HospitalInspections.org

Based on records review and staff interview the facility failed to ensure that battery powered emergency lighting devices are tested for 30 seconds monthly. This deficient practice could result in the lack of lighting during an interruption of power and does not ensure that the light is tested as required, affecting all residents in all 16 smoke zones. The facility has a capacity of 25 with a census of 8.

Findings include:

During the survey on February 17, 2017 between the hours of 8:30AM and 2:30PM the following is observed:

1. No documentation is available for the monthly testing of emergency lighting in March of 2016.

The Maintenance Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Computer-based, self-testing/self-diagnostic battery operated emergency lighting equipment shall be provided.
(2) Not less than once every 30 days, emergency lighting equipment shall automatically perform a test with a duration of a minimum of 30 seconds and a diagnostic routine.
(3) The emergency lighting equipment shall automatically perform annually a test for a minimum of 11?2 hours.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.3(2) and (3).
(5) The computer-based system shall be capable of providing a report of the history of tests and failures at all times. 2012 NFPA 101, 7.9.3.1.3

Review of the following NFPA Standard revealed: The emergency lighting system shall be either continuously in operation or shall be capable of repeated automatic operation without manual intervention. 2012 NFPA 101, 7.9.2.7

Based on observation and staff interview the facility failed to ensure proper separation of hazardous areas from other spaces. This deficient practice would allow for the spread of smoke and fire to travel into the adjacent area, affecting 9 residents in 1 of 16 smoke zones. The facility has a capacity of 25 with a census of 8.

Findings include:

During the survey on February 17, 2017 between the hours of 8:30AM and 2:30PM the following is observed:

1. At 11:30 AM room 206 is being used as a storage room and is not equipped with an automatic closer.


The Maintenance Director was present and acknowledged the findings.


Review of the following NFPA Standard revealed: Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. 2012 NFPA 101, 19.3.2.1

Review of the following NFPA Standard revealed: The doors shall be self-closing or automatic-closing. 2012 NFPA 101, 19.3.2.1.3

Based on observation and staff interview, the facility is not providing a kitchen exhaust hood that is in compliance with NFPA 96. Failure to provide baffles and grease tray has the potential to affect 1 of 16 smoke zones. The facility has a capacity of 25 with a census of 8.

Findings include:

During the survey on February 17, 2017 between the hours of 8:30AM and 2:30PM the following is observed:

1. At 1:00 PM the baffles in the center of the kitchen hood are missing creating a large gap.

2. At 1:02 PM there is no drip tray where the catch rail has been cut away to make room for piping. This would allow grease to drip onto the floor.


The Maintenance Director was present and acknowledged the findings.


Review of the following NFPA Standard revealed: Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service. 2012 NFPA 101, 9.2.3

Based on observation, interview and record review, the facility failed to provide and maintain documentation of annual inspection and testing of the fire alarm system as required by 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 in all 16 smoke zones. The facility has a capacity of 25 with a census of 8.

Findings include:

During the survey on February 17, 2017 between the hours of 8:30AM and 2:30PM the following is observed:

1. During the record review it was revealed that the annual fire alarm inspection testing was 5 days overdue. The most recent annual was performed on 2-12-16.
2. During the entrance interview and record review it was revealed that the fire alarm system is at an age where it is no longer serviceable per the fire alarm inspection report.
Entrance interview and record review revealed that this facility was cited for deficiency #2 on a prior survey and they have asked for and been granted a waiver regarding this condition.



The Maintenance Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: 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

Based on observation and staff interview the facility is not ensuring that room doors 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 0 residents in 1 of 16 smoke zones. The facility has a capacity of 25 with a census of 8.

Findings include:

During the survey on February 17, 2017 between the hours of 8:30AM and 2:30PM the following is observed:

1. At 11:01 AM the clinical manager office door is wedged open.





The Maintenance Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following:
(1) 13?4 in. (44 mm) thick, solid-bonded core wood
(2) Material that resists fire for a minimum of 20 minutes
2012 NFPA 101, 19.3.6.3.1

Review of the following NFPA Standard revealed: Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply:
(1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.
(2) Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7.
2012 NFPA 101, 19.3.6.3.5

Review of the following NFPA Standard revealed: Doors shall not be held open by devices other
than those that release when the door is pushed or pulled. 2012 NFPA 101, 19.3.6.3.10

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 9 residents in 1 of 16 smoke zones. The facility has a capacity of 25 with a census of 8.

Findings include:

During the survey on February 17, 2017 between the hours of 8:30AM and 2:30PM the following is observed:

1. At 10:49 AM the 3rd floor admissions area has a power strip suspended by its wires.

2. At 11:24 AM room 234 has an extension cord in use.

3. At 1:00 PM a refrigerator is plugged into a power strip in physical therapy.

4. At 1:14 PM an open junction box is located in room 107.




The Maintenance Director was present 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

Based on record review and staff interview the facility failed to provide a written fire safety plan that addresses the evacuation of each smoke compartment. The deficient practice may prevent the staff in identifying the need to evacuate occupants beyond the compartment of origin to another smoke compartment, affecting all residents in all 16 smoke zones. The facility has a capacity of 25 with a census of 8.

Findings include:

During the survey on February 17, 2017 between the hours of 8:30AM and 2:30PM the following is observed:

1. Review of the fire evacuation procedures revealed that no plans for individual smoke compartments are available, only a whole building evacuation plan.

2. Review of the emergency procedures revealed that no policies indicate that there is any training or information available to staff on the kitchen class K extinguisher and its specific uses.


The Maintenance Director 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. Employees of health care occupancies shall be instructed in life safety procedures and devices. 2012 NFPA 101, 19.7.1.1-3,8

Review of the following NFPA Standard revealed: For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel.
The basic response required of staff shall include
the following:
(1) Removal of all occupants directly involved with the fire emergency
(2) Transmission of an appropriate fire alarm signal to warn other building occupants and summon staff
(3) Confinement of the effects of the fire by closing doors to isolate the fire area
(4) Relocation of patients as detailed in the health care occupancy's fire safety plan
Fire Safety Plan. 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, 19.7.2.1-2

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 residents in all 16 smoke zones. The facility has a capacity of 25 with a census of 8.

Findings include:

During the survey on February 17, 2017 between the hours of 8:30AM and 2:30PM the following is observed:

1. Review of the fire drills revealed that no scenarios are being documented.

2. Review of the fire drills revealed that no drills were performed for the 3rd shift in the 1st quarter of 2016.

3. Review of the fire drills revealed that no drills were performed for the 3rd shift in the 2nd quarter of 2016.

4. Review of the fire drills revealed that no drills were performed for the 2nd shift in the 3rd quarter of 2016.

5. Review of the fire drills revealed that no drills were performed for the 3rd shift in the 4th quarter of 2016.

6. Review of the fire drills revealed that the two drills performed in the 2nd quarter of 2016 were performed on consecutive days. One was performed in the 3rd shift of 6-28-16 then the next drill was performed the 1st shift of 6-29-16

7. Review of the fire drills revealed that the two drills performed in the 3rd quarter of 2016 were performed on consecutive days. One was performed in the 3rd shift of 8-24-16 then the next drill was performed the 1st shift of 8-25-16.



The Maintenance Director 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

Review of the following NFPA Standard revealed: The basic response required of staff shall include the following:

(1) Removal of all occupants directly involved with the fire Emergency

(2) Transmission of an appropriate fire alarm signal to warn other building occupants and summon staff

(3) Confinement of the effects of the fire by closing doors to isolate the fire area

(4) Relocation of patients as detailed in the health care occupancy's fire safety plan

2012 NFPA 101, 19.7.2.1.2