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Based on observation it was determined the facility failed to:

1. ensure the soiled utility room corridor door closed and latch in a hazardous area when tested three of three times; and

2. maintain and safeguard the room being used as a storage room and bed recovery maintenance room.

Findings include:

1. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.1, Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

On September 20, 2017, surveyors accompanied by the Director of Facility Services and Heating Ventilation Air Conditioning Technician observed the soiled utility room on the second floor of the hospital marked 2B275 did not close and latch when tested three of three times by the HVAC Technician.

During the exit conference on September 21, 2017, the above findings were again acknowledged by the Administrative Director and Director of Facilities Services.

Failing to maintain a smoke/fire resistance door to close and latch in a hazardous room could cause harm to the patients in time of a fire.

2. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.1, Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.
Observation of the emergency management storage room and a bed recovery maintenance repair room with the Director of Facility Services was determined the facility failed to maintain and safeguard the room being used as a storage room and bed recover maintenance room.

On September 21, 2017, surveyors accompanied by the Director of Facility Services and Heating Ventilation Air Conditioning Technician observed the first floor emergency management storage room and bed recovery maintenance repair room.

The following was observed during the survey of the room.

1. The room was being used as an emergency management storage room and bed recovery maintenance repair room for hospital beds.
2. The corridor door to the room did not self or automatic close. There was no self or automatic closure on the door to the room.
3. Three of four walls in the room were missing approximately eight feet of sheetrock and the room was not smoke proof.
4. Flammable products were being used to repair several beds in the room.
5. There was no rated flammable cabinet in the room for the flammable products being used for the maintenance repair of the beds in the room..

The following flammable products were observed next to the beds being repaired:

1. One and a quarter gallons of oil stored in two one gallon plastic containers.
2. Three in one oil dry lubricant spray
3. WD 40 spray

During the exit conference on September 21, 2017, the above findings were again acknowledged by the Administrative Director and Director of Facilities Services.

Failing to maintain a room being used as a storage room and bed recover maintenance room could result in a fire and could cause harm to the patients

Based on observation with the Director of Facility Services and Heating Ventilation Air Conditioning Technician it was determined:

1. the facility failed to maintain the fire pump from leaking excessively more than one drop per second.

2. the facility failed to maintain the sprinkler system, sprinkler heads and assembly free from lint (foreign material) on the third floor of the hospital.

Findings include:

1. NFPA 101, Life Safety Code, 2012 Edition, Chapter 4 General. "Section 4.5.8 "Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained, unless the code exempts such maintenance. NFPA 25, Standard for the inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, Chapter 8, Section 8.2. Inspection. The purpose of inspection shall be to verify that the pump assembly appears to be in operating condition and is free from physical damage. Section 8.2.2 The pertinent visual observations specified in the following checklists shall be performed weekly: See Table A.8.2.2 (2) Check packing adjustment approximately one drop per second is necessary to keep packing lubricated."

On September 20, 2017, the surveyors accompanied by the Director of Facility Services and Heating Ventilation Air Conditioning Technician observed the fire pump. The packing gland of the fire pump had a steady flow of running water as seen in the drip pocket of the fire pump at the time of the survey. The normal amount of water should be one drop per second to keep the packing gland lubricated.

During the exit conference on September 21, 2017, the above findings were again acknowledged by the Administrative Director and Director of Facilities Services.

Failing to maintain the fire pump during a fire may cause a failure in the automatic sprinkler system and cause harm to the patients, in time of a fire.

2. NFPA 101 Life Safety Code, 2012 edition, Chapter 19, Section 19.3.5.1 "Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Chapter 9, Section 9.7.1 "Each automatic sprinkler system required by another section of this Code shall be in accordance with on of the following." " NFPA 13, Standard for the Installation of Sprinkler Systems." Chapter 26, Section 26.1 "General." "A sprinkler system installed in accordance with standard shall be properly inspected, tested, and maintained by the property owner or their authorized representative in accordance with NFPA 25. NFPA 25, Section 5.2.1 "Sprinklers, Section 5.2.1.1.1 "Sprinklers shall not show signs of leakage, shall be free of corrosion, foreign materials, paint and physical damage." Section 5.2.1.1.2 Any sprinkler that shows the signs of any of the following shall be replaced. 1. leakage 2. Corrosion 3. Physical damage 4. Loss of fluid in the glass bulb heat responsive element 5. * Loading See A.5.2.1.1.2 (5) In lieu of replacing sprinklers that are loaded with a coating of dust , it is permitted to clean sprinklers with compressed air or by a vacuum provided that the equipment does not touch the sprinkler. 6. Painting unless painted by the manufacturer. Section 5.2.1.1.4 Any sprinkler shall be replaced that has signs of leakage, is painted other than by the manufacturer, corroded, damaged, or loaded, is in the improper orientation. Annex E Examples of Classification of needed repairs Sprinklers and Escutcheon plates that are missing, painted or rusted.

On September 20, 2017 the surveyors accompanied by the Director of Facility Services and Heating Ventilation Air Conditioning Technician observed sprinkler heads with dust/lint or sheetrock spray on the sprinkler heads in the following locations on the third floor of the hospital.

1. Rooms 343 through 348
2. Rooms 350, 352, 355
3. The equipment storage room on the third floor, the sprinkler head and assembly was bent to one side, and it appears out of alignment.

During the exit conference on September 21, 2017, the above findings were again acknowledged by the Administrative Director and Director of Facilities Services.

Failing to maintain the sprinkler heads and escutcheon plates which are part of the entire sprinkler assembly could cause harm to the residents by allowing a fire to spread before the temperature is reached to set of the sprinkler head.

Based on observation it was determined the facility failed to fill penetrations in two smoke barriers in the entire hospital.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of at least ½ hour." Chapter 8, Section 8.5.6.2 Penetrations for cables cable trays, conduits, pipes, tubes, vents wires and similar items to accommodate electrical, plumbing and communications systems that pass through a wall , floor or /ceiling assembly constructed as a smoke barrier , or through the ceiling membrane of the roof /ceiling of a smoke barrier assembly shall be protected by a system or material capable of restricting the transfer of smoke.

Findings include:

On September 20, 2017, the surveyor, accompanied by the Director of Facility Services and Heating Ventilation Air Conditioning Technician observed observed unsealed penetrations, holes that went through both sides of two smoke barriers located on the second and fourth floors.

The second floor marked 2A236A and fourth floor by smoke barrier marked 4A104A.

During the exit conference on September 21, 2017, the above findings were again acknowledged by the Administrative Director and Director of Facilities Services.

Failing to protect the penetrations, and holes in the smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility, which could cause harm to the patients in time of a fire.

Based on observation it was determined the facility:

1. failed to secure one oxygen E-type cylinder in a storage rack or stand in the main exterior oxygen storage location for the hospital.

2. failed to protect electrical devices from physical damage in an oxygen storage room on the third floor of the hospital.

Findings include:

1. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 11 Section 11.6.2.3 (11) Free standing cylinders shall be properly chained or supported in a proper cylinder stand or cart."

2. NFPA 99 2012 Edition Standard for Health Care Facilities." Chapter 5 Section 5.1.3.3.2 Design and Construction. Section 5.1.3.3.2 (5) They shall be in compliant with NFPA 70 National Electrical Code, for ordinary locations. Locations for central supply systems and the storage of positive -pressure gases shall meet the following requirements. Section 5-1.3.3.2 (5) Electrical devices should be physically protected, such as by use of protective barrier around the electrical devices, or by location of the electrical device such that it will avoid causing damage to the cylinders or containers. The device could be located at or above finished floor 1.5 m (5 ft) or other location that will not allow the possibility of the cylinders or containers to come into contact with the electrical device required by this section . Section 5.1.3.3.2 (10) They shall protect electrical devices from physical damage.

Findings include:

1. On September 20, 2017, the surveyors accompanied by the Director of Facility Services and Heating Ventilation Air Conditioning Technician observed one unsecured medical gas oxygen cylinder E-type located in the exterior main oxygen storage area was not secured in a rack or stand.

2. The third floor oxygen storage room the wall electrical receptacle outlets in the oxygen storage room were not physically protected from physical damage.

During the exit conference on September 21, 2017, the above findings were again acknowledged by the Administrative Director and Director of Facilities Services.

Failing to secure a compressed medical gas cylinder could cause harm to the patients and staff if oxygen cylinders are not secured in a rack or stand. Failure to protect electrical receptacles from physical damage could result in a fire if a oxygen cylinder hits the exposed electrical receptacle outlets.