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Based on observation and staff interview, the facility failed to provide exit access that is arranged so that exits are readily accessible at all times. The deficient practice renders the exiting obstructed and impeded to a full instant use, affecting patients staff in 1 of 12 smoke zones. The facility has a capacity of 25 and a census of 15 at the time of the survey.

Findings include:

During the survey on August 21, 2018 the following is observed

1.At 10:02 am, Storage of furnishings and maintenance equipment is being stored in the egress back stairwell from the basement.

2.At 2:26 pm, medical carts and soiled linen carts are found to be stored on both sides of the egress corridor of the south patient's wing.

Staff B was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Open space within the exit enclosure shall not be used
for any purpose that has the potential to interfere with egress.
2012 NFPA 101,7.2.2.5.3.1

Based on observation and staff interview, the facility failed to assure that task lighting for medication rooms are arranged to provide the required illumination automatically in the event of any interruption of normal lighting. This deficient practice of allowing lights to be switched off as not to provide emergency lighting. Affecting patients and staff in 1 of 12 smoke zones. The facility has a capacity of 25 and a census of 15 at the time of survey.

During the survey on August 21, 2018 the following is observed

1.At 11:07 am, it is observed the light in the pharmacy is equipped with a light switch this allows power interruption of emergency lighting in the east task room.

Staff B was present and acknowledged the findings.

Review of the following NFPA Standard revealed: The emergency lighting system shall be arranged to provide the required illumination automatically in the event of any interruption of normal lighting due to any of the following:

(1) Failure of a public utility or other outside electrical power supply
(2) Opening of a circuit breaker or fuse
(3) Manual act(s), including accidental opening of a switch controlling normal lighting facilities
2012 NFPA 101, 7.9.2.2

Review of the following NFPA Standard revealed: Task illumination battery charger for battery powered lighting unit(s) and selected receptacles at the generator set and essential transfer switch locations. 2011 NFPA 70, 517.32 (E)

Review of the following NFPA Standard revealed: Delayed-Automatic Connections to Equipment Branch. The following equipment shall be permitted to be connected to the equipment branch and shall be arranged for delayed-automatic connection to the alternate power source:
(1) Task illumination and select receptacles in the following:
(a) Patient care rooms
(b) Medication preparation areas
(c) Pharmacy dispensing areas
(d) Nurses' stations (unless adequately lighted by corridor luminaires)
(2) Supply, return, and exhaust ventilating systems for airborne infectious isolation rooms
(3) Sump pumps and other equipment required to operate for the safety of major apparatus and associated control systems and alarms
(4) Smoke control and stair pressurization systems
(5) Kitchen hood supply or exhaust systems, or both, if required to operate during a fire in or under the hood
2012 NFPA 99, 6.5.2.2.3.3

Based on observation and staff interview the facility failed to ensure that portable fire extinguishers are not mounted 3.5 inches above the floor surface. This deficient practice may prevent the portable fire extinguisher from being readily accessible due to difficulty in retrieving it without a bracket, affecting patient and staff 1 of 12 smoke zones. This facility has a capacity of 25 and a census of 15.

Findings include:

During the tour on August 21, 2018 the following is observed:

1.At 1:40 pm a portable fire extinguisher in the maintenance shop is found to be setting on the floor

Staff B was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Where required by the provisions of another section
of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 2012 101,9.7.4.1

Review of the following NFPA Standard revealed: Portable fire extinguishers having a gross weight of not exceeding 40 pounds shall be installed so that the top is not more than 5 feet above the floor. Extinguishers having a gross weight exceeding 40 pounds shall be installed so that the top is not more than 3.5 feet above the bottom not less than 4 inches above floor. 2010 NFPA 10

Based on observation and staff interviews, the facility fails to maintain smoke barriers doors to self close and resistance the passage of smoke and fire. This deficient practice would cause containment of fire and smoke, affecting patients and staff in 2 of 12 smoke zones. The facility has a capacity of 25 with a census of 15 at the time of survey.

Findings include:

During the survey on August 21, 2018, the following is observed:

1.At 1:45 pm, it is observed that the 2nd floor hall smoke barrier doors to the office area did not completely self close

Staff B was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Doors in smoke barriers shall close the opening, leaving only the minimum clearance necessary for proper operation, and shall be without louvers or grilles. The clearance under the bottom of a new door shall be a maximum of 3?4 in. (19 mm).
2012 NFPA 101, 8.5.4.1

Review of the following NFPA Standard revealed: Where required by Chapters 11 through 43, doors in smoke barriers that are required to be smoke leakage-rated shall comply with the requirements of 8.2.2.4.
2012 NFPA 101,8.5.4.2

Review of the following NFPA Standard revealed: Latching hardware shall be required on doors in smoke barriers, unless specifically exempted by Chapters 11 through 43.
2012 NFPA 101,8.5.4.3

Review of the following NFPA Standard revealed: Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1.
2012 NFPA 101,8.5.4.4

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 19.2.2.2.7.

(2) Latching hardware shall not be required

(3) The doors shall not be required to swing in the direction
of egress travel.
2012 NFPA 101 19.3.7.8

Based on observation and staff interviews, 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 patients and staff in 2 of 12 smoke zones. The facility has a capacity of 25 with a census of 15 at the time of survey.

Findings Include:

During the survey on August 21,2018 the following is observed:

1.At 9:48 am, an open electrical box was found in the medical waste disposal room by clock

Staff B 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

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, 210.23K351

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 and staff in all 12 smoke zones. The facility has a capacity of 25 with a census of 15 at the time of survey.

Findings include:

1.It is observed during record review of the facility's fire drill documentation on August 20, 2018, between 1:30 pm and 3:00 pm. revealed that the facility did not test the fire alarm system the following day of any silent drill.

Staff B was present and acknowledged the findings.

Review of the following NFPA Standard revealed: 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

Review of the following NFPA Standard revealed: 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. 2012 NFPA 101, 19.7.1.6

Review of the following NFPA Standard revealed: Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency. 2012 NFPA 101, 4.7.4*