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Based on observation and staff February 7, 2019 between approximately 0815 and 1630 hours the facility has failed to have appropriate testing of the fire alarm system which result in the failure to notify staff of a problem with the fire alarm system. This could lead to the system not functioning as intended and lead to people within the building not being notified of a fire.

The findings include:

The detector in doctor's sleeping room 4 had been removed and placed in a dresser drawer.

The above was discussed and acknowledged by the facility maintenance staff.

Based on observation and staff interviews on February 7, 2019 between approximately 0815 and 1630 hours the facility has failed to maintain the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire and allow the fire to increase in size and intensity which would endanger the patients, staff, and/or visitors within the facility.

The findings include:

Storage exceeded the 18" clearance from sprinkler head requirements in the administrator's assistant's office storage closet.

The above was discussed and acknowledged by the facility maintenance staff.

Based on observation and staff interviews on February 7, 2019 between approximately 0815 and 1630 hours the facility has failed to maintain doors without impediments to their closing and latching. This could result in a delay in getting the door to the room closed in the event of a fire. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the patients, staff, and/or visitors within the smoke compartment.

The findings include:

The following doors do not close and latch:

Entrance to the intensive care unit
Entrance to the administrator's office

The following doors were blocked open:

Staff hydration room in the pediatric unit
Charity program director's office
Receiving room

The above was discussed and acknowledged by facility maintenance staff.

Based on observation and staff interviews on February 7, 2019 between approximately 0815 and 1630 hours the facility has failed to maintain electric and gas equipment in a safe manner and in accordance with NFPA 54 and NFPA 70. This could endanger people in the building by risk of fire, electrocution, or other harm.

The findings include:

Open junction box behind the blanket warmer in the Intensive Care Unit.

There is a water leak at the electrical conduit where the conduit penetrates the ceiling creating an electrical hazard.

The above was discussed and acknowledged by the facility maintenance staff.

Based on documentation review and staff interviews on February 7, 2019 between approximately 0815 and 1630 hours the facility has failed to ensure dampers in the facility were inspected and provided necessary maintenance at least every four years in accordance with NFPA 90A. LSC 9.2.1 requires heating, ventilating and air conditioning (HVAC), ductwork and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems.

NFPA 90A, 2012 Edition, Section 5.4.8.1 states fire dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. NFPA 80, 2010 Edition, Section 19.4.1 states each damper shall be tested and inspected 1 year after installation. The test and inspection frequency shall be every 6 years. If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in-place if so equipped. The damper shall not be blocked from closure in any way. All inspections and testing shall be documented, indicating the location of the fire damper, date of inspection, name of inspector and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected. This deficient practice could affect all patients, staff, and visitors.

The findings include:

Testing report for damper performed on January 25, 2016 reflected deficiencies. Five of the sixteen failed dampers have not been repaired and retested.

The above was discussed and acknowledged by the facility maintenance staff.

Based on observation, documentation review and staff interviews on February 7, 2019 between approximately 0815 and 1630 hours the facility has failed to maintain a written policy or regulation for residents and staff. Additionally, the facility has failed to provide the required equipment at the designated smoking area(s). This could result in the ignition of the combustible materials adjacent to the staff smoking area which would endanger the patients, staff, and/or visitors within the facility.

The findings include:

The facility failed to enforce the smoking policy requiring staff to smoke in designated locations.

The facility failed to provide required equipments for disposable of smoking materials.

The above was discussed and acknowledged by the facility maintenance staff.

Based upon documentation review and staff interviews on February 7, 2019 between approximately 0815 and 1630 hours the facility has failed to test all fire rated doors in accordance with NFPA 80. This could lead to the doors not functioning as required in a fire, endangering those inside the building.

The findings include:

Inspection report of fire doors performed on November 11, 2018 reflected deficiencies. Not all failures have been corrected, including missing hardware and penetrations.

The above was discussed and acknowledged by the facility maintenance staff.

Based on documentation review and staff interviews on February 7, 2019 between approximately 0815 and 1630 hours the facility failed to maintain their medical gas equipment through testing and inspection possible leading to a problem not being detected.

The findings include:

Inspection documentation of the medical gas and vacuum system performed on December 22, 2017 reflected deficiencies which have not been correct.

The above was discussed and acknowledged by the facility maintenance staff.

Based on documentation review and staff interviews on February 7, 2019 between approximately 0815 and 1630 hours the facility failed to keep records or conduct maintenance on their hospital grade receptacles, non-hospital grade receptacles, and Line Isolation Monitors. This could cause an increased risk of fire due to the non-maintenance of the electrical system.

The findings include:

The facility was unable to provide documentation of hospital grade receptacle performance data or testing after initial installation, replacement, or servicing.

The facility was unable to provide documentation of non-hospital grade receptacle testing in the vicinity of patient beds and in treatment areas.

The above was discussed and acknowledged by the facility maintenance staff.