Henry County Health Center

“42 CFR 483.90(a) Henry County Health Center Hospital was found to be NOT in compliance with the requirements for participating in Medicare/Medicaid at 42 CFR 483.90(a), Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101 - 2012 edition. Henry County Health Center Hospital is a three-story building of Type 1 (332) construction that was built in 2004. The building is partially sprinklered and there is supervised smoke detection located in the corridors and spaces open to the corridors. Resident rooms have smoke detectors that are connected to the nurse call system. The facility has 25 certified beds. At the time of survey, the census was 8. The requirement at 42 CFR 483.90(a) is NOT MET as evidence by:”

“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, affecting all occupants in the First Floor CS Pharmacy. This facility had a capacity of 25 and a census of 8 residents at the time of the survey. Findings include: Observations on 1/29/25 at approximately 12:30 p.m., revealed the First Floor CS Pharmacy Housekeeping Room (1120) was not equipped with a self-closing device. Maintenance Staff confirmed the observation at the time of discovery.”

“Fire Alarm - Control Functions CFR(s): NFPA 101 Fire Alarm - Control Functions The fire alarm automatically activates required control functions and is provided with an alternative power supply in accordance with NFPA 72. 18.3.4.4, 19.3.4.4, 9.6.1, 9.6.5, NFPA 72 This Standard is not met as evidenced by: 49482 Based on observation and interview, the facility failed to assure that when the fire alarm is activated it automatically activates the required control functions and is provided with an alternate power supply in accordance with NFPA 72. Findings include: Observation on 1/29/25 at approximately 1:08 p.m., revealed the double doors located at “Hallway at Lab” and the door to “HEC” (AD101) did not automatically activate and close when the fire alarm system was tested. This deficient practice was confirmed by Maintenance staff at time of survey.”

“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 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 deficient practice affects all occupants in the first floor Kitchen area. This facility has a capacity of 25 and a census of 8 residents at the time of the survey. Findings include: Record review and observations on 1/29/25 at approximately 12:27 p.m., revealed five Sprinkler heads located in the First Floor Kitchen area were soiled with corrosion and a buildup of dust and debris. This deficient practice was confirmed by Maintenance Staff at the survey.”

“Sprinkler System - Out of Service CFR(s): NFPA 101 Sprinkler System - Out of Service Where the sprinkler system is impaired, the extent and duration of the impairment has been determined, areas or buildings involved are inspected and risks are determined, recommendations are submitted to management or designated representative, and the fire department and other authorities having jurisdiction have been notified. Where the sprinkler system is out of service for more than 10 hours in a 24-hour period, the building or portion of the building affected are evacuated or an approved fire watch is provided until the sprinkler system has been returned to service. 18.3.5.1, 19.3.5.1, 9.7.5, 15.5.2 (NFPA 25) This Standard is not met as evidenced by: 49482 Based on record review and interview, the facility failed to provide an adequate outage policy for the sprinkler system being out of service in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (Section-15.5.2), 2011 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 8. Findings include: Record review and interview on 1/29/25 at approximately 10:51 a.m., revealed the provided Sprinkler Outage Policy for the system being out of service for 10 or more hours in a 24 hour period did not determine the extent and expected duration of the impairment. Nor did the policy address emergency impairments such as system leakage, interruption of water supply, ruptured piping, or other equipment failure. Maintenance Staff verified this observation at the time of the survey process.”

“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 plan did not include information on all of the types of fire extinguishers and range hood and how to operate them. The deficient practice affected all smoke zones and all occupants. This facility had a capacity of 25 and a census of 8 residents at the time of the survey. Findings include: Record review on 1/29/25, at approximately 10:55 a.m., revealed the plan does not address the use of K class fire extinguishers and how to use them or information about the range hood. 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 hold fire drills at least quarterly on each shift in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.7.1.6/19.7.1.6. 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 8 residents at the time of the survey. Findings include: Record review on 1/29/25, at approximately 10:05 a.m., of the facility fire drill documentation conducted during 2024-2025 revealed the following: 1. No documentation of drills conducted on third shift of second quarter. 2. Documentation also revealed the following: two of four drills during first shift were conducted at 12:58 p.m. and 1:00 p.m. Two of four drill during second shift were conducted at 8:20 p.m. and 8:30 p.m., and two of four drills on second shift were conducted at 7:00 p.m. Two of four drills during third shift were conducted at 11:30 p.m. and 11:25 p.m. Results of the record review were acknowledged by Maintenance Staff at the time of exit.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 49482 Based on observation, interview and record review, the facility did not store oxygen tanks in accordance with National Fire Protection Association (NFPA) Standard 99, Health Care Facilities Code, 2012 edition, 11.6.2.3 and 11.6.5, by ensuring tanks were adequately secured to prevent them from accidental damage or dislocation that may result in a missile-like action when the contents are rapidly discharged. This deficient practice occurred in the Second Floor Medical Surgery oxygen storage room (M202B) and affected approximately 8 occupants. This facility had a capacity of 25 and a census of 8 residents at the time of the survey. Findings include: Observation on 1/29/25, at approximately 12:49 p.m., revealed the Second Floor Medical Surgery oxygen storage room (M202B) had four cylinders not properly secured. This deficient practice was confirmed by Maintenance Staff at the time of discovery.”