Davis County Hospital

“42 CFR 483.90(a) Davis County Hospital was found to be NOT in compliance with the requirements for participating in Medicare/Medicaid at 42 CFR 482.41(b), Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101 - 2012 edition. Davis County Hospital is a one-story building that was built in 1950. The building is composed of Type II (111) construction. The facility is fully sprinklered and there is supervised smoke detection located in the corridors, resident rooms and spaces open to the corridors. The facility has 25 certified beds. At the time of survey, the census was 2. The requirement at 42 CFR 485.623(d) is NOT MET as evidence by:”

“Building Construction Type and Height CFR(s): NFPA 101 Building Construction Type and Height 2012 EXISTING Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7 19.1.6.4, 19.1.6.5 Construction Type 1 I (442), I (332), II (222) Any number of stories non-sprinklered and sprinklered 2 II (111) One story non-sprinklered Maximum 3 stories sprinklered 3 II (000) Not allowed non-sprinklered 4 III (211) Maximum 2 stories sprinklered 5 IV (2HH) 6 V (111) 7 III (200) Not allowed non-sprinklered 8 V (000) Maximum 1 story sprinklered Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5) Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate. This Standard is not met as evidenced by: 49482 Based on observation and interview, the facility failed to maintain minimum construction requirements in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.1.6), 2012 Edition. This facility has a capacity of 25 and a census of 2. Finding include: Observation and interview on 7/7/25, at approximately 11:05 a.m., revealed the facility failed to maintain the ceiling in the IT Switch Gear Room. Three two inch penetrations were observed in the ceiling. Maintenance Staff verified these observations at the time of the survey process.”

“Egress Doors CFR(s): NFPA 101 Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 This Standard is not met as evidenced by: 49482 Based on observation, interview and record review, the facility did not assure that all doors in a means of egress are limited to one locking device in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.2.2.2.6(2)/19.2.2.2.6(2). The doors allow access to a public way (a street or similar area open to the outside air and dedicated to public use). Visitors, staff and residents use these paths in the event of an emergency evacuation and this deficient practice affected all occupants in the Senior Life Solutions building. Findings include: Observation on 7/7/25, at approximately 12:44 p.m., revealed the following doors had two locking devices (deadbolt locks) on the doors: 1. West Exit Door. 2. East Exit Door. 3. North Exit Door. Maintenance Staff confirmed the observations and findings at the times of discovery.”

“Aisle, Corridor, or Ramp Width CFR(s): NFPA 101 Aisle, Corridor or Ramp Width 2012 EXISTING The width of aisles or corridors (clear or unobstructed) serving as exit access shall be at least 4 feet and maintained to provide the convenient removal of nonambulatory patients on stretchers, except as modified by 19.2.3.4, exceptions 1-5. 19.2.3.4, 19.2.3.5 This Standard is not met as evidenced by: 49482 Based on observation and interview, the facility is not providing a corridor arranged with clear or unobstructed exit access to the convenient removal of non-ambulatory persons carried on stretchers in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 19.2.3.5. This deficient practice affects all residents, staff, and visitors that my need to be evacuated from the Old West Wing. This facility had a capacity of 25 with a census of 2 residents at the time of the survey. Findings include: Observation and interview on 7/7/25, at approximately 11:20 a.m., revealed an excess of storage in the Old West Wing Hallway that protruded into the corridor. Maintenance Staff confirmed this observation at the time of the survey.”

“Discharge from Exits CFR(s): NFPA 101 Discharge from Exits Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface. 18.2.7, 19.2.7 This Standard is not met as evidenced by: 49482 Based on observation and interview, the facility failed to maintain exit doors in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-7.2.4), 2012 Edition. This deficient practice affects all residents, staff, and visitors in the Senior Life Solutions Building. Findings include: Observation and interview on 7/7/25 at approximately 12:44 p.m., revealed the North, West, and East Exit Doors leading to the outside, in the Senior Life Solutions Building, did not swing in the direction of egress. Maintenance Staff confirmed these findings at the time of discovery.”

“Exit Signage CFR(s): NFPA 101 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.) This Standard is not met as evidenced by: 49482 Based on observation and interview, the facility failed to maintain exit signage in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-7.10.5.1), 2012 Edition. This deficient practice affects all residents, staff, and visitors in the North Ambulance Garage and the East Ambulance Garage. This facility has a capacity of 25 and a census of 2. Findings include: Observation and interview on 7/7/25 revealed the following: 1. At approximately 11:46 a.m., revealed the North Ambulance Garage did not have an Emergency Exit Sign. 2. At approximately 11:27 a.m., revealed the East Ambulance Garage did not have an Emergency Exit Sign. Administrative Staff and Maintenance Staff confirmed the findings at the time of discovery.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 49482 Based on observation and interview, the facility failed to provide self-closing devices on doors to hazardous areas in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.3.2.1/19.3.2.1.3 and 8.7. This deficient practice would prevent self-closing of doors when released to self-closing action. This facility had a capacity of 25 and a census of 2 residents at the time of the survey. Findings include: Observations on 7/7/25 revealed the following: 1. At approximately 11:29 a.m., revealed the South End West Storage Room was not equipped with a self-closing device. 2. At approximately 11:38 a.m., revealed the Medical Imaging Storage Room was equipped with a self-closing device that had been disconnected. 3. At approximately 12:21 p.m., revealed the E.V.S. Storage Room door was not equipped with a self-closing device. Maintenance Staff confirmed the observation at the time of discovery.”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 49482 Based on interview and record review, the facility failed to protect the range hood in accordance with National Fire Protection Association (NFPA) 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition, 11.2.1 by having them inspected and tested every six months. This facility had a capacity of 25 and a census of 2 residents at the time of the survey. Findings include: Record review conducted on 7/7/25, at approximately 12:31 p.m., revealed this facility was unable to provide documentation for their semi-annual Hood Suppression System inspection. This deficient practice was confirmed by Maintenance Staff at the time of exit.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 49482 Based on observation, record review and interview, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, 5.2.1.1.2, by ensuring sprinklers were replaced if corroded. This deficient practice of failing to provide prompt correction of deficiencies did not ensure proper operation and prompt repair of the system. This affected all staff and residents. This facility has a capacity of 25 and a census of 2 residents at the time of the survey. Findings include: Observation and interview on 7/7/25, revealed the following: 1. At approximately 11:47 a.m., revealed one soiled Sprinkler Head in E.R Exam Room 3. 2. At approximately 12:31 p.m., revealed the facility was unable to provide documentation for their most recent Sprinkler inspection. This deficient practice was confirmed by Maintenance Staff at the time of discovery.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 49482 Based on observation and interview, the facility failed to ensure that smoke barriers are free of penetrations which would prevent the passage of smoke to an adjacent smoke compartment in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-8.5.6.2), 2012 Edition. This deficient practice affects all residents, staff, and visitors in the South End West Storage Room and the Accounting Records Storage Room. This facility has a capacity of 25 and a census of 2. Findings include: Observation and interview on 7/7/25 revealed the following: 1. At approximately 11:29 a.m., revealed the South End West Hall Storage Room had ceiling tiles missing. 2. At approximately 11:10 a.m., revealed the Accounting Records Room had ceiling tiles missing. Maintenance Staff and Administrative Staff confirmed these findings at time of discovery.”

“Evacuation and Relocation Plan CFR(s): NFPA 101 Evacuation and Relocation Plan There is a written plan for the protection of all patients and for their evacuation in the event of an emergency. Employees are periodically instructed and kept informed with their duties under the plan, and a copy of the plan is readily available with telephone operator or with security. The plan addresses the basic response required of staff per 18/19.7.2.1.2 and provides for all of the fire safety plan components per 18/19.2.2. 18.7.1.1 through 18.7.1.3, 18.7.2.1.2, 18.7.2.2, 18.7.2.3, 19.7.1.1 through 19.7.1.3, 19.7.2.1.2, 19.7.2.2, 19.7.2.3 This Standard is not met as evidenced by: 49482 Based on interview and record review, the facility failed to provide a complete fire plan in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.7.1/19.7.1 and 18.7.2/19.7.2. The fire plan also did not include information on the range hood and how to operate it. The deficient practice affected all smoke zones and all occupants. This facility had a capacity of 25 and a census of 2 residents at the time of the survey. Findings include: Record review on 7/7/25 at approximately 10:36 a.m., of the Facilities Emergency Plan and Procedures revealed it did not address information about the range hood an how to operate it. Administrative Staff and Maintenance Staff confirmed the findings at the time of exit.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 49482 Based on record review and interview, the facility failed to adequately document and hold fire drills under varied conditions at different times of the day in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.7.1.6/19.7.1.6 for four of four quarters reviewed. The documentation did not show the drills have been held as required, including varying conditions (such as timing). This had the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This facility had a capacity of 25 and a census of 2 residents at the time of the survey. Findings include: Record review on 7/7/25, at approximately 9:49 a.m., of the facility fire drill documentation conducted during 2024/2025 revealed the following: 1. Three of four second shift drills were conducted at 10:00 a.m., 9:30 a.m. and 9:26 a.m. Results of the record review were acknowledged by Administrative Staff and Maintenance Staff at the time of exit.”