Chadron Hospital

“42 CFR 483.90(a) (b) The facility must meet the applicable provisions of the 2012 Edition of the Life Safety Code of the National Fire Protection Association. This facility is governed by Chapter 19, Existing Health Care Occupancies of the 2012 Edition of the National Fire Protection Association [NFPA], Chapter 101: Life Safety Code. Chadron Community Hospital and Health Services is a two-story building of Type II (111) construction with a plan approval date on 2010. The lower level of the facility houses building services, heating, electrical, kitchen, dining, laundry, central supply and storage. The lower level also contains a Dialysis patient area, outpatient services, physical therapy, administrative services. The main level includes a 25 be patient facility, surgery, emergency services and lab area. The main level also included a medical clinic which is separated by two-hour fire rated construction with 90-minute rated fire doors. The entire facility is protected by an automatic fire sprinkler system and a fire alarm system that are interconnected to transmit an alarm throughout the entire facility. Smoke alarms are located throughout the corridors, lobbies patient waiting areas. The fire alarm also transmits an alarm to a 911 center for dispatching the local fire department. The facility has 25 skilled certified beds. At the time of the survey the census was 12. Chadron Community Hospital and Health Services was found not to be in compliance with the requirements for participation 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.”

“Stairways and Smokeproof Enclosures CFR(s): NFPA 101 Stairways and Smokeproof Enclosures Stairways and Smokeproof enclosures used as exits are in accordance with 7.2. 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2 This Standard is not met as evidenced by: 15537 Based on observation and interview, the facility failed to maintain the stair enclosure free of combustible material. This has the potential of affecting approximately 12 occupants in one of six smoke zones, by possible allowing stair enclosure to become affected by fire. This facility has a capacity of 25 and census of 12 patients at the time of the survey. Findings are: On 7/29/24 at 1:15 P.M., observations revealed that the facility failed to prohibit the storage of items within the West stair enclosure. During interview conducted on 7/29/24 at 1:15 P.M., Maintenance personnel stated that they were unaware that there were items stored within the stair enclosure.”

“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: 15537 Based on observation and interview, the facility failed to maintain the required separation for hazardous areas. This has the potential of affecting approximately 12 occupants in one of six smoke zones, by allowing fire and smoke to spread from a hazardous area. This facility has a capacity of 25 and census of 12 residents at the time of the survey. Findings are: On 7/29/24 at 1:50 P.M., observations revealed that the facility failed to provide the required self-closing door for North Equipment Room that is being used for storage. During interview conducted on 7/29/2024 at 1:50 P.M., Maintenance personnel stated that they were unaware that the door was required to be self-closing.”

“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: 15537 Based on observation and record review, the facility failed to conduct fire drills at one per shift per quarter. This has the potential of affecting approximately 12 occupants in six of six smoke zones. This deficient practice has the potential to affect the readiness of the staff in the case of fire emergency. This facility has a capacity of 25 and census of 12 patients at the time of the survey. Finding are: On 7/29/2024 at 12:00 P.M., record review, the facility failed to conduct a fire drill for the first and second shifts of the first and second quarter of 2024, the second and third shift of the third quarter of 2023, and the first and second shifts of the four quarter of 2023. During interview conducted on 7/29/2024 at 12:00 P.M., Maintenance personnel stated that they were unaware of the missing drills.”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 15537 Based on record review and interview, the facility failed to provide annual inspections and testing for fire door assemblies. This deficient practice has the potential to allow the spread of fire or smoke throughout the smoke zones. This deficient practice has the potential to affect all occupants in six of six smoke zones. Facility has the capacity of 25 with a census 12 patients at the time of the survey. Findings are: Record review on 7/29/2024 at 12:30 P.M. revealed the records for the annual inspection and testing for the fire door assemblies were not available for review. During an interview on 7/29/2024 at 12:30 P.M. Maintenance Personnel indicated that they did not have the records of the door inspections.”