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Based on observation, the facility failed to provide free egress from required exits by not using all of the approved methods listed in NFPA 101. This deficiency had the potential to affect 13 of 13. When all of the access control criteria are met the exterior Exit doors provide safe passage to all occupants in need of egress during normal operations as well as in the event of a emergency situation. One of one exit discharge doors are deficient in the (ER) Emergency Room.

During the facility tour on January 27, 2020, between the hours of 10:00 a.m. to 3:30 p.m. it was observed the Emergency Room exterior sliding door did not slide in the open position due to the motion sensor failing to operate properly.

NFPA 101: 7.2.1.6.2* Access-Controlled Egress Door Assemblies. Where permitted in Chapters 11 through 43, door assemblies in the means of egress shall be permitted to be equipped with electrical lock hardware that prevents egress, provided that all of the following criteria are met:
(1) A sensor shall be provided on the egress side, arranged to unlock the door leaf in the direction of egress upon detection of an approaching occupant.
(2) Door leaves shall automatically unlock in the direction of egress upon loss of power to the sensor or to the part of the access control system that locks the door leaves.
(3) Door locks shall be arranged to unlock in the direction of egress from a manual release device complying with all of the following criteria:
(a) The manual release device shall be located on the egress side, 40 in. to 48 in. (1015 mm to 1220 mm ) vertically above the floor, and within 60 in. (1525 mm) of the secured door openings.
(b) The manual release device shall be readily accessible and clearly identified by a sign that reads as follows:
PUSH TO EXIT.
(c) When operated, the manual release device shall result in direct interruption of power to the lock - independent of the locking system electronics-and the lock shall remain unlocked for not less than 30 seconds.
(4) Activation of the building fire-protective signaling system, if provided, shall automatically unlock the door leaves in the direction of egress, and the door leaves shall remain unlocked until the fire-protective signaling system has been manually reset.
(5) The activation of manual fire alarm boxes that activate the building fire-protective signaling system specified in 7.2.1.6.2(4) shall not be required to unlock the door leaves.
(6) Activation of the building automatic sprinkler or fire detection system, if provided, shall automatically unlock the door leaves in the direction of egress, and the door leaves shall remain unlocked until the fire-protective signaling system has been manually reset.
(7) The egress side of access-controlled egress doors, other than existing access-controlled egress doors, shall be provided with emergency lighting in accordance with Section 7.9.

Interview with the Maintenance Supervisor revealed the facility was not aware that one the motion sensor on the egress side of the Emergency Exit door was not functioning.

Based on visual observation the facility failed to assure that the building had a complete, supervised, automatic sprinkler system installed in accordance with NFPA 13. Activation of the sprinkler system shall trigger notification of the emergency to the fire alarm system within 90 seconds, which results in protection of life and property. This deficiency has the potential to affect 13 of 13 residents.

Findings:

During the facility tour on January 27, 2020, between the hours of 10:00 a.m. to 3:30 p.m. it was observed the kitchen cooler had lacked sprinkler coverage.

NFPA 13:8.1.1* The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers shall be installed throughout the premises.
(2) Sprinklers shall be located so as not to exceed the maximum protection area per sprinkler.
(3) Sprinklers shall be positioned and located so as to provide satisfactory performance with respect to activation timeand distribution.
(4) Sprinklers shall be permitted to be omitted from areas specifically allowed by this standard.
(5) When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.
(6) Clearance between sprinklers and ceilings exceeding the maximums specified in this standard shall be permitted, provided that tests or calculations demonstrate comparable sensitivity and performance of the sprinklers to those installed in conformance with these sections.
(7) Furniture, such as portable wardrobe units, cabinets, trophy cases, and similar features not intended for occupancy, does not require sprinklers to be installed in them. This type of feature shall be permitted to be attached to the finished structure.

Interview with the Maintenance Supervisor revealed the facility was not aware the automatic sprinkler system lacked sprinkler protection within the kitchen cooler.

Based on visual observation and record review the facility failed to maintain documentation for fire drills conducted during each quarter on each shift. Fire drills provide training in procedures in cases of emergency. The deficient practice had the potential to affect 13 of 13 patients.
1 of 4 quarters in 2019 were deficient.

Findings:

During the record review on January 27, 2020, between the hours of 10:00 a.m. to 3:30 p.m. it was observed the fourth quarter hospital nursing staff shift from 7:00 p.m. to 7:00 a.m. was not documented.

NFPA 101:19.7.1.6 states, "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."

Interview with the Maintenance Supervisor revealed the facility was not aware the fourth quarter fire drill logs were not documented for the hospital nursing shift from 7:00 p.m. to 7:00 a.m..

Based on visual observation the facility failed to provide a enclosure without motor driven equipment to store medical gas full or empty cylinders. When motor driven equipment are not stored in an enclosure with medical gas cylinders, the risk of a fire/smoke emergency increases. The deficiency has the potential to affect 0 of 0 patients.
Findings:

During the facility tour on January 27, 2020, between the hours of 10:00 a.m. to 3:30 p.m. it was observed the medical gas cylinders located in the maintenance building were lacking identifying labeling of full or empty and were in the same room with a energized (PTAC) Portable Terminal Air Conditioner.

NFPA 99: 5.1.3.3.4.2 Cylinders, whether full or empty, shall not be stored in enclosures containing motor-driven machinery, with the exception of cylinders intended for instrument air reserve headers complying with 5.1.3.9.5, which shall be permitted to be placed in the same location containing an instrument air compressor when it is the only motor-driven machinery located within the room. Only cylinders intended for instrument air reserve headers complying with 5.1.3.9.5 shall be permitted to be stored in enclosures containing instrument air compressors.
NFPA 99:11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders.
NFPA 99:11.6.5.3 Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner.
Interview with the Maintenance Supervisor revealed the facility was not aware the PTAC unit was prohibited from being in the same room with medical gas cylinders and identifying labeling of all the medical gas cylinders were required.

Based on record review, the facility failed to assure that a polarity, ground and retention resident / patient room electrical receptacle test had been conducted and documented. When the correct protocols are routinely completed by qualified personnel to the resident / patient electrical receptacle outlets chances of creating a unsafe electrical event or possible fire emergency are reduced or possibly eliminated. The deficient practice had the potential to affect 13 of 13 patients.

Findings:

During the record review on Janurary 27, 2020, between the hours of 10:00 a.m. to 3:30 p.m. it was observed the electrical receptacles located in the patient rooms only lacked annual documentation for testing the polarity, ground and retention capacbilities of each patient room receptacle.

NFPA 99 6.3.3.2 Receptacle Testing in Patient Care Rooms 6.3.3.2.1
6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall not be less than 115 g (4oz.)

Interview with the Maintenance Supervisor revealed the facility was not aware that all documentation was not complete regarding the inspection/testing of the emergency generator.

Based on visual observation the facility failed to assure that the generator or other alternate power source is capable of restoring electrical service within 10 seconds. Generator sets are inspected weekly and a monthly testing program on the emergency generator must be conducted a min. of 12 times a year under load for a min. of 30 minutes. In cases of a power outage the emergency generator powers essential life safety equipment for the facility. The deficient practice had the potential to affect 13 of 13 patients.
12 of 12 months were deficient.

Findings:

During the record review on January 27, 2020, between the hours of 10:00 a.m. to 3:30 p.m. the weekly inspection logs were unable to be retrieved due to the computer software denying access for the Maintenance Supervisor.

NFPA 110:8.3.7* states, "Storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer's specifications".

NFPA 110:8.4.1* states, "EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly".


Interview with the Maintenance Supervisor revealed the facility was not aware the computer software was not allowing access to the generator weekly logs. .