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Based on observations and interviews during a tour of this facility with the Engineering Supervisor on November 5, 2014, the facility failed to assure that dead end pathways over 30 feet were not in use, potentially affecting all 7 patients and residents.

1. At 11:05 am, it was observed that there was a portion of the hospital corridor near the Administrative Offices that was a dead end and exceeded 30 feet. The Administrator confirmed the finding and indicated that a planned egress was originally in the plans, but was not constructed.

2. At 2:35 pm, it was observed that there was a portion of the DDU that was a dead end and exceeded 30 feet. The DDU could be a separate Board and Care facility and the dead end would be allowable as residents could escape by the windows. However, the windows were inoperable and therefore non-complaint. The Enginering Supervisor confirmed the finding and reviewed alternative egresses.

Based on observations and interviews during a tour of this facility with the Engineering Supervisor on November 5, 2014, the facility failed to assure that the sprinkler system was installed and maintained in accordance with the Life Safety Code and NFPA 13 potentially affecting 1 patient.

1. At 9:55 am, it was observed that the main stairway was missing a sprinkler head on the bottom floor. The Engineering Supervisor confirmed the finding.

Based upon observations on November 5, 2014, the facility failed to assure that the emergency power supply system was installed and maintained with the required testing and maintenance program required by NFPA 99 (Health Care Facilities), NFPA 110 (Standard for Emergency and Standby Power Systems), and NFPA 70 (National Electric Code). This deficienct practice had the potential to affect all 7 residents and patients.

1. At 11:35 am, it was observed that there was no placard or no smoking sign associated with the generator fuel source and a remote stop was not available for the generator.


I. Note: NFPA 99, 1999 Edition:

1. NFPA 99, Chapter 16, "Nursing Homes," 16.3.3.2 Essential electrical distribution shall conform to the Type 2 systems as described in Chapter 3.

2. NFPA 99, Chapter 3, "Electrical Systems," Section 3.5 Essential Electrical Systems - Type 2.
- 3-5.1 Sources (Type 2 EES). - The requirements for sources for Type 2 essential electrical system shall conform to those listed in 3-4.1 (Sources [Type 1 EES]).

II. Note: NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition:

1. NFPA 110, Chapter 2-2 Classification of Emergency Power Supply Systems (EPSS)
2-3.4 Level.
2-2.3.1 - Level 1 defines the most stringent equipment performance requirements for application where failure of equipment to perform could result in loss of human life or serious injuries. All Level 1 equipment shall be permanently installed.

2. NFPA 110, Chapter 6, Routine Maintenance and Operational Testing
(Requirements for Weekly, Monthly, Semi-annually, Annually, and every 2 years are explained.)