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Based on observation and staff interview, the facility failed to maintain positive latching of a corridor door in 1 of 6 smoke compartments. This condition had the potential to allow smoke and fire to migrate into the exit corridor. Facility census was 7 of 25.

Findings are:
Observations during the facility tour on 6/7/12, at 1:09 pm revealed the Beauty Shop Door failed to latch when pulled shut.
In an interview conducted at the time of observations, (6/7/12, at 1:09 pm), Maintenance A acknowledged that the door failed to latch.

Based on observation and staff interview, the facility failed to maintain fire barriers with at least one hour fire resistance rating for 1 of 3 fire barriers. This condition had the potential to allow smoke or fire to migrate between smoke compartments. Facility census was 7 of 25.

Findings are:
Observations during the facility tour on 6/7/12, from 2:17 pm to 2:25 pm revealed:
1. The Station Two Fire Doors by the Shower revealed holes around pipes and wires that failed to be sealed in the barrier above ceiling.
2. A hole around a sprinkler pipe in the barrier wall above ceiling near the Patient Wing, North Stairwell failed to be sealed.
3. Holes failed to be sealed in the barrier wall that separated Admissions and Station One.
4. Holes failed to be sealed in the barrier wall that separated Station Two and the Radiology Corridor.
In an interview conducted at the time of observation, (6/7/12, from 2:17 pm to 2:25 pm), Maintenance A confirmed the penetrations in the barrier walls.

Based on observation and staff interview, the facility failed to install battery backup emergency lighting in accordance with the National Fire Protection Association 99. This condition would leave 1 of 2 Operating Rooms in darkness during the 1-10 second gap from loss of power until the emergency generator restored power. Facility census was 7 of 25.

Findings are:
Observation during the facility tour on 6/7/12, at 12:58 pm revealed the Operating Room One failed to have battery backup emergency lighting/task illumination installed in the room.
In an interview conducted at the time of observations (6/7/12, at 12:58 pm), Maintenance A acknowledged the findings.

Actual NFPA Standard:
NFPA 99, 3-3.2.1.2.5e Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

Based on observation, record review and staff interview, the facility failed to install a line isolation monitor or ground-fault circuit interrupter protection in 1 of 2 operating rooms in accordance with NFPA 99. This condition had the potential to allow a patient to receive electrical shock during a surgery.

Findings are:
Observations during the facility tour on 6/7/12, at 12:57 pm revealed GFCI protection or a line isolation monitor failed to be installed in Operating Room One.
Record review revealed no written specifics of which type of procedures will normally take place in each operating room and what special protection against electric shock has to be provided if wet procedures are likely to be performed.
In an interview conducted at the time of observation, (6/7/12, at 12:57 pm), Maintenance A verified that GFCI protection or line isolation monitoring failed to be installed and that a policy did not exist of normally conducted procedures with what, if any, special protection was needed.

Actual NFPA Standard:
NFPA 99, 3-3.2.1.2 All Patient Care Areas.
(f) Wet Locations.
1. * Wet location patient care areas shall be provided with special protection against electric shock. This special protection shall be provided by a power distribution system that inherently limits the possible ground-fault current due to a first fault to a low value, without interrupting the power supply; or by a power distribution system in which the power supply is interrupted if the ground-fault current does, in fact, exceed a value of 6 mA.
2. The use of an isolated power system (IPS) shall be permitted as a protective means capable of limiting ground fault current without power interruption. When installed, such a power system shall conform to the requirements of 3-3.2.2.
3. Where power interruption under first fault condition (line-to-ground fault) is tolerable, the use of a ground-fault circuit interrupter (GFCI) shall be permitted as the protective means that monitors the actual ground fault current and interrupts the power when that current exceeds 6 mA.

Based on record review and staff interview, the facility failed to provide documentation that 2 of 2 generators had been tested in accordance with the National Fire Protection Association 110. This condition increased the potential that the generators would not function during an emergency. Facility census was 7 of 25.

Findings are:
Record review during the facility tour of emergency generator maintenance and testing revealed that the facility failed to document weekly testing of both generators.
In an interview conducted at the time of record review (6/7/12 at 10:30 am), Maintenance A confirmed that the information was not recorded.

Actual NFPA Standard:
NFPA 110, 6-3.1*
The EPSS shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class.

Note: Please refer to A-6-3.1 for an example of a complete maintenance checklist.

Based on observation and staff interview, the facility failed to use electrical wiring and equipment in accordance with the National Fire Protection Association, 70 in 3 of 3 smoke compartments. This condition had the potential to start an electrical fire. Facility census was 7 of 25.

Findings are:
Observations during the facility tour on 6/7/12, from 11:11 am to 1:33 pm revealed:
1. The open electrical junction box above the door in Storage Room 2 failed to have the cover replaced.
2. Computer equipment was plugged into an extension cord in the Support Office. The facility failed to not use an extension cord in lieu of permanent wiring.
3. A microwave was plugged into a power strip in the Kitchen. The facility failed to plug the heat producing device into a hardwired outlet.
4. A six-outlet power tap was in use in OR 1 underneath the counter cabinets. An outlet strip tested in accordance with UL 60601-1 failed to be used.
In an interview conducted at the time of observations (6/7/12, from 11:11 am to 1:33 pm), Maintenance A acknowledged the findings.

Based on observation and staff interview, the facility failed to maintain positive latching of a corridor door in 1 of 6 smoke compartments. This condition had the potential to allow smoke and fire to migrate into the exit corridor. Facility census was 7 of 25.

Findings are:
Observations during the facility tour on 6/7/12, at 1:09 pm revealed the Beauty Shop Door failed to latch when pulled shut.
In an interview conducted at the time of observations, (6/7/12, at 1:09 pm), Maintenance A acknowledged that the door failed to latch.

Based on observation and staff interview, the facility failed to maintain fire barriers with at least one hour fire resistance rating for 1 of 3 fire barriers. This condition had the potential to allow smoke or fire to migrate between smoke compartments. Facility census was 7 of 25.

Findings are:
Observations during the facility tour on 6/7/12, from 2:17 pm to 2:25 pm revealed:
1. The Station Two Fire Doors by the Shower revealed holes around pipes and wires that failed to be sealed in the barrier above ceiling.
2. A hole around a sprinkler pipe in the barrier wall above ceiling near the Patient Wing, North Stairwell failed to be sealed.
3. Holes failed to be sealed in the barrier wall that separated Admissions and Station One.
4. Holes failed to be sealed in the barrier wall that separated Station Two and the Radiology Corridor.
In an interview conducted at the time of observation, (6/7/12, from 2:17 pm to 2:25 pm), Maintenance A confirmed the penetrations in the barrier walls.

Based on observation and staff interview, the facility failed to install battery backup emergency lighting in accordance with the National Fire Protection Association 99. This condition would leave 1 of 2 Operating Rooms in darkness during the 1-10 second gap from loss of power until the emergency generator restored power. Facility census was 7 of 25.

Findings are:
Observation during the facility tour on 6/7/12, at 12:58 pm revealed the Operating Room One failed to have battery backup emergency lighting/task illumination installed in the room.
In an interview conducted at the time of observations (6/7/12, at 12:58 pm), Maintenance A acknowledged the findings.

Actual NFPA Standard:
NFPA 99, 3-3.2.1.2.5e Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

Based on observation, record review and staff interview, the facility failed to install a line isolation monitor or ground-fault circuit interrupter protection in 1 of 2 operating rooms in accordance with NFPA 99. This condition had the potential to allow a patient to receive electrical shock during a surgery.

Findings are:
Observations during the facility tour on 6/7/12, at 12:57 pm revealed GFCI protection or a line isolation monitor failed to be installed in Operating Room One.
Record review revealed no written specifics of which type of procedures will normally take place in each operating room and what special protection against electric shock has to be provided if wet procedures are likely to be performed.
In an interview conducted at the time of observation, (6/7/12, at 12:57 pm), Maintenance A verified that GFCI protection or line isolation monitoring failed to be installed and that a policy did not exist of normally conducted procedures with what, if any, special protection was needed.

Actual NFPA Standard:
NFPA 99, 3-3.2.1.2 All Patient Care Areas.
(f) Wet Locations.
1. * Wet location patient care areas shall be provided with special protection against electric shock. This special protection shall be provided by a power distribution system that inherently limits the possible ground-fault current due to a first fault to a low value, without interrupting the power supply; or by a power distribution system in which the power supply is interrupted if the ground-fault current does, in fact, exceed a value of 6 mA.
2. The use of an isolated power system (IPS) shall be permitted as a protective means capable of limiting ground fault current without power interruption. When installed, such a power system shall conform to the requirements of 3-3.2.2.
3. Where power interruption under first fault condition (line-to-ground fault) is tolerable, the use of a ground-fault circuit interrupter (GFCI) shall be permitted as the protective means that monitors the actual ground fault current and interrupts the power when that current exceeds 6 mA.

Based on record review and staff interview, the facility failed to provide documentation that 2 of 2 generators had been tested in accordance with the National Fire Protection Association 110. This condition increased the potential that the generators would not function during an emergency. Facility census was 7 of 25.

Findings are:
Record review during the facility tour of emergency generator maintenance and testing revealed that the facility failed to document weekly testing of both generators.
In an interview conducted at the time of record review (6/7/12 at 10:30 am), Maintenance A confirmed that the information was not recorded.

Actual NFPA Standard:
NFPA 110, 6-3.1*
The EPSS shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class.

Note: Please refer to A-6-3.1 for an example of a complete maintenance checklist.

Based on observation and staff interview, the facility failed to use electrical wiring and equipment in accordance with the National Fire Protection Association, 70 in 3 of 3 smoke compartments. This condition had the potential to start an electrical fire. Facility census was 7 of 25.

Findings are:
Observations during the facility tour on 6/7/12, from 11:11 am to 1:33 pm revealed:
1. The open electrical junction box above the door in Storage Room 2 failed to have the cover replaced.
2. Computer equipment was plugged into an extension cord in the Support Office. The facility failed to not use an extension cord in lieu of permanent wiring.
3. A microwave was plugged into a power strip in the Kitchen. The facility failed to plug the heat producing device into a hardwired outlet.
4. A six-outlet power tap was in use in OR 1 underneath the counter cabinets. An outlet strip tested in accordance with UL 60601-1 failed to be used.
In an interview conducted at the time of observations (6/7/12, from 11:11 am to 1:33 pm), Maintenance A acknowledged the findings.