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Based on observation and staff interview, the facility failed to provide positive latching hardware for the Dish Room corridor door, and maintain positive latching of the Conference Room door so the doors resisted the passage of smoke. This condition would allow smoke to migrate into the exit corridor.

Findings are:
Observation during the facility tour on 4/13/16, from 12:18 pm to 1:20 pm revealed:
1. The Dish Room corridor door failed to have positive latching hardware installed in the door. The door was held shut by a deadbolt lock, only.
2. The Conference Room Door failed to positively latch when self-closed.
In an interview conducted at the time of observation, (4/13/16, from 12:18 pm to 1:20 pm), Maintenance A acknowledged the findings.

Based on observation and staff interview, the facility failed to maintain smoke barriers free of penetrations. This condition had the potential to allow smoke to migrate between smoke compartments.

Findings are:
Observation above ceiling during the facility tour on 4/13/16, from 2:59 pm to 3:07 pm revealed:
1. A hole around a conduit failed to be sealed near the roof deck at the fire doors by Room 22.
2. Multiple penetrations around cables, conduits and pipe failed to be sealed at the Front Fire Doors.
3. Holes around flex conduits failed to be sealed at the fire doors by the Front Desk

In an interview conducted at the time of observation, (4/13/16, from 2:59 pm to 3:07 pm), Maintenance A acknowledged the findings.

Based on observation and staff interview, the facility failed to provide a self-closing door for the Work Room. This condition would allow smoke and fire to migrate into the exit corridor.

Findings are:
Observation during the facility tour on 4/13/16 at 1:01 pm revealed the Work Room, which exceeded 50 square feet, was used for combustible storage and maintenance. The room door failed to self-close.

In an interview conducted at the time of observation, (4/13/16 at 1:01 pm), Maintenance A acknowledged the findings.

Based on observation and staff interview, the facility failed to provide illumination of an exit corridor that was either continuously in operation, or automatic operation. This condition would leave occupants in darkness during an emergency.

Findings are:
Observation during the facility tour on 4/13/16, at 1:57 pm revealed the exit corridor by Room 7 failed to be continuously illuminated, or restored automatically with the loss of power. All lights in the hallway were switched off at the time of observation.
In an interview conducted at the time of observation, (4/13/16, at 1:57 pm), Administration A acknowledged that all of the lights were switchable.

Based on record review and staff interview, the facility failed to maintain battery backup emergency lights in various areas of the facility. This condition had the potential to leave occupants in darkness during loss of power.

Findings are:
Record review during the facility tour on 4/13/16, at 11:23 am revealed an annual battery backup emergency light test failed to be documented for the last year for all battery backup lights in the facility.

In an interview conducted at the time of observation and record review, (4/13/16, at 11:23 am), Maintenance A acknowledged the findings.

2000, NFPA 101, 7.9.3, Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 ½ hours. Equipment shall be fully operation for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Based on record review and staff interview, the facility failed to conduct fire drills quarterly with varying times. This condition did not provide simulated training for staff to respond to a fire emergency.

Findings are:
Record review of fire drills on 4/13/16, at 10:55 am revealed fire drills failed to have at least one hour difference between each quarter for the past year for the following shifts:
1st Shift: 3/3/16 at 1:30 pm, 10/15/15 at 2:14 pm, 7/28/15 at 2:41 pm, and 6/29/15 at 1:45 pm.
3rd Shift: 2/28/16 at 2:28 am, 11/30/15 at 7:02 am, 8/31/15 at 6:25 am, and 5/27/15 at 7:10 pm.

In an interview conducted at the time of record review (4/13/16, at 10:55 am), Maintenance A acknowledged the fire drill times were not varied.

NFPA 101, 2000, 19.7.1.2*
Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

Based on record review and staff interview, the facility failed to have all of the required information recorded for testing of the fire sprinkler system quarterly. This condition did not specify how many seconds were required before the flow switch activated during quarterly testing, and increased the likelihood that the sprinkler system would fail to suppress a fire.
Findings are:
Record review during the facility tour on 4/13/16, at 11:05 am revealed:
1. The amount of seconds that were required before the fire sprinkler system flow switch activated during the quarterly main drain test failed to be recorded for the past year.
2. A quarterly test of the sprinkler system failed to be documented for the 2nd quarter of 2015.
In an interview conducted at the time of observation and record review, (4/13/16, at 11:05 am), Maintenance A confirmed the findings.
1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1. Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection and test every quarter of a calendar year.
1999 NFPA 13, 12.1. A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed.
NFPA 13, 5-6.5.3. Water flow alarm devices including, but not limited to, water motor gongs, vane-type water flow devices, and pressure switches that provide audible or visual signals shall be tested quarterly per 1998 NFPA 25, 2-3.3.

Based on observation and staff interview, the facility failed to provide a remote manual stop for the emergency generator. This condition had the potential to prevent the shutdown of the generator during an emergency.

Findings are:
Observation during the facility tour on 4/13/16, at 2:19 pm revealed the facility failed to provide a remote manual stop for the emergency generator outside of, and away from the generator enclosure.

In an interview conducted at the time of observation, 4/13/16, at 2:19 pm, Maintenance A confirmed the facility failed to provide a remote manual stop, and stated the generator was installed after 1999.

1999 NFPA 110, 3-5.5.6*
All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.
For Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.

Based on record review and staff interview, the facility failed to provide documentation that the emergency generator was inspected weekly and tested monthly, as required. This condition increased the potential that the emergency generator would fail to run during loss of power.

Findings are:
Record review on 4/13/16, at 11:51 am of weekly emergency generator inspection and monthly testing revealed:
1. The percentage of KW that the generator ran at during monthly load testing failed to be documented to verify the generator ran at the minimum 30% of the rated capacity.
2. The lubrication system failed to be inspected weekly and documented.
3. The fuel system failed to be inspected weekly and documented.
4. The exhaust system failed to be inspected weekly and documented.
5. The electrical system failed to be inspected weekly and documented.
6. The prime mover failed to be inspected weekly and documented.

In an interview conducted at the time of record review, (4/13/16, at 11:51 am), Maintenance A acknowledged the findings.

Actual 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, record review, and staff interview, the facility failed to use electrical equipment as listed, and as permitted by CMS regulations. This condition created the potential of an electrical fire.
Findings are:
Observation during the facility tour on 4/13/16, from 1:05 pm to 2:45 pm revealed:
1. Hospital grade power strips were used in patient care areas within the patient care vicinity in LDR One and Two. The power strips failed to be plugged directly into a wall outlet, and were plugged into battery backup power strips.
2. An extension cord was plugged into a power strip, which was plugged into another power strip for the computer. The computer failed to be plugged in without the use of an extension cord, or the daisy chaining of power strips.
3. The calculator in the middle desk in the Finance Office failed to be plugged in so the use of an extension cord was not necessary.
4. A power strip was plugged into a battery backup power strip in the East IT Closet, and the power strips failed to be plugged in directly to a wall outlet.
5. Both radios in the HIM Office by the windows failed to be plugged in so the use of an extension cord was not necessary.
6. The extension cord at S L ' s Desk in HIM failed to be removed prior to the survey.
7. The printer in the Micro Lab failed to be plugged in so the use of an extension cord was not necessary.
8. The equipment in OR 1 failed to be plugged in so the use of an extension cord was not necessary.
Record review on 4/13/16, at 1:51 pm revealed the CMS S&C 14-46 LSC Waiver failed to be adopted to allow the use of power strips in patient care areas.
In an interview conducted at the time of observation, (4/13/16, from 1:05 pm to 2:45 pm), Maintenance A confirmed the use of the electrical equipment, and that the CMS S&C 14-46 LSC Waiver to allow the use of power strips in patient care areas was not adopted.

Based on record review and staff interview, the facility failed to provide an approved fire watch policy describing procedures to be followed when the fire sprinkler system was out of service for more than 4 hours in a 24 hour period. This condition had the potential to allow fire to start and spread through the facility unnoticed during fire sprinkler system failure.

Findings are:
Record review on 4/13/16, at 11:27 am revealed:
1. The fire sprinkler system fire watch policy failed to specify that fire watch intervals would be conducted in affected areas every 30 minutes.
2. The fire sprinkler system fire watch policy failed to specify how long the sprinkler system had to be down before a fire watch was implemented.
3. Details of who was to conduct the fire watch, and how, failed to be documented.

In an interview conducted at the time of record review, (4/13/16, at 11:27 am) Maintenance A confirmed the missing information.

Nebraska State Fire Marshal Official Interpretation 05-01.

NFPA 101, 9.7.6.1Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.

Based on record review and staff interview, the facility failed to provide an approved fire watch policy describing procedures to be followed when the fire alarm system was out of service for more than 4 hours in a 24 hour period. This condition had the potential to allow fire to start and spread through the facility unnoticed during fire alarm system failure.

Findings are:
Record review on 4/13/16, at 11:27 am revealed:
1. The fire alarm system fire watch policy failed to specify that fire watch intervals would be conducted in affected areas every 30 minutes.
2. The fire alarm system fire watch policy failed to specify how long the alarm system had to be down before a fire watch was implemented.
3. Details of who was to conduct the fire watch, and how, failed to be documented.

In an interview conducted at the time of record review, (4/13/16, at 11:27 am) Maintenance A confirmed the missing information.

Nebraska State Fire Marshal Official Interpretation 05-01.

2000 NFPA 101, 9.6.1.8*Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

Based on observation and staff interview, the facility failed to provide positive latching hardware for the Dish Room corridor door, and maintain positive latching of the Conference Room door so the doors resisted the passage of smoke. This condition would allow smoke to migrate into the exit corridor.

Findings are:
Observation during the facility tour on 4/13/16, from 12:18 pm to 1:20 pm revealed:
1. The Dish Room corridor door failed to have positive latching hardware installed in the door. The door was held shut by a deadbolt lock, only.
2. The Conference Room Door failed to positively latch when self-closed.
In an interview conducted at the time of observation, (4/13/16, from 12:18 pm to 1:20 pm), Maintenance A acknowledged the findings.

Based on observation and staff interview, the facility failed to maintain smoke barriers free of penetrations. This condition had the potential to allow smoke to migrate between smoke compartments.

Findings are:
Observation above ceiling during the facility tour on 4/13/16, from 2:59 pm to 3:07 pm revealed:
1. A hole around a conduit failed to be sealed near the roof deck at the fire doors by Room 22.
2. Multiple penetrations around cables, conduits and pipe failed to be sealed at the Front Fire Doors.
3. Holes around flex conduits failed to be sealed at the fire doors by the Front Desk

In an interview conducted at the time of observation, (4/13/16, from 2:59 pm to 3:07 pm), Maintenance A acknowledged the findings.

Based on observation and staff interview, the facility failed to provide a self-closing door for the Work Room. This condition would allow smoke and fire to migrate into the exit corridor.

Findings are:
Observation during the facility tour on 4/13/16 at 1:01 pm revealed the Work Room, which exceeded 50 square feet, was used for combustible storage and maintenance. The room door failed to self-close.

In an interview conducted at the time of observation, (4/13/16 at 1:01 pm), Maintenance A acknowledged the findings.

Based on observation and staff interview, the facility failed to provide illumination of an exit corridor that was either continuously in operation, or automatic operation. This condition would leave occupants in darkness during an emergency.

Findings are:
Observation during the facility tour on 4/13/16, at 1:57 pm revealed the exit corridor by Room 7 failed to be continuously illuminated, or restored automatically with the loss of power. All lights in the hallway were switched off at the time of observation.
In an interview conducted at the time of observation, (4/13/16, at 1:57 pm), Administration A acknowledged that all of the lights were switchable.

Based on record review and staff interview, the facility failed to maintain battery backup emergency lights in various areas of the facility. This condition had the potential to leave occupants in darkness during loss of power.

Findings are:
Record review during the facility tour on 4/13/16, at 11:23 am revealed an annual battery backup emergency light test failed to be documented for the last year for all battery backup lights in the facility.

In an interview conducted at the time of observation and record review, (4/13/16, at 11:23 am), Maintenance A acknowledged the findings.

2000, NFPA 101, 7.9.3, Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 ½ hours. Equipment shall be fully operation for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Based on record review and staff interview, the facility failed to conduct fire drills quarterly with varying times. This condition did not provide simulated training for staff to respond to a fire emergency.

Findings are:
Record review of fire drills on 4/13/16, at 10:55 am revealed fire drills failed to have at least one hour difference between each quarter for the past year for the following shifts:
1st Shift: 3/3/16 at 1:30 pm, 10/15/15 at 2:14 pm, 7/28/15 at 2:41 pm, and 6/29/15 at 1:45 pm.
3rd Shift: 2/28/16 at 2:28 am, 11/30/15 at 7:02 am, 8/31/15 at 6:25 am, and 5/27/15 at 7:10 pm.

In an interview conducted at the time of record review (4/13/16, at 10:55 am), Maintenance A acknowledged the fire drill times were not varied.

NFPA 101, 2000, 19.7.1.2*
Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

Based on record review and staff interview, the facility failed to have all of the required information recorded for testing of the fire sprinkler system quarterly. This condition did not specify how many seconds were required before the flow switch activated during quarterly testing, and increased the likelihood that the sprinkler system would fail to suppress a fire.
Findings are:
Record review during the facility tour on 4/13/16, at 11:05 am revealed:
1. The amount of seconds that were required before the fire sprinkler system flow switch activated during the quarterly main drain test failed to be recorded for the past year.
2. A quarterly test of the sprinkler system failed to be documented for the 2nd quarter of 2015.
In an interview conducted at the time of observation and record review, (4/13/16, at 11:05 am), Maintenance A confirmed the findings.
1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1. Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection and test every quarter of a calendar year.
1999 NFPA 13, 12.1. A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed.
NFPA 13, 5-6.5.3. Water flow alarm devices including, but not limited to, water motor gongs, vane-type water flow devices, and pressure switches that provide audible or visual signals shall be tested quarterly per 1998 NFPA 25, 2-3.3.

Based on observation and staff interview, the facility failed to provide a remote manual stop for the emergency generator. This condition had the potential to prevent the shutdown of the generator during an emergency.

Findings are:
Observation during the facility tour on 4/13/16, at 2:19 pm revealed the facility failed to provide a remote manual stop for the emergency generator outside of, and away from the generator enclosure.

In an interview conducted at the time of observation, 4/13/16, at 2:19 pm, Maintenance A confirmed the facility failed to provide a remote manual stop, and stated the generator was installed after 1999.

1999 NFPA 110, 3-5.5.6*
All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.
For Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.

Based on record review and staff interview, the facility failed to provide documentation that the emergency generator was inspected weekly and tested monthly, as required. This condition increased the potential that the emergency generator would fail to run during loss of power.

Findings are:
Record review on 4/13/16, at 11:51 am of weekly emergency generator inspection and monthly testing revealed:
1. The percentage of KW that the generator ran at during monthly load testing failed to be documented to verify the generator ran at the minimum 30% of the rated capacity.
2. The lubrication system failed to be inspected weekly and documented.
3. The fuel system failed to be inspected weekly and documented.
4. The exhaust system failed to be inspected weekly and documented.
5. The electrical system failed to be inspected weekly and documented.
6. The prime mover failed to be inspected weekly and documented.

In an interview conducted at the time of record review, (4/13/16, at 11:51 am), Maintenance A acknowledged the findings.

Actual 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, record review, and staff interview, the facility failed to use electrical equipment as listed, and as permitted by CMS regulations. This condition created the potential of an electrical fire.
Findings are:
Observation during the facility tour on 4/13/16, from 1:05 pm to 2:45 pm revealed:
1. Hospital grade power strips were used in patient care areas within the patient care vicinity in LDR One and Two. The power strips failed to be plugged directly into a wall outlet, and were plugged into battery backup power strips.
2. An extension cord was plugged into a power strip, which was plugged into another power strip for the computer. The computer failed to be plugged in without the use of an extension cord, or the daisy chaining of power strips.
3. The calculator in the middle desk in the Finance Office failed to be plugged in so the use of an extension cord was not necessary.
4. A power strip was plugged into a battery backup power strip in the East IT Closet, and the power strips failed to be plugged in directly to a wall outlet.
5. Both radios in the HIM Office by the windows failed to be plugged in so the use of an extension cord was not necessary.
6. The extension cord at S L ' s Desk in HIM failed to be removed prior to the survey.
7. The printer in the Micro Lab failed to be plugged in so the use of an extension cord was not necessary.
8. The equipment in OR 1 failed to be plugged in so the use of an extension cord was not necessary.
Record review on 4/13/16, at 1:51 pm revealed the CMS S&C 14-46 LSC Waiver failed to be adopted to allow the use of power strips in patient care areas.
In an interview conducted at the time of observation, (4/13/16, from 1:05 pm to 2:45 pm), Maintenance A confirmed the use of the electrical equipment, and that the CMS S&C 14-46 LSC Waiver to allow the use of power strips in patient care areas was not adopted.

Based on record review and staff interview, the facility failed to provide an approved fire watch policy describing procedures to be followed when the fire sprinkler system was out of service for more than 4 hours in a 24 hour period. This condition had the potential to allow fire to start and spread through the facility unnoticed during fire sprinkler system failure.

Findings are:
Record review on 4/13/16, at 11:27 am revealed:
1. The fire sprinkler system fire watch policy failed to specify that fire watch intervals would be conducted in affected areas every 30 minutes.
2. The fire sprinkler system fire watch policy failed to specify how long the sprinkler system had to be down before a fire watch was implemented.
3. Details of who was to conduct the fire watch, and how, failed to be documented.

In an interview conducted at the time of record review, (4/13/16, at 11:27 am) Maintenance A confirmed the missing information.

Nebraska State Fire Marshal Official Interpretation 05-01.

NFPA 101, 9.7.6.1Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.

Based on record review and staff interview, the facility failed to provide an approved fire watch policy describing procedures to be followed when the fire alarm system was out of service for more than 4 hours in a 24 hour period. This condition had the potential to allow fire to start and spread through the facility unnoticed during fire alarm system failure.

Findings are:
Record review on 4/13/16, at 11:27 am revealed:
1. The fire alarm system fire watch policy failed to specify that fire watch intervals would be conducted in affected areas every 30 minutes.
2. The fire alarm system fire watch policy failed to specify how long the alarm system had to be down before a fire watch was implemented.
3. Details of who was to conduct the fire watch, and how, failed to be documented.

In an interview conducted at the time of record review, (4/13/16, at 11:27 am) Maintenance A confirmed the missing information.

Nebraska State Fire Marshal Official Interpretation 05-01.

2000 NFPA 101, 9.6.1.8*Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.