - 1st Floor - Door to Hallway - 90 Min. - Door 155563 - Latchset not securely fastened. (2 Hr.)

dd) Main Building - 1st Floor - Cross corridor Rm 1 - 20 Min. - Door 155565 - Missing Coordinator. (SB)

ee) Main Building - 1st Floor - Soiled OR Utility - 45 Min. - Door 155567 - Excessive clearance. (1 Hr.)

ff) Main Building - 1st Floor - Storage - 45 Min. - Door 155569 - Excessive clearance. (1 Hr.)

gg) Main Building - 1st Floor - Chief Nursing Officer - Door 155570 - Repair mising/damaged arm. (1 Hr.)

ii) Main Building - 1st Floor - Utilization Room - Door 155571 - Door closure not installed. (1 Hr.)

jj) Main Building - 1st Floor - Utilization Room - Door 155571 - Excessive clearance. ( 1 Hr.)

kk) Main Building - 1st Floor - Utilization Room - Door 155571 - Door label misssing. (1 Hr.)

ll) Main Building - 1st Floor - Utilization Room - Door 155571 - Label is missing. (1 Hr.)

mm) Main Building - 1st Floor - Cross Corridor by 25 - 45 Min. - Door 155573 - Excessive clearance. (SB)

nn) Main Building - 1st Floor - Supply Room Trauma Room - 45 Min. Door 155575 - Excessive clearance. (1 Hr.)

oo) Main Building - 1st Floor - Suppy Rm in ER 1 - 45 Min. - Door 155576 - Excessive undercut 45min+ (1 Hr.)

pp) Main Building - 1st Floor - Soiled OR Utility - 45 Min. - Door 155580 - Excessive clearance. (1 Hr.)

qq) Main Building - 1st Floor - Soiled OR Utility - 45 Min. - Door 155581 - Excessive undercut 45min+ (1 Hr.)

rr) Main Building - 1st Floor - SP Outpatient - Door 155582 - Door closure not installed (SB)

ss) Main Building - 1st Floor - SP Outpatient - Door 155582 - Excessive clearance (SB)

tt) Main Building - 1st Floor - Cross Corridor by Main Entrance - 90 Min. - Door 155583 - Label is missing. (2 Hr.)

uu) Main Building - 1st Floor - Physicians Lounge - 20 Min. - Door 155587 - Escessive clearance - (SB)

vv) Main Building - 2nd Floor - Elevator Lobby North - 45 Min. - Door 155544 - Missing Filler Plates. (1 Hr.)

ww) Main Building - 2nd Floor - Laundry Floor 2 - 90 Min. - Door 155546 - Excessive clearance.

xx) Main Building - 2nd Floor - Second Floor Stairwell Door South - 90 min. - Door 155549 - Open unused fastener holes.



Staff Member M1 was present and acknowledged the findings. .


NFPA Standard: NFPA 80 2010 5.2.1 Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ. 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing. 5.2.4.2 As a minimum, the following items shall be verified: (1) No open holes or breaks exist in the surfaces of either the door or frame. (2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped. (3) The door, frame, hinges, hardware, and non combustible threshold are secured, aligned, and in working order with no visible signs of damage. (4) No parts are missing or broken. (5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7 (6) The self-closing device is operational; that is, the active door completely closes when operated from the open position. (7) If a coordinator is installed, the inactive leaf closes before the active leaf. (8) Latching hardware operates and secures the door when it is in the closed position. (9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame. (10) No field modifications to the door assembly have been performed that void the label. (11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity. 3.3.95 Qualified Person. A person who, by possession of a recognized degree, certificate, professional standing, or skill, and who by knowledge, training, and experience, has demonstrated the ability to deal with the subject matter, the work, or the project.

Based upon a review of records and staff interview, the facility fails to provide a documented maintenance program for medical gas and vacuum piped systems. The deficient practice reduces the reliability of the medical gas systems, affecting all patients within the facility in 8 of 8 smoke zones. The facility has a capacity of 25 with a census of 2 at the time of this survey.

Findings include:

During the survey on July 17th and 18th, 2018 the follow discrepancies were noted::

1) It was observed there is no documentation of an inspection and testing being performed on the Med Gas systems at this facility. (The hospital was original in 1948 with an addition in 2009 interview with staff member M1 indicated it was unknown this was a requirement). Unknown if there have ever been any previous Medgas inspections as there was no documentation in the records.


Staff Member M1 was present and acknowledged the finding.


NFPA Standard: Medical gas, vacuum, WAGD, or support gas systems have documented maintenance programs. The program includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets. Inspection and maintenance schedules are established through risk assessment considering manufacturer recommendations. Inspection procedures and testing methods are established through risk assessment. Persons maintaining systems are qualified as demonstrated by training and certification or credentialing to the requirements of AASE 6030 or 6040.
5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14, 5.3.13.4.2 (NFPA 99)

Based on observation the facility fails to provide the appropriate signs on the oxygen storage room door and provide appropriate spacing between combustibles and oxygen cylinders. This deficient practice affects all ER patients in 1 of 8 smoke zones. The facility has a capacity of 25 and census of 2 at the time of the survey.

Findings include:

During the survey on July 18th, 2018, the following is observed:

1) 1:14 p.m. It was observed in Emergency Department oxygen storage room there are combustibles within 5 feet of the cylinders.


2) 1:15 p.m. It was observed the Emergency Department oxygen storage room does not have assign readable from 5 feet which states: "CAUTION OXIDIZING GAS(ES) STORED WITHIN NO SMOKING"


Staff Member M1 was present and acknowledged the findings.

Review of the following NFPA standard revealed: Storage shall be planned so that cylinders can be used in the order in which they are received from the supplier. If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders. When the facility employs cylinders with integral pressure gauge, it shall establish the threshold pressure at which a cylinder is considered empty. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner. (NFPA 99), 11.4

Review of the following NFPA standard revealed: Containers shall be stored, used, and operated in accordance with the manufacturer's instructions and labeling. Containers shall not be placed in the following areas: (1) Where they can be tipped over by the movement of a door (2) Where they interfere with foot traffic (3) Where they are subject to damage from falling objects (4) Where exposed to open flames and high-temperature. (NFPA 99), 11.7.3

Review of the following NFPA standard revealed: A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum: CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING. (NFPA 99), 11.4
Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following: (1) Minimum distance of 6.1 m (20 ft) (2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems (3) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1?2 hour. (NFPA 99) 11.3.2.3