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Based on observation and staff interview, the facility fails to ensure that corridor doors are maintained properly. This deficient practice of failing to assure that door latch tightly in their frame would not prevent the passage of fire or smoke to other areas of the building, affecting approximately 10 patients, and any visitors or staff in 3 of 7 smoke zones. The facility has a capacity 54 of with a census of 31 at the time of the survey.

Findings include:

During the tour conducted on 10/19/2016, it is observed:

-- 1. Between 8:45 a.m. and 12:15 p.m., during records review for the last 5 quarters, it is revealed that rolling doors separating Pharmacy and Laboratory from the corridor are past due for annual maintenance and testing. Reports from vendor indicate "needs to be fused (fusible links) on both sides of the wall".

-- 2. At 3:29 p.m., the corridor door to Patient Room 114 has an over-the-door rack with infection control items. The rack restricts closing of the door, requiring additional effort to assure closure and positive latching of the door.

-- 3. At 3:39 p.m., the corridor door to the Nursing Office at the Admissions Nursing Desk would not latch tightly in its frame.

-- 4. At 5:16 p.m., at Respiratory Therapy office, door latch has been removed; door will not latch tightly in its frame.


Chief Operations Officer or Plant Operations Lead Technician was present and acknowledged the findings.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop down or plunger type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3.

Based on observation and staff interview, the facility failed to maintain doors to hazardous rooms in a fashion that allows it to close automatically in the event of an emergency. This condition would allow for the spread of smoke to other areas of the building, affecting approximately 8 patients and any visitors or staff in 2 of 7 smoke zones. The facility has a capacity for 54 and a census of 31 at the time of this survey.

During the tour conducted on 10/19/2016, it is observed:

-- 1. At 2:43 p.m. it was observed in the kitchen dry good storage room that the rated 1 1/2 hour fire door has been propped open using two containers of approximately 2 1/2 gallons each of cooking oil.

-- 2. At 4:46 p.m. it was observed in the hallway corridor between the pharmacy and the lab the south leaf of the fire doors would not latch upon drop test.

Chief Operations Officer or Plant Operations Lead Technician was present and acknowledged the findings.

NFPA Standard: A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2. 2000 NFPA 101, 7.2.1.8.1

Based upon observation and staff interview, the facility fails to assure that spaces between penetrating items and smoke barriers are filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. The deficient practice would not prevent the passage of smoke to other areas of the building, affecting all patients, visitors and staff in 4 of 7 smoke zones. The facility has a capacity of 54 with a census of 31 at the time of the survey.

Findings include:

During the tour conducted on 10/19/2016, it is observed:

-- 1. At 3:14 p.m., smoke barrier wall in corridor above ceiling, north of room 102 has unsealed gaps around cold water pipes and cables. spaces filled with insulation but not sealed.
-- 2. At 3:20 p.m., smoke barrier wall on south side of corridor of room 102 has unsealed gaps around water pipes and conduit.
-- 3. At 4:42 p.m., sprinkler assembly has pulled away from corridor wall causing a unsealed gap in the east/west corridor - south of operating room below sky light.

Chief Operations Officer or Plant Operations Lead Technician was present and acknowledged the findings.

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other spaces. The area of deficient practice would not prevent the passage of fire or smoke to other area of the building, affecting all patients and any staff or visitors in 7 of 7 smoke zones. The facility has a capacity of 54 with a census of 31 at the time of this survey.

Findings Include:

During the tour conducted on 10/19/16 it is observed


-- 1. At approximately 1:56 p.m., Mechanical Room 11 has unsealed penetrations around all thread in ceiling.

-- 2. At approximately 3:03 p.m., Solid Utility Room 01 door to corridor does not self close and latch

-- 3. At approximately 3:24 p.m., Mechanical Room by Patient Room 109 has unsealed penetration around conduit near ceiling, north west wall.

-- 4. At approximately 4:09 p.m., Mechanical Room 4, has multiple unsealed penetrations around all thread in ceiling.

-- 5. At approximately 4:10 p.m., Mechanical room 4, has unsealed penetrations around cold water pipes through wall to corridor.

Chief Operations Officer or Plant Operations Lead Technician was present and acknowledged the findings.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1.

Based on observation and interview the facility fails to maintain the exit discharge lighting. The deficient practice could result in leaving an exit pathway from the facility in darkness, affecting approximately all patients and any visitors or staff in 7 of 7 smoke zones. This facility has a capacity of 54 and a census of 31 at the time of this survey.

Findings include:

During the tour conducted on 10/19/2016, in the afternoon, it is observed that each exterior exit is equipped with only single-bulb fixtures.

Chief Operations Officer and Plant Operations Lead Technician were present and acknowledged the findings

NFPA Standard: Required illumination shall be arranged so that the failure of any single bulb or unit does not result in less than .2 foot-candles of illumination in any designated area. 2000 NFPA 101, 7.8.1.4

Based upon a review of records and staff interview, the facility fails to assure that fire drills are held at unexpected times, under varying conditions and at least once per shift per quarter. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all residents and occupants in the event of a fire, affecting all patients, visitors and staff in 7 of 7 smoke zones. The facility has a capacity 54 of with a census of 31 at the time of the survey.

Findings include:

During the tour conducted on 10/19/2016, between 8:45 a.m. and 12:15 p.m., a review of records for the last 5 quarters revealed the following:

-- 1. Drills held in close proximity. Drills for the 2nd shift for the 4th Qtr. 2015 and 1st, 2nd and 3rd shifts of 2016 were held at 7:30 p.m., 7:25 p.m., 7:25 p.m. and 7:23 p.m., respectively.

Chief Operations Officer and Plant Operations Lead Technician were present and acknowledged the findings and results of the records review.

NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 19.7.1.2

Based upon observation, record review and staff interview, the facility fails to assure that the automatic sprinkler system is inspected, tested and maintained in accordance with NFPA 25. The deficient practice could result in the unexpected failure of the automatic fire sprinkler system, affecting all patients and any staff or visitors in 7 of 7 smoke zones. The facility has a capacity of 54 with a census of 31 at the time of this survey.

Findings include:

During the tour conducted on 10/19/2016 it is observed that

-- 1. Between 8:45 a.m. and 12:15 p.m. a review of records revealed there is no documentation of monthly visual inspections of the sprinkler systems.

-- 2. At approximately 2:20 p.m., there are missing ceiling tiles located in the Telecom room may cause smoke and fire to spread above sprinkler protection.

-- 3. At approximately 2:30 p.m., sprinkler head located in the kitchen south of range hood is covered with grease and other foreign material which could prevent it from functioning
properly.

-- 4. At approximately 2:38 p.m., sprinkler head located just outside of kolpak cooler is covered with dirt and other foreign material which could prevent it from functioning properly.

-- 5. At approximately 3:34 p.m., sprinkler head located in the telemetry west nurses station is covered with dirt and other foreign material which could prevent it from functioning properly.

-- 6. At approximately 4:14 p.m., northeast sprinkler assembly located in the receiving room has unsealed gap between the sprinkler head and ceiling tile.

-- 7. At approximately 4:32 p.m., sprinkler head located in the east Operating Room, small storage room is covered with dirt and other foreign material which could prevent it from functioning properly.

-- 8. At approximately 4:40 p.m., furthest west sprinkler head located in ICU waiting room is covered with dirt and other foreign material which could prevent it from functioning properly.

-- 9. At approximately 4:47 p.m., sprinkler head located in the Radiology work room is covered with dirt and other foreign material which could prevent it from functioning properly.

-- 10. At approximately 5:07 p.m.,sprinkler assembly located in the Intermediate nurses supply room has unsealed gap between the sprinkler head and ceiling tile.

Chief Operations Officer or Plant Operations Lead Technician was present and acknowledged the findings.

NFPA Standard: Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. 1998 NFPA 25, 2-2.1.1

NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1

Based on record review and staff interview the facility fails to assure fire extinguishers are inspected monthly in accordance with NFPA 10. This deficiency practice fails to ensure that a fire extinguisher will be in proper working condition when needed in the event of a fire emergency, affecting zero patients in zero of 7 smoke zones. The facility has a capacity of 54 and census of 31 at the time of the survey.

Findings Include:

During the tour conducted on 10/19/2016, it is observed:

-- 1. At 5:14 p.m. it was observed at the liquid oxygen storage tank located outside on the north side of the facility there is a fire extinguisher mounted on the fence within the perimeter of the servicing area that has not been annually serviced and is discharged.

Chief Operations Officer or Plant Operations Lead Technician was present and acknowledged the findings.

NFPA Standard: Fire extinguishers shall be inspected when placed in service and thereafter at approximately 30-day intervals per 1998 NFPA 10, 4-3.1

NFPA Standard: Portable fire extinguishers shall be maintained in a fully charged and operable condition, and kept in their designated places at all times when they are not being used. 1998 NFPA 10, 1-6.2

Based upon observation, a review of records and staff interview, the facility fails to assure that generators are inspected and exercised in accordance with NFPA 99 and facility fails to provide a remote shut-off for the generator in accordance with NFPA 110. These deficient practices could result the reduction of reliability of the generator in the event of an emergency and could result in the inability to remotely discontinue electrical services of the generator to avoid electrocution, affecting all patients, visitors and staff in 7 of 7 smoke zones. The facility has a capacity 54 of with a census of 31 at the time of the survey.

Findings include:

During the tour conducted on 10/19/2016, it is observed:

-- 1. Between 8:45 a.m. and 12:15 p.m., a review of records for the last 5 quarters revealed that for the months of October, November and December of 2015, August, or September of 2016, monthly testing under load conditions was conducted for a period of less than the required minimum of 30 minutes per month.

-- 2. Between 8:45 a.m. and 12:15 p.m., a review of records for the last 5 quarters revealed that there is no policy for generator malfunction or refueling

-- 3. Observation of the generator at 5:07 p.m., revealed that there is no remote emergency shut-off provided for the automatic diesel generator.

Chief Operations Officer or Plant Operations Lead Technician was present and acknowledged the findings and results of the records review.

NFPA Standard: Level 1 and level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes. 1999 NFPA 110, 6.4.1 and 6.4.2

NFPA Standard: 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.

NFPA Standard: 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 observation and staff interview, the facility fails to ensure that all electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2. This deficient practice could result in an electrical short causing a fire, affecting all patients, visitors and staff in 7 of 7 smoke zones. The facility has a capacity of 54 and a census of 31 at the time of the survey.

Findings include:

During the tour conducted on 10/19/16 it is observed:

-- 1. At 1:56 p.m. it was observed in the northeast large conference room at the north end of the room on both the east and west sides of the TV monitor there is an open junction box on each side with exposed wiring.

-- 2. At 2:11 p.m. it was observed in mechanical room #11 above the door there is a humidifier mounted from the ceiling; the door on the west end has been left unsecured and open allowing exposed wiring.

-- 3. At 2:15 p.m. it was observed in the front lobby at the receptionist desk there is a power strip plugged into a multiplug adapter below the desk.

-- 4. At 2:19 p.m. it was observed in the COO's Office along the east wall there is a power strip hanging by the power cord.

-- 5. At 2:44 p.m. it was observed in the kitchen above the steam table in the west hallway there is an electrical outlet within 6 feet of a water source that does not have Ground-Fault Circuit-Interrupter (GFCI) protection.

-- 6. At 3:06 p.m. it was observed in room 02 - mechanical room there is a 4 inch by 4 inch open junction box above the electrical panels.

-- 7. At 3:22 p.m. it was observed in the mechanical room by patient room 109 above the door there is an electrical box missing the cover panel leaving exposed wiring.

-- 8. At 3:45 p.m. it was observed at the admissions nursing desk (Grand Central) on the east wall above the sink there is an electrical outlet within 6 feet of a water source that does not have Ground-Fault Circuit-Interrupter (GFCI) protection.

-- 9. At 5:25 p.m. it was observed in the Immediate Care hallway corridor by room 10 there is an open junction box above the ceiling.

Chief Operations Officer or Plant Operations Lead Technician was present and acknowledged the findings.

NFPA Standard: Unused openings in boxes, race- ways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment. 1999 NFPA 70 110.12
NFPA Standard: Flexible cords and cables shall be connected to devices and to fittings so that tension will not be transmitted to joints or terminals. 1999 NFPA 70, 400-10
NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8

Based on observation and staff interview, the facility fails to ensure that corridor doors are maintained properly. This deficient practice of failing to assure that door latch tightly in their frame would not prevent the passage of fire or smoke to other areas of the building, affecting approximately 10 patients, and any visitors or staff in 3 of 7 smoke zones. The facility has a capacity 54 of with a census of 31 at the time of the survey.

Findings include:

During the tour conducted on 10/19/2016, it is observed:

-- 1. Between 8:45 a.m. and 12:15 p.m., during records review for the last 5 quarters, it is revealed that rolling doors separating Pharmacy and Laboratory from the corridor are past due for annual maintenance and testing. Reports from vendor indicate "needs to be fused (fusible links) on both sides of the wall".

-- 2. At 3:29 p.m., the corridor door to Patient Room 114 has an over-the-door rack with infection control items. The rack restricts closing of the door, requiring additional effort to assure closure and positive latching of the door.

-- 3. At 3:39 p.m., the corridor door to the Nursing Office at the Admissions Nursing Desk would not latch tightly in its frame.

-- 4. At 5:16 p.m., at Respiratory Therapy office, door latch has been removed; door will not latch tightly in its frame.


Chief Operations Officer or Plant Operations Lead Technician was present and acknowledged the findings.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop down or plunger type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3.

Based on observation and staff interview, the facility failed to maintain doors to hazardous rooms in a fashion that allows it to close automatically in the event of an emergency. This condition would allow for the spread of smoke to other areas of the building, affecting approximately 8 patients and any visitors or staff in 2 of 7 smoke zones. The facility has a capacity for 54 and a census of 31 at the time of this survey.

During the tour conducted on 10/19/2016, it is observed:

-- 1. At 2:43 p.m. it was observed in the kitchen dry good storage room that the rated 1 1/2 hour fire door has been propped open using two containers of approximately 2 1/2 gallons each of cooking oil.

-- 2. At 4:46 p.m. it was observed in the hallway corridor between the pharmacy and the lab the south leaf of the fire doors would not latch upon drop test.

Chief Operations Officer or Plant Operations Lead Technician was present and acknowledged the findings.

NFPA Standard: A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2. 2000 NFPA 101, 7.2.1.8.1

Based upon observation and staff interview, the facility fails to assure that spaces between penetrating items and smoke barriers are filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. The deficient practice would not prevent the passage of smoke to other areas of the building, affecting all patients, visitors and staff in 4 of 7 smoke zones. The facility has a capacity of 54 with a census of 31 at the time of the survey.

Findings include:

During the tour conducted on 10/19/2016, it is observed:

-- 1. At 3:14 p.m., smoke barrier wall in corridor above ceiling, north of room 102 has unsealed gaps around cold water pipes and cables. spaces filled with insulation but not sealed.
-- 2. At 3:20 p.m., smoke barrier wall on south side of corridor of room 102 has unsealed gaps around water pipes and conduit.
-- 3. At 4:42 p.m., sprinkler assembly has pulled away from corridor wall causing a unsealed gap in the east/west corridor - south of operating room below sky light.

Chief Operations Officer or Plant Operations Lead Technician was present and acknowledged the findings.

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other spaces. The area of deficient practice would not prevent the passage of fire or smoke to other area of the building, affecting all patients and any staff or visitors in 7 of 7 smoke zones. The facility has a capacity of 54 with a census of 31 at the time of this survey.

Findings Include:

During the tour conducted on 10/19/16 it is observed


-- 1. At approximately 1:56 p.m., Mechanical Room 11 has unsealed penetrations around all thread in ceiling.

-- 2. At approximately 3:03 p.m., Solid Utility Room 01 door to corridor does not self close and latch

-- 3. At approximately 3:24 p.m., Mechanical Room by Patient Room 109 has unsealed penetration around conduit near ceiling, north west wall.

-- 4. At approximately 4:09 p.m., Mechanical Room 4, has multiple unsealed penetrations around all thread in ceiling.

-- 5. At approximately 4:10 p.m., Mechanical room 4, has unsealed penetrations around cold water pipes through wall to corridor.

Chief Operations Officer or Plant Operations Lead Technician was present and acknowledged the findings.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1.

Based on observation and interview the facility fails to maintain the exit discharge lighting. The deficient practice could result in leaving an exit pathway from the facility in darkness, affecting approximately all patients and any visitors or staff in 7 of 7 smoke zones. This facility has a capacity of 54 and a census of 31 at the time of this survey.

Findings include:

During the tour conducted on 10/19/2016, in the afternoon, it is observed that each exterior exit is equipped with only single-bulb fixtures.

Chief Operations Officer and Plant Operations Lead Technician were present and acknowledged the findings

NFPA Standard: Required illumination shall be arranged so that the failure of any single bulb or unit does not result in less than .2 foot-candles of illumination in any designated area. 2000 NFPA 101, 7.8.1.4

Based upon a review of records and staff interview, the facility fails to assure that fire drills are held at unexpected times, under varying conditions and at least once per shift per quarter. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all residents and occupants in the event of a fire, affecting all patients, visitors and staff in 7 of 7 smoke zones. The facility has a capacity 54 of with a census of 31 at the time of the survey.

Findings include:

During the tour conducted on 10/19/2016, between 8:45 a.m. and 12:15 p.m., a review of records for the last 5 quarters revealed the following:

-- 1. Drills held in close proximity. Drills for the 2nd shift for the 4th Qtr. 2015 and 1st, 2nd and 3rd shifts of 2016 were held at 7:30 p.m., 7:25 p.m., 7:25 p.m. and 7:23 p.m., respectively.

Chief Operations Officer and Plant Operations Lead Technician were present and acknowledged the findings and results of the records review.

NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 19.7.1.2

Based upon observation, record review and staff interview, the facility fails to assure that the automatic sprinkler system is inspected, tested and maintained in accordance with NFPA 25. The deficient practice could result in the unexpected failure of the automatic fire sprinkler system, affecting all patients and any staff or visitors in 7 of 7 smoke zones. The facility has a capacity of 54 with a census of 31 at the time of this survey.

Findings include:

During the tour conducted on 10/19/2016 it is observed that

-- 1. Between 8:45 a.m. and 12:15 p.m. a review of records revealed there is no documentation of monthly visual inspections of the sprinkler systems.

-- 2. At approximately 2:20 p.m., there are missing ceiling tiles located in the Telecom room may cause smoke and fire to spread above sprinkler protection.

-- 3. At approximately 2:30 p.m., sprinkler head located in the kitchen south of range hood is covered with grease and other foreign material which could prevent it from functioning
properly.

-- 4. At approximately 2:38 p.m., sprinkler head located just outside of kolpak cooler is covered with dirt and other foreign material which could prevent it from functioning properly.

-- 5. At approximately 3:34 p.m., sprinkler head located in the telemetry west nurses station is covered with dirt and other foreign material which could prevent it from functioning properly.

-- 6. At approximately 4:14 p.m., northeast sprinkler assembly located in the receiving room has unsealed gap between the sprinkler head and ceiling tile.

-- 7. At approximately 4:32 p.m., sprinkler head located in the east Operating Room, small storage room is covered with dirt and other foreign material which could prevent it from functioning properly.

-- 8. At approximately 4:40 p.m., furthest west sprinkler head located in ICU waiting room is covered with dirt and other foreign material which could prevent it from functioning properly.

-- 9. At approximately 4:47 p.m., sprinkler head located in the Radiology work room is covered with dirt and other foreign material which could prevent it from functioning properly.

-- 10. At approximately 5:07 p.m.,sprinkler assembly located in the Intermediate nurses supply room has unsealed gap between the sprinkler head and ceiling tile.

Chief Operations Officer or Plant Operations Lead Technician was present and acknowledged the findings.

NFPA Standard: Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. 1998 NFPA 25, 2-2.1.1

NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1

Based on record review and staff interview the facility fails to assure fire extinguishers are inspected monthly in accordance with NFPA 10. This deficiency practice fails to ensure that a fire extinguisher will be in proper working condition when needed in the event of a fire emergency, affecting zero patients in zero of 7 smoke zones. The facility has a capacity of 54 and census of 31 at the time of the survey.

Findings Include:

During the tour conducted on 10/19/2016, it is observed:

-- 1. At 5:14 p.m. it was observed at the liquid oxygen storage tank located outside on the north side of the facility there is a fire extinguisher mounted on the fence within the perimeter of the servicing area that has not been annually serviced and is discharged.

Chief Operations Officer or Plant Operations Lead Technician was present and acknowledged the findings.

NFPA Standard: Fire extinguishers shall be inspected when placed in service and thereafter at approximately 30-day intervals per 1998 NFPA 10, 4-3.1

NFPA Standard: Portable fire extinguishers shall be maintained in a fully charged and operable condition, and kept in their designated places at all times when they are not being used. 1998 NFPA 10, 1-6.2

Based upon observation, a review of records and staff interview, the facility fails to assure that generators are inspected and exercised in accordance with NFPA 99 and facility fails to provide a remote shut-off for the generator in accordance with NFPA 110. These deficient practices could result the reduction of reliability of the generator in the event of an emergency and could result in the inability to remotely discontinue electrical services of the generator to avoid electrocution, affecting all patients, visitors and staff in 7 of 7 smoke zones. The facility has a capacity 54 of with a census of 31 at the time of the survey.

Findings include:

During the tour conducted on 10/19/2016, it is observed:

-- 1. Between 8:45 a.m. and 12:15 p.m., a review of records for the last 5 quarters revealed that for the months of October, November and December of 2015, August, or September of 2016, monthly testing under load conditions was conducted for a period of less than the required minimum of 30 minutes per month.

-- 2. Between 8:45 a.m. and 12:15 p.m., a review of records for the last 5 quarters revealed that there is no policy for generator malfunction or refueling

-- 3. Observation of the generator at 5:07 p.m., revealed that there is no remote emergency shut-off provided for the automatic diesel generator.

Chief Operations Officer or Plant Operations Lead Technician was present and acknowledged the findings and results of the records review.

NFPA Standard: Level 1 and level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes. 1999 NFPA 110, 6.4.1 and 6.4.2

NFPA Standard: 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.

NFPA Standard: 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 observation and staff interview, the facility fails to ensure that all electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2. This deficient practice could result in an electrical short causing a fire, affecting all patients, visitors and staff in 7 of 7 smoke zones. The facility has a capacity of 54 and a census of 31 at the time of the survey.

Findings include:

During the tour conducted on 10/19/16 it is observed:

-- 1. At 1:56 p.m. it was observed in the northeast large conference room at the north end of the room on both the east and west sides of the TV monitor there is an open junction box on each side with exposed wiring.

-- 2. At 2:11 p.m. it was observed in mechanical room #11 above the door there is a humidifier mounted from the ceiling; the door on the west end has been left unsecured and open allowing exposed wiring.

-- 3. At 2:15 p.m. it was observed in the front lobby at the receptionist desk there is a power strip plugged into a multiplug adapter below the desk.

-- 4. At 2:19 p.m. it was observed in the COO's Office along the east wall there is a power strip hanging by the power cord.

-- 5. At 2:44 p.m. it was observed in the kitchen above the steam table in the west hallway there is an electrical outlet within 6 feet of a water source that does not have Ground-Fault Circuit-Interrupter (GFCI) protection.

-- 6. At 3:06 p.m. it was observed in room 02 - mechanical room there is a 4 inch by 4 inch open junction box above the electrical panels.

-- 7. At 3:22 p.m. it was observed in the mechanical room by patient room 109 above the door there is an electrical box missing the cover panel leaving exposed wiring.

-- 8. At 3:45 p.m. it was observed at the admissions nursing desk (Grand Central) on the east wall above the sink there is an electrical outlet within 6 feet of a water source that does not have Ground-Fault Circuit-Interrupter (GFCI) protection.

-- 9. At 5:25 p.m. it was observed in the Immediate Care hallway corridor by room 10 there is an open junction box above the ceiling.

Chief Operations Officer or Plant Operations Lead Technician was present and acknowledged the findings.

NFPA Standard: Unused openings in boxes, race- ways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment. 1999 NFPA 70 110.12
NFPA Standard: Flexible cords and cables shall be connected to devices and to fittings so that tension will not be transmitted to joints or terminals. 1999 NFPA 70, 400-10
NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8