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Based on observation and interview, the facility failed to maintain the smoke resistive properties of a smoke barrier wall. This potentially exposed residents to a smoke or fire environment. The deficient practice affected two of seven smoke compartments, staff and 1 patient. The facility is licensed for 25 beds and had a census of 7 on the day of survey.

Findings include:

On 04/16/13 between 09:30 a.m. and 10:00 a.m., an approximately one inch by three inch open penetration in the wall above the cross corridor door identified as number 98 and an approximately three inch penetration in the annular space around pipes above the cross corridor door identified as number 90. Interview on 04/16/13 between 09:30 a.m. and 10:00 a.m., with the facility Maintenance Supervisor revealed that the facility was not aware of the unsealed penetrations in the smoke barrier walls.

The findings were acknowledged by the Chief Executive Office and verified by the facility Maintenance Supervisor at the exit interview on 04/16/13.

Actual NFPA Standard: NFPA 101, 19.3.7.3. Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

Actual NFPA Standard: NFPA 101, 8.3.6.1 (1) a. and b. Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected by filling the space between the penetrating item and the smoke barrier with a material that is capable of maintaining the smoke resistance of the smoke barrier or it shall be protected by an approved device that is designed for the specific purpose.

Based on observation, interview, and record review, the facility failed to properly maintain the water based fire protection systems. This has the potential of exposing residents to a fire/smoke environment. The deficient practice affected all smoke compartments, staff, and all patients. The facility is licensed for 25 beds and had a census of 7 on the day of survey.

Findings include:

1.) Observation during record review of the facility's fire sprinkler testing reports for the last 60 month period on 04/15/13 at 2:50 p.m., the facility was unable to provide any documented 5 year internal piping inspection reports of the automatic sprinkler system. Interview with the facility Maintenance Supervisor 04/16/13 at 9:00 a.m., revealed the facility was not aware of the 5 year internal piping inspection requirement.

2.) Observation on 04/16/13 at 10:49 a.m., revealed that data cable and metal clad electric cable were attached to the sprinkler system piping above the ceiling in the PACU Quiet Room. Interview on 04/16/13 at 10:49 a.m., with the facility Maintenance supervisor disclosed the facility was not aware that cables were attached to the fire sprinkler system piping.

The finding was acknowledged by the Chief Executive Officer and verified by the Maintenance Supervisor at the exit interview on 04/16/13.

Actual NFPA Standards:

Item 1) NFPA 25, 10-2.2 Obstruction Prevention.
Systems shall be examined internally for obstructions where conditions exist that could cause obstructed piping. If the condition has not been corrected or the condition is one that could result in obstruction of piping despite any previous flushing procedures that have been performed, the system shall be examined internally for obstructions every 5 years. This investigation shall be accomplished by examining the interior of a dry valve or preaction valve and by removing two cross main flushing connections.

Item 2.) NFPA 13, NFPA 13, 6-1.1.5
Sprinkler piping or hangers shall not be used to support non-system components.

Based on observation and interview, the facility failed to prohibit the use of outlet adapters to provide power to appliances or other equipment in patient care areas. This potentially exposed residents to electrical fire hazard. The deficient practice affected two of seven smoke compartments, staff, and 7 patients. The facility is licensed for 25 beds and had a census of 7 on the day of survey.

Findings include:

Observation on 04/16/13 between 9:00 a.m. and 10:30 a.m., in 22 of 25 patient rooms surveyed, revealed televisions in patient care areas plugged into outlet adapters that were plugged into wall outlets. Interview with the Maintenance Supervisor on 04/16/13 at 9:30 a.m. revealed that the facility was not aware the use of outlet adapters in patient care areas is prohibited.


The finding was acknowledged by the Chief Executive Officer and verified by the Maintenance Supervisor at the exit interview on 04/16/13.

Actual NFPA Standard: NFPA 70, National Electric Code
ARTICLE 517 -- Health Care Facilities
517-18. General Care Areas
(b) Patient Bed Location Receptacles. Each patient bed location shall be provided with a minimum of four receptacles. They shall be permitted to be of the single or duplex types or a combination of both. All receptacles, whether four or more, shall be listed " hospital grade " and so identified. Each receptacle shall be grounded by means of an insulated copper conductor sized in accordance with Table 250-122.

Based on observation and interview, the facility failed to maintain the smoke resistive properties of a smoke barrier wall. This potentially exposed residents to a smoke or fire environment. The deficient practice affected two of seven smoke compartments, staff and 1 patient. The facility is licensed for 25 beds and had a census of 7 on the day of survey.

Findings include:

On 04/16/13 between 09:30 a.m. and 10:00 a.m., an approximately one inch by three inch open penetration in the wall above the cross corridor door identified as number 98 and an approximately three inch penetration in the annular space around pipes above the cross corridor door identified as number 90. Interview on 04/16/13 between 09:30 a.m. and 10:00 a.m., with the facility Maintenance Supervisor revealed that the facility was not aware of the unsealed penetrations in the smoke barrier walls.

The findings were acknowledged by the Chief Executive Office and verified by the facility Maintenance Supervisor at the exit interview on 04/16/13.

Actual NFPA Standard: NFPA 101, 19.3.7.3. Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

Actual NFPA Standard: NFPA 101, 8.3.6.1 (1) a. and b. Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected by filling the space between the penetrating item and the smoke barrier with a material that is capable of maintaining the smoke resistance of the smoke barrier or it shall be protected by an approved device that is designed for the specific purpose.

Based on observation, interview, and record review, the facility failed to properly maintain the water based fire protection systems. This has the potential of exposing residents to a fire/smoke environment. The deficient practice affected all smoke compartments, staff, and all patients. The facility is licensed for 25 beds and had a census of 7 on the day of survey.

Findings include:

1.) Observation during record review of the facility's fire sprinkler testing reports for the last 60 month period on 04/15/13 at 2:50 p.m., the facility was unable to provide any documented 5 year internal piping inspection reports of the automatic sprinkler system. Interview with the facility Maintenance Supervisor 04/16/13 at 9:00 a.m., revealed the facility was not aware of the 5 year internal piping inspection requirement.

2.) Observation on 04/16/13 at 10:49 a.m., revealed that data cable and metal clad electric cable were attached to the sprinkler system piping above the ceiling in the PACU Quiet Room. Interview on 04/16/13 at 10:49 a.m., with the facility Maintenance supervisor disclosed the facility was not aware that cables were attached to the fire sprinkler system piping.

The finding was acknowledged by the Chief Executive Officer and verified by the Maintenance Supervisor at the exit interview on 04/16/13.

Actual NFPA Standards:

Item 1) NFPA 25, 10-2.2 Obstruction Prevention.
Systems shall be examined internally for obstructions where conditions exist that could cause obstructed piping. If the condition has not been corrected or the condition is one that could result in obstruction of piping despite any previous flushing procedures that have been performed, the system shall be examined internally for obstructions every 5 years. This investigation shall be accomplished by examining the interior of a dry valve or preaction valve and by removing two cross main flushing connections.

Item 2.) NFPA 13, NFPA 13, 6-1.1.5
Sprinkler piping or hangers shall not be used to support non-system components.

Based on observation and interview, the facility failed to prohibit the use of outlet adapters to provide power to appliances or other equipment in patient care areas. This potentially exposed residents to electrical fire hazard. The deficient practice affected two of seven smoke compartments, staff, and 7 patients. The facility is licensed for 25 beds and had a census of 7 on the day of survey.

Findings include:

Observation on 04/16/13 between 9:00 a.m. and 10:30 a.m., in 22 of 25 patient rooms surveyed, revealed televisions in patient care areas plugged into outlet adapters that were plugged into wall outlets. Interview with the Maintenance Supervisor on 04/16/13 at 9:30 a.m. revealed that the facility was not aware the use of outlet adapters in patient care areas is prohibited.


The finding was acknowledged by the Chief Executive Officer and verified by the Maintenance Supervisor at the exit interview on 04/16/13.

Actual NFPA Standard: NFPA 70, National Electric Code
ARTICLE 517 -- Health Care Facilities
517-18. General Care Areas
(b) Patient Bed Location Receptacles. Each patient bed location shall be provided with a minimum of four receptacles. They shall be permitted to be of the single or duplex types or a combination of both. All receptacles, whether four or more, shall be listed " hospital grade " and so identified. Each receptacle shall be grounded by means of an insulated copper conductor sized in accordance with Table 250-122.