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Based on observation and interview, it was determined the Facility did not maintain one of four exit corridors free of obstructions to allow the full width of the corridor for use in the event of emergency exiting. The failed practice had the potential to affect all patients, staff and visitors because the rapid egress of building occupants was impeded by the obstructed corridor. The Facility had a census of seven patients on 03/09/15. The findings follow:

A. On a tour of the Facility on 03/10/15 at 1210 with the Maintenance Director, the exit corridor serving the Surgery Waiting Room was observed with the following items that obstructed the means of egress:
1. Two infant beds;
2. Three adult patient beds;
3. Six chairs; and
4. Two patient tray tables.

B. The Maintenance Director verified the items were obstructing the means of egress corridor at the time of observation.

Based on observation and interview, it was determined four of six medical gas cylinders were not secured to prevent them from falling. The failed practice had the potential to affect staff that worked around the medical gas enclosure due to the potential of injury presented by a cylinder falling over. The failed practice had the potential to affect all patients, staff and visitors due to the potential for the cylinders to become a projectile if the cylinder heads were knocked off if the cylinders fell over. The Facility had a census of seven patients on 03/09/15. The findings follow:

A. On a tour of the Facility on 03/11/15 at 1415, four medical gas cylinders were observed unsecured by a chain or other means to prevent them from falling over.

B. The Maintenance Director verified the cylinders were unsecured at the time of observation.

Reference: NFPA 99, Chapter 4-3.5.2 (b) 27

Based on Fire Prevention Management Manual Review, fire damper testing documentation review and interview, it was determined the Facility failed to inspect 13 of 13 fire dampers in the Facility every four years (or every six years under CMS Waiver per S&C Letter 10-04-LSC dated October 30, 2009). The failed practice had the potential to affect all patients, staff and visitors because the Facility failed to ensure the reliability of the dampers to close in the event of a fire or smoke event. The Facility had a census of seven patients on 03/09/15. This is a recurring deficiency from the previous survey dated 03/18/11. The findings follow:

A. Review of the Fire Damper inspection documentation available for review on 03/09/15 at 1445 revealed the most recent documentation of fire damper inspection was dated July 2, 2004.

B. Review of the Fire Prevention Management Manual on 03/11/15 at 10:30 revealed Policy Number G.5, "Fire Alarm System Testing & Inspection" required "all fire and smoke dampers are operated (with fusible links removed where applicable) to verify that they fully close at least every five years."

C. In an interview on 03/11/15 at 12:00 the Maintenance Director verified there was no further documentation available for review.

Based on observation and interview, it was determined the facility failed to post signage prohibiting smoking at the medical gas enclosure as required. The failed practice had the potential to affect all patients, staff and visitors due to the potential of explosion or fire presented by smoking near the medical gas enclosure. The Facility had a census of seven patients on 03/09/15. The findings follow:

A. On a tour of the Facility on 03/11/15 at 1414, the medical gas enclosure was observed without signage on the enclosure prohibiting smoking in the area.

B. The Maintenance Director verified the enclosure did not have signage prohibiting smoking at the time of observation.

Based on Generator Load Bank Test documentation review, Maintenance Policy and Procedure Manual review and interview, it was determined the Facility failed to perform an annual Load Bank Test. The failed practice had the potential affect all patients, staff and visitors because the ability of the generator to power the Facility under building electrical load conditions was not evaluated or verified. The Facility had a census of seven patients on 03/09/15. The findings follow:

A. Review of the most recent Load Bank Test on 03/10/15 at 0830 revealed the most recent Load Bank Test was conducted on 05/24/12.

B. Review of the Maintenance Policy and Procedure Manual on 03/11/15 at 1030 revealed Policy Number B.9, "Maintenance & Inspection Electrical Distribution System & Emergency Generator" required "a Load Bank Test is performed on the Generator at least every 5 years or more often if necessary."

C. In an interview on 03/10/15 at 1435 the Maintenance Director verified there was no further documentation available for review.

Reference NFPA 110, Chapter 6-4.2.

Based on observation and interview, it was determined the Facility did not maintain one of four exit corridors free of obstructions to allow the full width of the corridor for use in the event of emergency exiting. The failed practice had the potential to affect all patients, staff and visitors because the rapid egress of building occupants was impeded by the obstructed corridor. The Facility had a census of seven patients on 03/09/15. The findings follow:

A. On a tour of the Facility on 03/10/15 at 1210 with the Maintenance Director, the exit corridor serving the Surgery Waiting Room was observed with the following items that obstructed the means of egress:
1. Two infant beds;
2. Three adult patient beds;
3. Six chairs; and
4. Two patient tray tables.

B. The Maintenance Director verified the items were obstructing the means of egress corridor at the time of observation.

Based on observation and interview, it was determined four of six medical gas cylinders were not secured to prevent them from falling. The failed practice had the potential to affect staff that worked around the medical gas enclosure due to the potential of injury presented by a cylinder falling over. The failed practice had the potential to affect all patients, staff and visitors due to the potential for the cylinders to become a projectile if the cylinder heads were knocked off if the cylinders fell over. The Facility had a census of seven patients on 03/09/15. The findings follow:

A. On a tour of the Facility on 03/11/15 at 1415, four medical gas cylinders were observed unsecured by a chain or other means to prevent them from falling over.

B. The Maintenance Director verified the cylinders were unsecured at the time of observation.

Reference: NFPA 99, Chapter 4-3.5.2 (b) 27

Based on Fire Prevention Management Manual Review, fire damper testing documentation review and interview, it was determined the Facility failed to inspect 13 of 13 fire dampers in the Facility every four years (or every six years under CMS Waiver per S&C Letter 10-04-LSC dated October 30, 2009). The failed practice had the potential to affect all patients, staff and visitors because the Facility failed to ensure the reliability of the dampers to close in the event of a fire or smoke event. The Facility had a census of seven patients on 03/09/15. This is a recurring deficiency from the previous survey dated 03/18/11. The findings follow:

A. Review of the Fire Damper inspection documentation available for review on 03/09/15 at 1445 revealed the most recent documentation of fire damper inspection was dated July 2, 2004.

B. Review of the Fire Prevention Management Manual on 03/11/15 at 10:30 revealed Policy Number G.5, "Fire Alarm System Testing & Inspection" required "all fire and smoke dampers are operated (with fusible links removed where applicable) to verify that they fully close at least every five years."

C. In an interview on 03/11/15 at 12:00 the Maintenance Director verified there was no further documentation available for review.

Based on observation and interview, it was determined the facility failed to post signage prohibiting smoking at the medical gas enclosure as required. The failed practice had the potential to affect all patients, staff and visitors due to the potential of explosion or fire presented by smoking near the medical gas enclosure. The Facility had a census of seven patients on 03/09/15. The findings follow:

A. On a tour of the Facility on 03/11/15 at 1414, the medical gas enclosure was observed without signage on the enclosure prohibiting smoking in the area.

B. The Maintenance Director verified the enclosure did not have signage prohibiting smoking at the time of observation.

Based on Generator Load Bank Test documentation review, Maintenance Policy and Procedure Manual review and interview, it was determined the Facility failed to perform an annual Load Bank Test. The failed practice had the potential affect all patients, staff and visitors because the ability of the generator to power the Facility under building electrical load conditions was not evaluated or verified. The Facility had a census of seven patients on 03/09/15. The findings follow:

A. Review of the most recent Load Bank Test on 03/10/15 at 0830 revealed the most recent Load Bank Test was conducted on 05/24/12.

B. Review of the Maintenance Policy and Procedure Manual on 03/11/15 at 1030 revealed Policy Number B.9, "Maintenance & Inspection Electrical Distribution System & Emergency Generator" required "a Load Bank Test is performed on the Generator at least every 5 years or more often if necessary."

C. In an interview on 03/10/15 at 1435 the Maintenance Director verified there was no further documentation available for review.

Reference NFPA 110, Chapter 6-4.2.