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Based on documentation review and interview, the facility failed to conduct all required weekly inspections of the emergency generator. This deficient practice increased the potential that the generator would fail to run during loss of power. The facility has the capacity for 64 beds with a census of 31 on the day of survey.

Findings are:
Documentation review on 2-25-19 at 9:40 am of the provided emergency generator maintenance log revealed the documentation failed to exhibit all required information for weekly testing in accordance with National Fire Protection Association Pamphlet 110:
1. The engine system and all the components failed to be inspected and documented weekly.
2. The exhaust system and all the components failed to be inspected and documented weekly.
3. The cooling system and all the components failed to be inspected and documented weekly.
4. The fuel system and all the components failed to be inspected and documented weekly.
5. The electrical system and all the components failed to be inspected and documented weekly.

During an interview on 2-25-19 at 9:40 am, Maintenance A confirmed that the generator testing documentation failed to be complete.

NFPA Standard:
NFPA 110, 1999, 6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.
6-4.2*
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.

Based on observation and interview, the facility failed to assure that the snow was removed from the sidewalks, so that egress from the exit would not impede it to full instant use in the case of fire or other emergency. The facility has the capacity for 64 beds with a census of 31 on the day of survey.

Findings are:
Observations on 2-25-19 at 12:08 pm revealed, the sidewalk from the exit door in the Cafeteria was covered with snow.

During an interview on 2-25-19 12:08 pm, Maintenance Staff A confirmed the snow and covered sidewalk to public way.

NFPA Standard:
2012 NFPA 101, 7.1.10.1
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on documentation review and interview, the facility failed to assure that the yearly emergency light testing was documented. This deficient practice has the potential for emergency lights in the facility not operating during an emergency. The facility has the capacity for 64 beds with a census of 31 on the day of survey.

Documentation review on 2-25-19 at 9:49 am revealed, the facility failed to provide documentation for the annual 1 ½ hour battery test for the emergency lights throughout the facility.

During an interview on 2-25-19 at 9:49 am, Maintenance Staff A confirmed the lack of testing documentation.

Based on observation and interview, the facility failed to assure the doors to a hazardous area would close and latch within the doorframe and failed to be smoke tight and failed to provide self-closing devices on rooms used as storage. These deficient practices would allow fire, smoke and gasses to migrate into the exit corridor. The facility has the capacity for 64 beds with a census of 31 on the day of survey.


Findings are:
Observation on 2-25-19 between 12:17 pm and 1:28 pm revealed:
1. The clean linen room door 1.188, equipped with a self-closing device failed to close and latch within the doorframe.
2. The Biohazard lab door within the lab area, equipped with a self-closing device failed to close and latch within the doorframe.
3. The CT water room, located within CT Storage failed to be smoke-tight, the room did not provide a ceiling.
4. The east Cath Lab 2 door, equipped with a self-closing device failed to close and latch within the doorframe.
5. Patient Room 8 was used as storage, the door failed to provide a self-closing device.
6. Patient Room 7 was used as storage, the door failed to provide a self-closing device.
7. Patient Room 1 was used as storage, the door failed to provide a self-closing device.

During an interview on 2-25-19 between 12:17 pm and 1:28, Maintenance Staff A confirmed that doors equipped with closures failed to latch within the doorframe and patient rooms were used as a storage room without the use of self-closing device.

Based on observation and interview, the facility failed to assure that sprinklers were not obstructed and allowed items to be attached to the sprinkler pipe. This deficient practice would affect the operating temperature of the fire sprinklers and increased the potential that the sprinkler system would fail to activate as designed during a fire. The facility has the capacity for 129 beds with a census of 60 on the day of survey.

Findings are:
Observation on 2-25-19 at 1:44 pm revealed:
1. Items encroached into the required clear space for the fire sprinkler, creating an obstruction in the Painters Room under the ductwork on the west side of room.
2. Black pipe insulation attached to the sprinkler pipe in the Painters room
3. Painting pole laying on top of the sprinkler pipe in the Painters room

During an interview on 9-25-19 at 1:44 pm, Maintenance Staff A confirmed the obstruction to the sprinkler and the pipe insulation on the sprinkler pipe.

Based on record review and interview, the facility did not assure that a complete policy was in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than ten hours in any twenty-four hour period. The lack of a complete written policy and procedure would result in staff failing to implement interim safety measures in the event of an emergency. The facility has the capacity for 64 beds with a census of 31 on the day of survey.

Findings are:
Record review on 2-25-19 at 10:52 am, of the fire watch procedures revealed the facility did not have a complete policy regarding the procedures to be taken in the event that the sprinkler system was out of service for more than ten hours in a twenty-four hour period. The policy provided failed to include that in a preplanned fire watch a designated person would contact the property owner, insurance company, alarm company and the authorities having jurisdiction. The policy failed to list unplanned fire watch for the emergency impairments would include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping and equipment failure.

During an interview on 2-25-19 at 10:52 am, Maintenance Staff A confirmed the lack of specific items in the fire watch policy.

NFPA Standard:
NFPA 25, 2011
15.5* Preplanned Impairment Programs.
15.5.1 All preplanned impairments shall be authorized by the impairment coordinator.
15.5.2 Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented:
(1) The extent and expected duration of the impairment have been determined.
(2) The areas or buildings involved have been inspected and the increased risks determined.
(3) Recommendations have been submitted to management or the property owner or designated representative.
(4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following:
(a) Evacuation of the building or portion of the building affected by the system out of service
(b)*An approved fire watch
(c)*Establishment of a temporary water supply
(d)*Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire
(5) The fire department has been notified.
(6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified.
(7) The supervisors in the areas to be affected have been notified.
(8) A tag impairment system has been implemented. (See Section 15.3.)
(9) All necessary tools and materials have been assembled on the impairment site.

15.6 Emergency Impairments.
15.6.1 Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure.
15.6.2 When emergency impairments occur, emergency action shall be taken to minimize potential injury and damage.
15.6.3 The coordinator shall implement the steps outlined in Section 15.5.

Based on observation and interview, the facility failed to secure a portable fire extinguisher. This deficient practice would not assure the extinguisher was available when needed. The facility has the capacity for 64 beds with a census of 31 on the day of survey.

Findings are:
Observations on 2-25-19 at 2:53 pm revealed, a portable fire extinguisher on the floor in the Elevator room.

During an interview on 2-25-19 at 2:53 pm, Maintenance Staff A confirmed the unsecured fire extinguisher.

NFPA Standard:
Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas. 1998 NFPA 10, 1-6.3

Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer's instructions. Wheeled-type fire extinguishers shall be located in a designated location. 1998 NFPA 10, 1-6.7

Based on observation and interview, the facility allowed obstruction of a corridor door and failed to ensure that a corridor room door would resist the passage of smoke. This deficient practice would not prevent the spread of fire and smoke within the exit corridors. The facility has the capacity for 64 beds with a census of 31 on the day of survey.

Findings are:
Observation on 2-25-19 at 11:32 am and 11:48 am revealed:
1. Patient room door 208 was obstructed with a dialysis machine.
2. Patient room door 204 failed to latch within the doorframe.

During an interview on 2-25-19 at 11:32 am and 11:48 am, Maintenance Staff A confirmed the findings. Nurse Staff A stated that the dialysis machine was placed there for three hours.


NFPA Standard:
2012 NFPA 101, 19.3.6.3.10*
Doors shall not be held open by devices other than those that release when the door is pushed or pulled.
2012 NFPA 101, A.19.3.6.3.10 Doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

Based on observation and interview, the facility did not ensure that fire rated corridor smoke separation doors would resist the passage of smoke from one compartment to another. This deficient practice would not prevent the spread of fire and smoke. The facility has the capacity for 64 beds with a census of 31 on the day of survey.

Findings are:
Observation on 2-25-19 at 12:06 pm and 12:20 pm revealed:
1. The east Administration door equipped with latching device failed to be smoke tight.
2. The west door to the Cafeteria, equipped with self-closing device failed to close and latch within the doorframe.

During an interview on 2-25-19 at 12:06 pm and 12:20 pm, Maintenance Staff A confirmed the findings.

Based on observation and interview, the facility allowed storage to obstruct access to electrical disconnect boxes. This deficient practice could cause a delay and injury when turning off the power during an electrical emergency. The facility has the capacity for 64 beds with a census of 31 on the day of survey.

Findings are:
Observations on 2-25-19 at 2:03 pm revealed, a rolling cart stored in front of the electrical panel box UP1B in the Server room.

During an interview on 2-25-19 at 2:03 pm, Maintenance Staff A confirmed the items stored in front of the electrical panel box.

NFPA Standard:
2011 NFPA 70, 110.26
Sufficient access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment.

Based on record review and staff interview, the facility failed to have a preventative maintenance plan in place to inspect and test all fire doors annually throughout the facility. This deficient practice would allow the spread of fire through faulty fire doors that would otherwise contain a fire. The facility has the capacity for 64 beds with a census of 31 on the day of survey.

Findings are:
Record review on 2-25-19 at 10:33 am revealed, the facility failed to inspect all fire rated doors throughout the facility.

During an interview on 2-25-19 at 10:33 am, Maintenance Staff A confirmed that the facility was unaware of the door inspection requirements.

NFPA Standard:
NFPA 80, 2010, 5.2*
5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.

Based on documentation review and interview, the facility failed to conduct all required weekly inspections of the emergency generator. This deficient practice increased the potential that the generator would fail to run during loss of power. The facility has the capacity for 64 beds with a census of 31 on the day of survey.

Findings are:
Documentation review on 2-25-19 at 9:40 am of the provided emergency generator maintenance log revealed the documentation failed to exhibit all required information for weekly testing in accordance with National Fire Protection Association Pamphlet 110:
1. The engine system and all the components failed to be inspected and documented weekly.
2. The exhaust system and all the components failed to be inspected and documented weekly.
3. The cooling system and all the components failed to be inspected and documented weekly.
4. The fuel system and all the components failed to be inspected and documented weekly.
5. The electrical system and all the components failed to be inspected and documented weekly.

During an interview on 2-25-19 at 9:40 am, Maintenance A confirmed that the generator testing documentation failed to be complete.

NFPA Standard:
NFPA 110, 1999, 6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.
6-4.2*
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.

Based on observation and interview, the facility allowed the use of a power strip in lieu of permanent wiring. This deficient practice increased the potential for an electrical fire. The facility has the capacity for 64 beds with a census of 31 on the day of survey.

Findings are:
Observation on 2-25-19 between 12:02 pm and 12:51 pm revealed:
1. A refrigerator and a microwave plugged into a power strip in the Call Center.
2. A microwave and refrigerator plugged into a power strip in the Receiving Dock area.
3. A microwave plugged into a power strip in the Respiratory Therapy office.
4. A microwave plugged into a power strip in the Cath Lab storage room.

During an interview on 2-25-19 between 12:02 pm and 12:51 pm, Maintenance Staff A confirmed the power strips.

Based on observation and interview, the facility failed to store oxygen cylinders so they were restrained from tipping over. This deficient practice would increase the potential for the oxygen cylinders to tip over, breaking the valve off and becoming a projectile. The facility has the capacity for 64 beds with a census of 31 on the day of survey.

Findings are:
Observation on 2-25-19 at 11:35 am revealed, an oxygen cylinder freestanding in the oxygen storage room in Pod 3 across from room 302.

During an interview on 2-25-19 at 11:35 am, Maintenance Staff A confirmed the oxygen was not restrained.

Based on documentation review and interview, the facility failed to assure that all OR staff were trained and provided with the policies for the fire prevention in the operating room. This deficient practice failed to assure the safety of all occupants in the OR. The facility has the capacity for 64 beds with a census of 31 on the day of survey.

Documentation review on 2-25-19 at 2:45 pm revealed that the policy of fire prevention in the operating room failed to include Surgeons.

During an interview on 2-25-19 at 2:25 pm, Nurse Staff B confirmed that the surgeons were not included for training of fire prevention.