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Based on observation and staff interviews, the facility failed to assure that the 2 hour separating wall is sealed, failing to provide the proper fire resistance rating, affecting 2 of 7 smoke zones. The facility has a capacity of 25 with a census of 13 at the time of the survey.

Findings Include:

During the tour from 2/10/16 to 2/11/16 it is noted that:

At 2:31 PM on 2/10/16 there is a 1 " x 3 " gap around the conduit penetration in the 2 hour rated wall above the ceiling at the west door of the Clinic.

The maintenance director was present during the findings.

NFPA Standard: Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition. Communicating openings in the fire barriers shall be permitted only in corridors and protected by approved self-closing fire doors. 2000 NFPA 101, 18/19.1.1.4.1 and 18/19.1.1.4.2.

NFPA Standard: Occupied buildings shall meet the minimum construction requirements of the occupancy chapters and NFPA 220. Additions or connected structures of different construction types shall have the ratings and classification based on: separate buildings if a 2-hour or greater vertically-aligned fire barrier wall in accordance with NFPA 221 exists between the buildings, or the least fire-resistive type of construction of the connected portions. 2000 NFPA 101, 8.2.1.

Based on observation and staff interview, the facility is not providing appropriate construction standards as required by the life safety code. A rated ceiling assembly is not provided as required by the building's construction type, which would prevent containment of smoke and/or fire, affecting 1 of 7 smoke zones. The facility has a capacity of 25 with a census of 13 at the time of the survey.


FINDINGS INCLUDE:

During the tour from 2/10/16 to 2/11/16 it is noted that:

At 10:51 AM on 2/10/16 there is a ¾ " hole for a cable penetration in the ER waiting room ceiling above the television.

The maintenance director was present during the findings.


NFPA Standard: Floor-ceiling assemblies and walls used as fire barriers, including supporting construction, shall be of a design that has been tested to meet the conditions of acceptance of NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials. Fire barriers shall be continuous in accordance with 8.2.2.2 per NFPA 101, 8.2.3.1.1. Space between wires and similar building service equipment that pass through fire barriers shall be protected by filling the space with a material that is capable of maintaining the fire resistance of the fire barrier or shall be protected by an approved device that is designed for the specific purpose 2000 NFPA 101, 8.2.3.2.4.2

Based on observation and staff interview the facility fails to maintain smoke barriers to at least one half hour fire resistance and ensure that all penetrations are properly sealed. This deficient practice would prevent containment of fire and smoke, affecting 4 of 7 smoke zones. The facility has a capacity of 25 with a census of 13 at the time of the survey.

Findings Include:

During the tour from 2/10/16 to 2/11/16 it is noted that:

1. At 2:07 PM on 2/10/16 there is a ½ " x 1 " penetration above the ceiling on the west side of the doors in the southwest corridor.
2. At 2:10 PM on 2/10/16 there is a 1 ½ " hole in the barrier above the ceiling on the west side of the barrier doors in the northwest corridor next to room 119.

The maintenance director was present during the findings.

NFPA Standard: Requires smoke walls to have a fire resistance rating of at least a half hour and to be continuous from floor to roof deck and from outside wall to outside wall. 2000 NFPA 101, 19.3.7.3.

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1.

Based on observation and staff interview the facility fails to provide doors that are self-closing or automatically closing in a smoke barrier. The deficient practice of not providing self-closing or automatically 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 1 of 7 smoke zones. The facility has a capacity of 25 with a census of 13 at the time of the survey.

Findings Include:

During the tour from 2/10/16 to 2/11/16 it is noted that:


At 1:32 PM on 2/10/16 the 20 minute rated door to Rehab/Physical Therapy does not latch upon drop test.

The maintenance director was present during the findings.

NFPA Standard: Requires doors in smoke barriers to be self-closing and have at least a 20-minute rating, 2000 NFPA 101, 19.3.7.6.

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 4 of 7 smoke zones. The facility has a capacity of 25 with a census of 13 at the time of the survey.

Findings Include:

During the tour from 2/10/16 to 2/11/16 it is noted that:

1. At 10:49 AM on 2/10/16 the greater than 50 sq. ft. Storage /Electrical room near the ER waiting room is not equipped with a self-closure on the corridor door.
2. At 1:01 PM on 2/10/16 there is damaged rated walls (approx.. 1 ½ " x 24 " on east wall and 1 ½ " x 18 " on the west wall) in the clean utility room.
3. At 1:38 PM on 2/10/16 room 118 is being used for storage (this is not a rated storage room and no self-closure is installed).
4. At 1:47 PM on 2/10/16 the laundry room door has tape over the striker plate and does not latch.

The maintenance director was present during the findings.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1.

NFPA Standard: Protection from any area having a degree of hazard greater than that normal to the general occupancy of the
building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1 hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42. 2000 NFPA 101, 8.4.1.

Based on observation and staff interview, the facility failed to provide means of egress that are maintained free of all obstructions or impediments to a full instant use in case of fire or other emergency. The deficient practice would prevent these exits from being arranged so that they are readily available and accessible, affecting 1 of 7 smoke zones. The facility has a capacity of 25 with a census of 13 at the time of the survey.

Findings Include:

During the tour from 2/10/16 to 2/11/16 it is noted that:

At 11:46 AM on 2/10/16 the emergency exit from the boiler room is blocked with a padlocked chain link gate.

The maintenance director was present during the findings.

NFPA Standard: Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1

NFPA Standard: Exits shall terminate directly at a public way or an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. 2000 NFPA 101, 7.7.1.

Based on records review and staff interview the facility failed to ensure that battery powered emergency lighting is tested for 90 minutes annually and documented. This deficient practice could result in the lights not operating for the minimum required time in the event of an emergency, affecting 7 of 7 smoke zones. The facility has a capacity of 25 with a census of 13 at the time of the survey.
Findings Include:

During the tour from 2/10/16 to 2/11/16 it is noted that:

1. At 1:14 PM on 2/10/16 the Med room is not provided with un interruptible emergency lighting (all lights in room can be turned off by switch).
2. At 1:20 PM on 2/10/16 the emergency light in operating room #2 failed to illuminate when tested.
3. At 1:22 PM on 2/10/16 the emergency light in operating room #1 failed to illuminate when tested.
4. At 11:00 AM on 2/10/16 no annual emergency light testing report for 2016 available during the documentation review.
5. At 11:01 AM on 2/10/16 no monthly emergency light tests reports available after 2/2015.

The maintenance director was present during the findings.

NFPA Standard: A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 and 1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 2000 NFPA 101, 7.9.3 and 7.10.9
NFPA Standard: Task illumination required at medication preparation areas. 1999 NFPA 99, 3-4.2.1, 3-5.2.1, 3-6.2.1

Based on observation, record review and staff interview the facility failed to provide exit signs marking the exit paths. The deficient practice may prevent the occupants of the building to be directed to the exit path and delay egress, affecting 7 of 7 smoke zones. The facility has a capacity of 25 with a census of 13 at the time of the survey.

Findings Include:

During the tour from 2/10/16 to 2/11/16 it is noted that:

1. At 11:04 AM on 2/10/16 no monthly exit sign testing reports available after 2/2015.
2. At 11:06 AM on 2/10/16 no annual exit sign testing report for 2016 available during the documentation review.

The maintenance director was present during the findings.

NFPA Standard: Means of egress shall have signs in accordance with Section 7.10.
Exception: Where the path of egress travel is obvious, signs shall not be required in one-story buildings with an occupant load of fewer than 30 persons. 2000 NFPA 101, 19.2.10.1.

NFPA Standard: Power Source. Where emergency lighting facilities are required by the applicable provisions of Chapters 11 through 42 for individual occupancies, the signs, other than approved self-luminous signs, shall be illuminated by the emergency lighting facilities. The level of illumination of the signs shall be in accordance with 7.10.6.3 or 7.10.7 for the required emergency lighting duration as specified in 7.9.2.1. However, the level of illumination shall be permitted to decline to 60 percent at the end of the emergency lighting duration. 2000 NFPA 101, 7.10.4.

NFPA Standard: Battery-operated electric lights and other types of portable lamps or lanterns shall not be used for primary illumination of means of egress. Battery-operated electric lights shall be permitted to be used as an emergency source to the extent
permitted under Section 7.9. 2000 NFPA 101, 7.8.2.2.

Based on record review and staff interview, the facility is not conducting fire drills as required quarterly on each shift 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 7 of 7 smoke zones. The facility has a capacity of 25 with a census of 13 at the time of the survey.

Findings Include:

During the tour from 2/10/16 to 2/11/16 it is noted that:

At 11:00 AM on 2/10/16 no fire drill documentation available for drills held in March and May or from August 2015 to current.

The maintenance director was present during the findings.

NFPA Standard: Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 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. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 2000 NFPA 101, 19.7.1.2.

Based on observation and staff interview the facility fails to provide a fire alarm system installed according to NFPA 72. The deficient practice of improperly installing manual fire alarm boxes or obstructing their use will delay the initiation of the fire alarm system via these devices, affecting 7 of 7 smoke zones. The facility has a capacity of 25 with a census of 13 at the time of the survey.

Findings Include:

During the tour from 2/10/16 to 2/11/16 it is noted that:

At 11:40 AM on 2/10/16 1 of the 3 Fire Control Panels (located in the boiler room) used to provide building wide detection and notification does not have battery backup.

The maintenance director was present during 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, and NFPA 72. 2000 NFPA 101 section 9.6.1.4.

Based on record review and staff interviews, the facility failed to assure that the sprinkler system is maintained and tested in accordance with the NFPA 13 and NFPA 25. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting 7 of 7 smoke zones. The facility has a capacity of 25 with a census of 13 at the time of the survey.


Findings Include:

During the tour from 2/10/16 to 2/11/16 it is noted that:

1. At 1:45 PM on 2/10/16 there are 4 sprinkler heads that are loaded with dust/lint in the laundry room.
2. At 11:04 AM on 2/10/16 no monthly sprinkler inspection reports available after 2/2015.
3. At 11:06 AM on 2/10/16 no 4th quarter 2015 sprinkler inspection report available during the documentation review.

The maintenance director was present during the findings.

NFPA Standard: Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. 2000 NFPA 101, 9.7.1.1.

NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. 1999 NFPA 13, 12.1.

NFPA Standard: Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. 1998 NFPA 25, 2 2.1.1.

NFPA Standard: Sprinklers shall not be altered in any respect or have any type of ornamentation, paint, or coatings applied after shipment from the place of manufacture. 1998 NFPA 25, 2 4.1.8.

NFPA Standard: Corrective maintenance includes, but is not limited to, replacing loaded, corroded, or painted sprinklers; replacing missing or loose pipe hangers; cleaning clogged fire pump impellers; replacing valve seats and gaskets; restoring heat in areas subject to freezing temperatures where water filled piping is installed; and replacing worn or missing fire hose or nozzles. 1998 NFPA 25, 1-11.3.

Based on observation and staff interview the facility fails to assure fire extinguishers are inspected monthly in accordance with NFPA 10. This deficiency practice fails to ensure that a code compliant fire extinguisher will be in proper working condition when needed in the event of a fire emergency, affecting 1 of 7 smoke zones. The facility has a capacity of 25 with a census of 13 at the time of the survey.

FINDINGS INCLUDE:

During the tour from 2/10/16 to 2/11/16 it is noted that:

Starting at 10:40 AM on 2/10/16 ending at 2:34 PM on 2/10/16 the fire extinguishers throughout the facility did not have the December 2015 monthly check noted on the tags.

The maintenance director was present during the findings.

NFPA Standard: Fire extinguishers shall be inspected when placed in service and thereafter at approximately 30-day intervals per 1998 NFPA 10, 4-3.1

Based on observation, staff interview and record review, the facility failed to ensure that the kitchen range hood is maintained in accordance with NFPA 96. The deficient practice would prevent the system from performing as expected, affecting 1 of 7 smoke zones. The facility has a capacity of 25 with a census of 13 at the time of the survey.

Findings Include:

During the tour from 2/10/16 to 2/11/16 it is noted that:

At 11:15 AM on 2/10/16 the tag on the kitchen hood suppression system states the cylinder is past due for hydro test.

The maintenance director was present during the findings.


NFPA Standard: Wet chemical containers, auxiliary pressure containers, and hose assemblies shall be subjected to a hydrostatic test pressure equal to the marked factory test pressure or the test pressure specified by the manufacturer. No leakage, rupture, or movement of hose couplings shall be permitted. The test procedure shall be in accordance with the manufacturers ' detailed written hydrostatic test instructions. NFPA 17A, 5-5.1

Based on observation, record review and interview, the facility could not provide documentation that curtains and decorations were flame resistant. This deficient practice has the potential of allowing rapid flame spread, affecting 4 of 7 smoke zones. The facility has a capacity of 25 with a census of 13 at the time of the survey.

Findings Include:

During the tour from 2/10/16 to 2/11/16 it is noted that:


1. At 10:57 AM on 2/10/16 the curtains in the patient changing area of X-ray room #1 are not provided with fire retardant label.
2. At 1:04 PM on 2/10/16 the shower curtain in the Bathing room is not provided with a fire retardant label.
3. At 1:05 PM on 2/10/16 the shower curtain in the tub room is not provided with a fire retardant label.
4. At 1:06 PM on 2/10/16 the curtain in room 105 is not provided with a fire retardant label.
5. At 1:42 PM on 2/10/16 the North hall shower room curtain is not provided with a fire retardant label.

The maintenance director was present during the findings.

NFPA Standard: Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films. 2000 NFPA 101, 10.3.1.

Based on observation and staff interview, the facility failed to assure that medical gas storage is protected in accordance with NFPA 99, including the storage of combustible items within the location of the oxygen storage area. This deficient practice fails to ensure the proper storage of combustible items, affecting 2 of 7 smoke zones. The facility has a capacity of 25 with a census of 13 at the time of the survey.

Findings Include:

During the tour from 2/10/16 to 2/11/16 it is noted that:

1. At 11:18 AM on 2/10/16 there is an unsecured oxygen cylinder in the oxygen storage room.
2. At 1:05 PM on 2/10/16 there is an unsecured oxygen cylinder in the tub room.

The maintenance director was present during the findings.
NFPA Standard: Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation. 1999 NFPA 99, 4.3.1.1.2

Based on record review and staff interview the facility failed to conduct and properly document testing, inspection, maintenance and installation of the generator in accordance with NFPA 99 and NFPA 110. This deficient practice fails to ensure that the generator will not fail when needed in the event of an emergency, affecting 7 of 7 smoke zones. The facility has a capacity of 25 with a census of 13 at the time of the survey.

Findings Include:

During the tour from 2/10/16 to 2/11/16 it is noted that:

1. At 1:49 PM on 2/10/16 there is no emergency remote stop provided for the generator.
2. At 9:28 AM on 2/10/16 no monthly generator inspection documentation available from 2/15 to 9/15.


The maintenance director was present during the findings.


NFPA Standard: Level 1 and level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes. 1999 NFPA 110, 6.4.1 and 6.4.2
NFPA Standard: Generator sets or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures. 1999 NFPA 99, 3-4.4.1.1
NFPA Standard: All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building. 1999 NFPA 110 3-5.5.6*
NFPA Standard: For Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified. 1999 NFPA 110 A-3-5.5.6

Based on observation and staff interview, the facility fails to assure that all electrical wiring and equipment is installed and maintained in accordance with the requirements NFPA 70. This deficient practice increases the risk of an electrical fire, affecting 5 of 7 smoke zones. The facility has a capacity of 25 with a census of 13 at the time of the survey.

FINDINGS INCLUDE:

During the tour from 2/10/16 to 2/11/16 it is noted that:
1. At 10:50 AM on 2/10/16 the electrical panel is blocked with storage in the storage/electrical room next to the ER waiting room.
2. At 10:56 AM on 2/10/16 there is an open junction box on the south wall in x-ray room #1.
3. At 11:03 AM on 2/10/16 there is a microwave powered by a power strip in the doctors lounge.
4. At 11:34 AM on 2/10/16 in the boiler room there is an open junction box on the southeast wall and an open conduit elbow on the south wall.
5. At 11:37 AM on 2/10/16 there is an open breaker space in the east electrical panel on the north wall in the boiler room.
6. At 11:52 AM on 2/10/16 there is an open junction box on the sprinkler riser in the maintenance office.
7. At 11:56 AM on 2/10/16 there are daisy chained power strips in the medical records room.
8. At 12:50 PM on 2/10/16 there are daisy chained power strips in the health information office.
9. At 12:56 PM on 2/10/16 there is a multi-plug adapter on the north wall in the mail room.
10. At 1:11 PM on 2/10/16 there are daisy chained power strips in the southeast corner of the nurses station.
11. At 1:16 PM on 2/10/16 there is a microwave powered by a power strip in the nurses reporting room.
12. At 1:30 PM on 2/10/16 there is a microwave and water cooler powered by a power strip in the physical therapy room.
13. At 1:34 PM on 2/10/16 there are daisy chained power strips in the pharmacy office.
14. At 1:36 PM on 2/10/16 there are daisy chained power strips in the respiratory therapy office.
15. At 2:09 PM on 2/10/16 in the southwest corridor there is an open junction box above the ceiling in front of the housekeeping closet.
16. At 2:26 PM on 2/10/16 there is an open junction box above the ceiling in the corridor in front of the east outreach clinic door.

The maintenance director was present during the findings.
NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8
NFPA standard: All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 379-22, Exception. 1999 NFPA 70, 370-28(3)(c).
NFPA Standard: 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 (a) through (d) and as summarized in Section 210-24. A 15- or 20-ampere branch circuit shall be permitted to supply lighting units or other utilization equipment, or a combination of both. The rating of any one cord- and plug-connected utilization equipment shall not exceed 80 percent of the branch-circuit ampere rating. The total rating of utilization equipment fastened in place, other than lighting fixtures, shall not exceed 50 percent of the branch-circuit ampere rating where lighting units, cord- and plug-connected utilization equipment not fastened in place, or both, are also supplied. 1999 NFPA 70, 210-23

Based on observation and staff interviews, the facility failed to assure that the 2 hour separating wall is sealed, failing to provide the proper fire resistance rating, affecting 2 of 7 smoke zones. The facility has a capacity of 25 with a census of 13 at the time of the survey.

Findings Include:

During the tour from 2/10/16 to 2/11/16 it is noted that:

At 2:31 PM on 2/10/16 there is a 1 " x 3 " gap around the conduit penetration in the 2 hour rated wall above the ceiling at the west door of the Clinic.

The maintenance director was present during the findings.

NFPA Standard: Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition. Communicating openings in the fire barriers shall be permitted only in corridors and protected by approved self-closing fire doors. 2000 NFPA 101, 18/19.1.1.4.1 and 18/19.1.1.4.2.

NFPA Standard: Occupied buildings shall meet the minimum construction requirements of the occupancy chapters and NFPA 220. Additions or connected structures of different construction types shall have the ratings and classification based on: separate buildings if a 2-hour or greater vertically-aligned fire barrier wall in accordance with NFPA 221 exists between the buildings, or the least fire-resistive type of construction of the connected portions. 2000 NFPA 101, 8.2.1.

Based on observation and staff interview, the facility is not providing appropriate construction standards as required by the life safety code. A rated ceiling assembly is not provided as required by the building's construction type, which would prevent containment of smoke and/or fire, affecting 1 of 7 smoke zones. The facility has a capacity of 25 with a census of 13 at the time of the survey.


FINDINGS INCLUDE:

During the tour from 2/10/16 to 2/11/16 it is noted that:

At 10:51 AM on 2/10/16 there is a ¾ " hole for a cable penetration in the ER waiting room ceiling above the television.

The maintenance director was present during the findings.


NFPA Standard: Floor-ceiling assemblies and walls used as fire barriers, including supporting construction, shall be of a design that has been tested to meet the conditions of acceptance of NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials. Fire barriers shall be continuous in accordance with 8.2.2.2 per NFPA 101, 8.2.3.1.1. Space between wires and similar building service equipment that pass through fire barriers shall be protected by filling the space with a material that is capable of maintaining the fire resistance of the fire barrier or shall be protected by an approved device that is designed for the specific purpose 2000 NFPA 101, 8.2.3.2.4.2

Based on observation and staff interview the facility fails to maintain smoke barriers to at least one half hour fire resistance and ensure that all penetrations are properly sealed. This deficient practice would prevent containment of fire and smoke, affecting 4 of 7 smoke zones. The facility has a capacity of 25 with a census of 13 at the time of the survey.

Findings Include:

During the tour from 2/10/16 to 2/11/16 it is noted that:

1. At 2:07 PM on 2/10/16 there is a ½ " x 1 " penetration above the ceiling on the west side of the doors in the southwest corridor.
2. At 2:10 PM on 2/10/16 there is a 1 ½ " hole in the barrier above the ceiling on the west side of the barrier doors in the northwest corridor next to room 119.

The maintenance director was present during the findings.

NFPA Standard: Requires smoke walls to have a fire resistance rating of at least a half hour and to be continuous from floor to roof deck and from outside wall to outside wall. 2000 NFPA 101, 19.3.7.3.

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1.

Based on observation and staff interview the facility fails to provide doors that are self-closing or automatically closing in a smoke barrier. The deficient practice of not providing self-closing or automatically 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 1 of 7 smoke zones. The facility has a capacity of 25 with a census of 13 at the time of the survey.

Findings Include:

During the tour from 2/10/16 to 2/11/16 it is noted that:


At 1:32 PM on 2/10/16 the 20 minute rated door to Rehab/Physical Therapy does not latch upon drop test.

The maintenance director was present during the findings.

NFPA Standard: Requires doors in smoke barriers to be self-closing and have at least a 20-minute rating, 2000 NFPA 101, 19.3.7.6.

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 4 of 7 smoke zones. The facility has a capacity of 25 with a census of 13 at the time of the survey.

Findings Include:

During the tour from 2/10/16 to 2/11/16 it is noted that:

1. At 10:49 AM on 2/10/16 the greater than 50 sq. ft. Storage /Electrical room near the ER waiting room is not equipped with a self-closure on the corridor door.
2. At 1:01 PM on 2/10/16 there is damaged rated walls (approx.. 1 ½ " x 24 " on east wall and 1 ½ " x 18 " on the west wall) in the clean utility room.
3. At 1:38 PM on 2/10/16 room 118 is being used for storage (this is not a rated storage room and no self-closure is installed).
4. At 1:47 PM on 2/10/16 the laundry room door has tape over the striker plate and does not latch.

The maintenance director was present during the findings.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1.

NFPA Standard: Protection from any area having a degree of hazard greater than that normal to the general occupancy of the
building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1 hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42. 2000 NFPA 101, 8.4.1.

Based on observation and staff interview, the facility failed to provide means of egress that are maintained free of all obstructions or impediments to a full instant use in case of fire or other emergency. The deficient practice would prevent these exits from being arranged so that they are readily available and accessible, affecting 1 of 7 smoke zones. The facility has a capacity of 25 with a census of 13 at the time of the survey.

Findings Include:

During the tour from 2/10/16 to 2/11/16 it is noted that:

At 11:46 AM on 2/10/16 the emergency exit from the boiler room is blocked with a padlocked chain link gate.

The maintenance director was present during the findings.

NFPA Standard: Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1

NFPA Standard: Exits shall terminate directly at a public way or an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. 2000 NFPA 101, 7.7.1.

Based on records review and staff interview the facility failed to ensure that battery powered emergency lighting is tested for 90 minutes annually and documented. This deficient practice could result in the lights not operating for the minimum required time in the event of an emergency, affecting 7 of 7 smoke zones. The facility has a capacity of 25 with a census of 13 at the time of the survey.
Findings Include:

During the tour from 2/10/16 to 2/11/16 it is noted that:

1. At 1:14 PM on 2/10/16 the Med room is not provided with un interruptible emergency lighting (all lights in room can be turned off by switch).
2. At 1:20 PM on 2/10/16 the emergency light in operating room #2 failed to illuminate when tested.
3. At 1:22 PM on 2/10/16 the emergency light in operating room #1 failed to illuminate when tested.
4. At 11:00 AM on 2/10/16 no annual emergency light testing report for 2016 available during the documentation review.
5. At 11:01 AM on 2/10/16 no monthly emergency light tests reports available after 2/2015.

The maintenance director was present during the findings.

NFPA Standard: A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 and 1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 2000 NFPA 101, 7.9.3 and 7.10.9
NFPA Standard: Task illumination required at medication preparation areas. 1999 NFPA 99, 3-4.2.1, 3-5.2.1, 3-6.2.1

Based on observation, record review and staff interview the facility failed to provide exit signs marking the exit paths. The deficient practice may prevent the occupants of the building to be directed to the exit path and delay egress, affecting 7 of 7 smoke zones. The facility has a capacity of 25 with a census of 13 at the time of the survey.

Findings Include:

During the tour from 2/10/16 to 2/11/16 it is noted that:

1. At 11:04 AM on 2/10/16 no monthly exit sign testing reports available after 2/2015.
2. At 11:06 AM on 2/10/16 no annual exit sign testing report for 2016 available during the documentation review.

The maintenance director was present during the findings.

NFPA Standard: Means of egress shall have signs in accordance with Section 7.10.
Exception: Where the path of egress travel is obvious, signs shall not be required in one-story buildings with an occupant load of fewer than 30 persons. 2000 NFPA 101, 19.2.10.1.

NFPA Standard: Power Source. Where emergency lighting facilities are required by the applicable provisions of Chapters 11 through 42 for individual occupancies, the signs, other than approved self-luminous signs, shall be illuminated by the emergency lighting facilities. The level of illumination of the signs shall be in accordance with 7.10.6.3 or 7.10.7 for the required emergency lighting duration as specified in 7.9.2.1. However, the level of illumination shall be permitted to decline to 60 percent at the end of the emergency lighting duration. 2000 NFPA 101, 7.10.4.

NFPA Standard: Battery-operated electric lights and other types of portable lamps or lanterns shall not be used for primary illumination of means of egress. Battery-operated electric lights shall be permitted to be used as an emergency source to the extent
permitted under Section 7.9. 2000 NFPA 101, 7.8.2.2.

Based on record review and staff interview, the facility is not conducting fire drills as required quarterly on each shift 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 7 of 7 smoke zones. The facility has a capacity of 25 with a census of 13 at the time of the survey.

Findings Include:

During the tour from 2/10/16 to 2/11/16 it is noted that:

At 11:00 AM on 2/10/16 no fire drill documentation available for drills held in March and May or from August 2015 to current.

The maintenance director was present during the findings.

NFPA Standard: Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 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. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 2000 NFPA 101, 19.7.1.2.

Based on observation and staff interview the facility fails to provide a fire alarm system installed according to NFPA 72. The deficient practice of improperly installing manual fire alarm boxes or obstructing their use will delay the initiation of the fire alarm system via these devices, affecting 7 of 7 smoke zones. The facility has a capacity of 25 with a census of 13 at the time of the survey.

Findings Include:

During the tour from 2/10/16 to 2/11/16 it is noted that:

At 11:40 AM on 2/10/16 1 of the 3 Fire Control Panels (located in the boiler room) used to provide building wide detection and notification does not have battery backup.

The maintenance director was present during 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, and NFPA 72. 2000 NFPA 101 section 9.6.1.4.

Based on record review and staff interviews, the facility failed to assure that the sprinkler system is maintained and tested in accordance with the NFPA 13 and NFPA 25. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting 7 of 7 smoke zones. The facility has a capacity of 25 with a census of 13 at the time of the survey.


Findings Include:

During the tour from 2/10/16 to 2/11/16 it is noted that:

1. At 1:45 PM on 2/10/16 there are 4 sprinkler heads that are loaded with dust/lint in the laundry room.
2. At 11:04 AM on 2/10/16 no monthly sprinkler inspection reports available after 2/2015.
3. At 11:06 AM on 2/10/16 no 4th quarter 2015 sprinkler inspection report available during the documentation review.

The maintenance director was present during the findings.

NFPA Standard: Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. 2000 NFPA 101, 9.7.1.1.

NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. 1999 NFPA 13, 12.1.

NFPA Standard: Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. 1998 NFPA 25, 2 2.1.1.

NFPA Standard: Sprinklers shall not be altered in any respect or have any type of ornamentation, paint, or coatings applied after shipment from the place of manufacture. 1998 NFPA 25, 2 4.1.8.

NFPA Standard: Corrective maintenance includes, but is not limited to, replacing loaded, corroded, or painted sprinklers; replacing missing or loose pipe hangers; cleaning clogged fire pump impellers; replacing valve seats and gaskets; restoring heat in areas subject to freezing temperatures where water filled piping is installed; and replacing worn or missing fire hose or nozzles. 1998 NFPA 25, 1-11.3.

Based on observation and staff interview the facility fails to assure fire extinguishers are inspected monthly in accordance with NFPA 10. This deficiency practice fails to ensure that a code compliant fire extinguisher will be in proper working condition when needed in the event of a fire emergency, affecting 1 of 7 smoke zones. The facility has a capacity of 25 with a census of 13 at the time of the survey.

FINDINGS INCLUDE:

During the tour from 2/10/16 to 2/11/16 it is noted that:

Starting at 10:40 AM on 2/10/16 ending at 2:34 PM on 2/10/16 the fire extinguishers throughout the facility did not have the December 2015 monthly check noted on the tags.

The maintenance director was present during the findings.

NFPA Standard: Fire extinguishers shall be inspected when placed in service and thereafter at approximately 30-day intervals per 1998 NFPA 10, 4-3.1

Based on observation, staff interview and record review, the facility failed to ensure that the kitchen range hood is maintained in accordance with NFPA 96. The deficient practice would prevent the system from performing as expected, affecting 1 of 7 smoke zones. The facility has a capacity of 25 with a census of 13 at the time of the survey.

Findings Include:

During the tour from 2/10/16 to 2/11/16 it is noted that:

At 11:15 AM on 2/10/16 the tag on the kitchen hood suppression system states the cylinder is past due for hydro test.

The maintenance director was present during the findings.


NFPA Standard: Wet chemical containers, auxiliary pressure containers, and hose assemblies shall be subjected to a hydrostatic test pressure equal to the marked factory test pressure or the test pressure specified by the manufacturer. No leakage, rupture, or movement of hose couplings shall be permitted. The test procedure shall be in accordance with the manufacturers ' detailed written hydrostatic test instructions. NFPA 17A, 5-5.1

Based on observation, record review and interview, the facility could not provide documentation that curtains and decorations were flame resistant. This deficient practice has the potential of allowing rapid flame spread, affecting 4 of 7 smoke zones. The facility has a capacity of 25 with a census of 13 at the time of the survey.

Findings Include:

During the tour from 2/10/16 to 2/11/16 it is noted that:


1. At 10:57 AM on 2/10/16 the curtains in the patient changing area of X-ray room #1 are not provided with fire retardant label.
2. At 1:04 PM on 2/10/16 the shower curtain in the Bathing room is not provided with a fire retardant label.
3. At 1:05 PM on 2/10/16 the shower curtain in the tub room is not provided with a fire retardant label.
4. At 1:06 PM on 2/10/16 the curtain in room 105 is not provided with a fire retardant label.
5. At 1:42 PM on 2/10/16 the North hall shower room curtain is not provided with a fire retardant label.

The maintenance director was present during the findings.

NFPA Standard: Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films. 2000 NFPA 101, 10.3.1.

Based on observation and staff interview, the facility failed to assure that medical gas storage is protected in accordance with NFPA 99, including the storage of combustible items within the location of the oxygen storage area. This deficient practice fails to ensure the proper storage of combustible items, affecting 2 of 7 smoke zones. The facility has a capacity of 25 with a census of 13 at the time of the survey.

Findings Include:

During the tour from 2/10/16 to 2/11/16 it is noted that:

1. At 11:18 AM on 2/10/16 there is an unsecured oxygen cylinder in the oxygen storage room.
2. At 1:05 PM on 2/10/16 there is an unsecured oxygen cylinder in the tub room.

The maintenance director was present during the findings.
NFPA Standard: Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation. 1999 NFPA 99, 4.3.1.1.2

Based on record review and staff interview the facility failed to conduct and properly document testing, inspection, maintenance and installation of the generator in accordance with NFPA 99 and NFPA 110. This deficient practice fails to ensure that the generator will not fail when needed in the event of an emergency, affecting 7 of 7 smoke zones. The facility has a capacity of 25 with a census of 13 at the time of the survey.

Findings Include:

During the tour from 2/10/16 to 2/11/16 it is noted that:

1. At 1:49 PM on 2/10/16 there is no emergency remote stop provided for the generator.
2. At 9:28 AM on 2/10/16 no monthly generator inspection documentation available from 2/15 to 9/15.


The maintenance director was present during the findings.


NFPA Standard: Level 1 and level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes. 1999 NFPA 110, 6.4.1 and 6.4.2
NFPA Standard: Generator sets or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures. 1999 NFPA 99, 3-4.4.1.1
NFPA Standard: All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building. 1999 NFPA 110 3-5.5.6*
NFPA Standard: For Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified. 1999 NFPA 110 A-3-5.5.6

Based on observation and staff interview, the facility fails to assure that all electrical wiring and equipment is installed and maintained in accordance with the requirements NFPA 70. This deficient practice increases the risk of an electrical fire, affecting 5 of 7 smoke zones. The facility has a capacity of 25 with a census of 13 at the time of the survey.

FINDINGS INCLUDE:

During the tour from 2/10/16 to 2/11/16 it is noted that:
1. At 10:50 AM on 2/10/16 the electrical panel is blocked with storage in the storage/electrical room next to the ER waiting room.
2. At 10:56 AM on 2/10/16 there is an open junction box on the south wall in x-ray room #1.
3. At 11:03 AM on 2/10/16 there is a microwave powered by a power strip in the doctors lounge.
4. At 11:34 AM on 2/10/16 in the boiler room there is an open junction box on the southeast wall and an open conduit elbow on the south wall.
5. At 11:37 AM on 2/10/16 there is an open breaker space in the east electrical panel on the north wall in the boiler room.
6. At 11:52 AM on 2/10/16 there is an open junction box on the sprinkler riser in the maintenance office.
7. At 11:56 AM on 2/10/16 there are daisy chained power strips in the medical records room.
8. At 12:50 PM on 2/10/16 there are daisy chained power strips in the health information office.
9. At 12:56 PM on 2/10/16 there is a multi-plug adapter on the north wall in the mail room.
10. At 1:11 PM on 2/10/16 there are daisy chained power strips in the southeast corner of the nurses station.
11. At 1:16 PM on 2/10/16 there is a microwave powered by a power strip in the nurses reporting room.
12. At 1:30 PM on 2/10/16 there is a microwave and water cooler powered by a power strip in the physical therapy room.
13. At 1:34 PM on 2/10/16 there are daisy chained power strips in the pharmacy office.
14. At 1:36 PM on 2/10/16 there are daisy chained power strips in the respiratory therapy office.
15. At 2:09 PM on 2/10/16 in the southwest corridor there is an open junction box above the ceiling in front of the housekeeping closet.
16. At 2:26 PM on 2/10/16 there is an open junction box above the ceiling in the corridor in front of the east outreach clinic door.

The maintenance director was present during the findings.
NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8
NFPA standard: All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 379-22, Exception. 1999 NFPA 70, 370-28(3)(c).
NFPA Standard: 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 (a) through (d) and as summarized in Section 210-24. A 15- or 20-ampere branch circuit shall be permitted to supply lighting units or other utilization equipment, or a combination of both. The rating of any one cord- and plug-connected utilization equipment shall not exceed 80 percent of the branch-circuit ampere rating. The total rating of utilization equipment fastened in place, other than lighting fixtures, shall not exceed 50 percent of the branch-circuit ampere rating where lighting units, cord- and plug-connected utilization equipment not fastened in place, or both, are also supplied. 1999 NFPA 70, 210-23