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Based on documentation review and interview, the facility failed to have a program for exercising main and feeder circuit breakers serving the Essential Electrical System. These deficient practices increase the probability that the generator would fail to run during an emergency loss of power and the emergency systems. The facility has the capacity for 63 beds with a census of 32 on the day of survey.

Findings are:
Documentation review on 11-7-23 at 1:38 pm of the emergency generator maintenance log revealed:
1. No program for exercising the main or feeder breakers was established.
2. Documents provide for the inspection of breakers failed to accurately describe the process of inspection.

During an interview on 11-7-23 at 1:38 pm, Staff A confirmed that the failed to be conducted and stated that they conducted thermal imagining on the breaker and not what the work order stated.

NFPA Standard:
NFPA 99, 2012, 6.4.4.1.2.1
Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer's recommendations.
A.6.4.4.1.2.1
Main and feeder circuit breakers should be periodically tested under simulated overload trip conditions to ensure reliability.

Based on observation and interview, the facility failed to maintain a 2-hour fire rated separation between the Medical Office Building and the Hospital. This deficient practice would allow smoke, fire and gases to migrate between the Hospital and Medical Office Building. The facility has the capacity for 63 beds with a census of 32 on the day of survey.

Findings are:
Observation on 11-7-23 at 9:59 am revealed the west 1 ½ -hour fire rated double doors leading into the Medical Office Building failed to latch.

During an interview on 11-7-23 at 9:59 am, Staff A confirmed the door failed to latch within the doorframe.

Based on observations and interview, the facility failed to assure a door in the means of egress opened with one motion. This deficient practice could delay egress in the event of an emergency. The facility has the capacity for 63 beds with a census of 32 on the day of survey.

Findings are:
Observations on 11-7-23 at 9:41 am revealed, the door to the Director of Nursing Office provided a doorknob and thumb lock which required two motions to exit the room if the upper locked was engaged.

During an interview on 11-7-23 at 9:41 am, Staff A confirmed that the door required two motions to open the door.

Based on observation and interview the facility failed to assure that a thumb lock was not functional. This deficient practice would delay egress and cause confusion. The facility has the capacity for 63 beds with a census of 32 on the day of survey.

Findings are:
Observation on 11-7-23 at 12:12 pm revealed, a thumb lock installed on the sliding lobby doors.

During an interview on 11-7-23 at 12:12 pm, Staff A confirmed the thumb lock on lobby doors.

Based on observation and interview, the facility failed to assure doors to hazardous areas latched within the doorframe and that ceiling tiles were in place. These deficient practices would allow fire, smoke and gases to migrate into the exit corridor. The facility has the capacity for 63 beds with a census of 32 on the day of survey.

Findings are:
Observation on 11-7-23 between 9:35 am and 10:52 am revealed:
1. Patient room 109 was used as a storage room, there was no self-closing device.
2. The door behind Nurses Station at Pod 2 equipped with a self-closing device failed to close and latch within the doorframe.
3. The Server room located within the Shell space door was held open with wooden door chock.
4. The door 1099 Sterile Processing equipped with a self-closing device, failed to close and latch within the doorframe.
5. The east door to the Data Center 1.154 equipped this a self-closing device failed to close and latch within the doorframe.
6. Unsealed penetration around conduits in the ceiling of the Network Closet.
7. Door 1.143 to the Staff Lounge equipped with a self-closing device, failed to close and latch within the doorframe.

During an interview on 11-7-23 between 10:32 am and 10:52 am, Staff A confirmed doors failed to close and latch within the frame, doors failed to provide self-closing devices and unsealed penetrations.

Based on observation and interview, the facility failed to assure that the kitchen exhaust hoods were free of excessive grease, failed to provide a cleaning schedule, failed to assure the wheeled cooking appliances under the hood provided chain to prevent movement and failed to maintain wheel chocks for appliances under the hood. These deficient practices would increase the potential for a fire, as a fire under the hood could possibly not be extinguished effectively. The facility has the capacity for 63 beds with a census of 32 on the day of survey.

Findings are:
Observations on 11-7-23 at 10:42 am revealed,
1. Gas powered, wheeled cooking appliances under the serving hood was not equipped with chains or similar devices to limit strain on fuel gas connections.
2. The wheeled stove/oven under the serving hood, failed to provide a method to ensure appliance would be returned to the original designed location.
3. The serving hood was extremely greasy, the filters appeared dirty.
4. No cleaning schedule was provided.

During interview on 11-7-23 at 10:42 am, Staff A confirmed no chain was provided behind the gas appliance and lack of wheel-chocks for the equipment under the hood. Staff B stated the hood was cleaned professionally semi annually and stated no other cleaning schedule was provided.

NFPA Standard:
1999 NFPA 54, 5.1.16
Avoiding Strain on Gas Piping. Gas utilization equipment shall be supported and so connected to the piping as not to exert undue strain on the connections.

NFPA Standard:
2001 NFPA 96, 12.1.2.3.1
An approved method shall be provided that will ensure that the appliance is returned to an approved design location.

Based on observation and interview, the facility failed to assure fire sprinklers were not obstructed and that the ceiling tiles were in the grid and smoke tight. This deficient practice would not allow the sprinkler system to operate as designed which would cause a delay in protection adding smoke, fire and gases to the area. The facility has the capacity of 63 beds with a census of 32 on the day of survey.

Findings are:
Observation on 11-7-23 at 10:13 am and 10:45 am revealed:
1. The escutcheon in the Biohazard Room within the Lab was not sealed at the ceiling.
2. Open ceiling tile in room 1.153.
3. Sprinkler in the Network Closet appeared to be located too close to the servers.

During an interview on 11-7-23 at 10:13 am and 10:45 am, Staff A confirmed unsealed penetration, open ceiling tiles and obstructed sprinkler.

Based on observation and interview, the facility failed to ensure corridor doors would resist the passage of smoke. This deficient practice would not prevent the spread of fire, smoke and gases within the exit corridors. The facility has the capacity for 63 beds with a census of 32 on the day of survey.

Findings are:
Observation on 11-7-23 at 9:24 am and 9:42 am revealed,
1. The north side double doors to the second floor waiting area "fishbowl" had an excessive gap between the doors.
2. The west door to the south side double doors to the second floor waiting area "fishbowl" failed to latch within the doorframe.

During the exit interview on 11-7-23 between 9:24 am, Staff A confirmed the door were obstructed or held open and had an excessive gap.

Based on observation and interview, the facility failed to limit the use of holiday lights. This deficient practice could create electrical injury and fire hazard. The facility has a capacity of 63 beds with a census of 32 on the day of survey.

Findings are:
Observation on 11-7-23, at 10:05 am, revealed, holiday lights attached to the walls in the Anesthesiology Office with no written policy to limit the use to 90 days.

During an interview on 11-7-23 at 10:05 am, Staff A confirmed the use of holiday lights without a limiting policy.

NFPA Standard:
2011, NFPA 70, article 590.3 Time Constraints.
(B) 90 Days. Temporary electric power and lighting installations shall be permitted for a period not to exceed 90 days for holiday decorative lighting and similar purposes.

Based on documentation review and interview, the facility failed to have a program for exercising main and feeder circuit breakers serving the Essential Electrical System. These deficient practices increase the probability that the generator would fail to run during an emergency loss of power and the emergency systems. The facility has the capacity for 63 beds with a census of 32 on the day of survey.

Findings are:
Documentation review on 11-7-23 at 1:38 pm of the emergency generator maintenance log revealed:
1. No program for exercising the main or feeder breakers was established.
2. Documents provide for the inspection of breakers failed to accurately describe the process of inspection.

During an interview on 11-7-23 at 1:38 pm, Staff A confirmed that the failed to be conducted and stated that they conducted thermal imagining on the breaker and not what the work order stated.

NFPA Standard:
NFPA 99, 2012, 6.4.4.1.2.1
Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer's recommendations.
A.6.4.4.1.2.1
Main and feeder circuit breakers should be periodically tested under simulated overload trip conditions to ensure reliability.

Based on observation and interview, the facility failed to cover electrical boxes. This deficient practice would create electrical injury and increase a fire hazard. The facility has the capacity for 63 beds with a census of 32 on the day of survey.

Findings are:
Observation on 11-7-23 at 11:04 am revealed, an open electrical junction box on the HVAC unit #1.

During an interview on 11-7-23, at 11:04 am, Staff A confirmed the open junction box.

Based on observation and interview, the facility failed to prohibit the use of extension cords as a substitute for adequate wiring. This deficient practice would create an increased fire hazard. The facility has the capacity for 63 beds with a census of 32 on the day of survey.

Findings are:
Observation on 11-7-23 at 10:07 am revealed, extension cords were used to power facility servers.

During an interview on 11-7-23 at 10:07 am, Staff A confirmed the extension cords.