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Based on observation and a staff interview, the facility failed to maintain one or more corridor doors in the means of egress in accordance with the requirements at NFPA 101 (2000) Chapter 19, Section 19.3.6.3. and Chapter 7, Section 7.2. In a fire emergency, this deficient practice could adversely affect any patients, staff or visitors within the affected smoke compartment.

Finding include:

On facility tour between 9:00 AM and 3:30 PM on 08/24/2015, it was observed the door to the Sprinkler Room did not latch in its frame.

This was confirmed by the Director Of Maintenance (JV).

Based on observation and a staff interview, the facility failed to maintain a hazardous area door in accordance with NFPA 101 (00), Chapter 19, Section 19.3.2.1 and 19.3.6.3.2, and Chapter 8, Section 8.2.3.2.3.2. In a fire emergency, this deficient practice could adversely affect any visitors, staff, or patients in that smoke compartment..

FINDINGS INCLUDE:

On 08/24/2015 between 9:00 Am and 3:30 PM, observation revealed, the IT Room door does not have automatic door closing hardware.

This finding was confirmed with the Maintenance Manager (JV) at the time of discovery.

Based on observation and a staff interview, it was confirmed the facility failed to conduct one or more fire drills on each shift, during each quarter of the previous year. This deficient practice was not in accordance with the requirements at NFPA 101 (2000) Chapter 18, Section 18.7.1.2, and CMS policy. In a fire emergency, this deficient practice could adversely affect all patients, staff and visitors.

Findings include:

On facility tour between 9:00 AM to 3:30 PM on 08/24/2015, during a documentation review of the available fire drill reports and interview with the Maintenance Manager (JV), it was revealed that the facility failed to conduct a fire drill during the following period:

1. 1st quarter 2nd shift
2. 2nd quarter 2nd shift
3 3rd quarter 2nd shift

This deficient practice was verified by the Maintenance Manager (JV).

This STANDARD is not met as evidenced by:

Based on review of reports, records and interview, it was determined that the facility failed vary the times of the fire drills and also failed to conduct the required number of fire drill in the last 12-month period. This deficient practice could affect how staff react in the event of a fire. Improper reaction by staff would affect the safety of all patients, visitors and staff.

Findings include:

On facility tour between 9:00 AM to 3:30 PM on 08/24/2015, during a documentation review of the available fire drill reports and interview with the Maintenance Manager (JV), it was revealed that the facility failed to conduct a fire drill during the following period:

1. 1st quarter 2nd shift
2. 2nd quarter 2nd shift
3 3rd quarter 2nd shift

This deficient practice was verified by the Maintenance Manager (JV).

Based on observation and staff interview, the facility failed to install and maintain the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 18.3.4.1 and 9.6, as well as 1999 NFPA 72, Sections 2-3.4.5.1.2, 2-3.5.1. These deficient practices could adversely affect the functioning of the fire alarm system that could delay the timely notification and emergency actions for the facility thus negatively affecting all patients, staff, and visitors of the facility.

Findings include:


On facility tour between 9:00 AM to 3:30 PM on 08/24/2015, observation revealed, that smoke detectors were located within 3 feet of air supply diffuser located in multiple areas of the hospital.


This deficient practice was verified by the Maintenance Manager (JV).

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to install and maintain the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1999 NFPA 72, Sections 2-3.4.5.1.2, 2-3.5.1. These deficient practices could adversely affect the functioning of the fire alarm system that could delay the timely notification and emergency actions for the facility thus negatively affecting all patients, staff, and visitors of the facility.


Findings include:


On facility tour between 9:00 AM to 3:30 PM on 08/24/2015, observation revealed, that smoke detectors were located within 3 feet of air supply diffuser located in multiple areas of the hospital.


This deficient practice was verified by the Maintenance Manager (JV).

Based on documentation review and staff interview revealed, that the automatic sprinkler system has not been installed in accordance with NFPA 13 Standard for the Installation of Sprinkler System 1999 edition. This deficient practice may allow a fire to grow uncontrolled which will negatively impact all the residents, visitors and staff.

Findings include:
Observations during the facility tour and documentation review on 08/24/2015, between 09:00 AM and 3:30 PM,revealed that:
1. IT cable trays in Health Information Services, Lower Level Administration Storage Area, Dietary Storage Area, Central Supply has boxes and other items with-in 18 inches of the sprinkler heads,
2. It could not be verified that the dumbwaiter was Sprinklered.



The Maintenance Manager (JV) Verified these findings during the facility tour.

Based on documentation review and staff interview, the facility failed to maintain the fire sprinkler system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1998 NFPA 25, section 2-3.3. This deficient practice could affect all patients, visitors and staff.


Findings include:

On facility tour between 9:00 AM and 3:30 PM on 08/24/2015, a review of the fire sprinkler annual reports shows that the last inspection was 05/13/2014.

This deficient practice was confirmed by the Maintenance Manager (JV) at the time of discovery.

Based on observation and staff interview, the facility failed to maintain the fire sprinkler system in accordance with the requirements of 2000 NFPA 101, Sections 18.3.4.1 and 9.6, as well as 1998 NFPA 25, section 2-2.1.1. The deficient practice could affect all patients, staff, and visitors.

Findings include:

On facility tour between 9:00 AM and 3:30 PM on 08/24/2015, a review of the fire sprinkler annual reports shows that the last inspection was 05/13/2014.

This deficient practice was confirmed by the Maintenance Manager (JV) at the time of discovery.

Based on documentation review and staff interview, it was determined that the facility has failed to ensure that 1 of 2 semi-annual inspections of the kitchen hood ventilation and fire suppression system protecting the cooking appliances have been completed. NFPA 96 8-3.1 per table 8-3.1, states that for moderate-volume cooking operations, the hood system and components shall be inspected and maintained semiannually by a properly trained, qualified, and certified company or person. This deficient practice could affect patients, all kitchen staff and visitors.

Findings Include:

On facility tour between 09:00 AM and 3:30 PM on 08/24/2015, the facility failed to provide bi-annual inspection reports showing that the kitchen hood ventilation and fire suppression system has been professionally inspected within the last 12 month time period. Last documented inspection was 05/13/2014.


This deficient practice was verified by the Maintenance Manager (JV).

Based on observation and interview, the facility failed to maintain the emergency generator in accordance with the requirements of NFPA 110-1999 edition, Section 6-4. This deficient practice could affect all residents.

Findings include:

On facility tour between 9:00 AM and 3:30 PM on 08/24/2015, At the time of the documentation review, weekly inspection logs of the diesel generator could not be located for August 2014 through August 2015.

This deficient practice was confirmed by the Maintenance Manager (JV) at the time of discovery.

Based on documentation review and staff interview, the facility failed to inspect the emergency generator in accordance with the requirements of 2000 NFPA 101 - 9.1.3 and 1999 NFPA 110 Chapter 6-4.1. The deficient practice could affect all patients, staff and visitors.

Findings include:

On facility tour between 09:00 AM and 3:30 PM on 08/24/2015, At the time of the documentation review, weekly inspection logs of the diesel generator could not be located for August 2014 through August 2015.

This deficient practice was confirmed by the Maintenance Manager (JV) at the time of discovery.

Based on observation and interview, electrical installations are not in accordance with NFPA 70 "The National Electrical Code 1999 edition. section 9.1.2. This deficiency could negatively effect the 10 of 20 residents.

Findings include:
On facility tour between 09:00 AM and 3:30 PM on 08/24/2015, it was observed that the "Placenta Refrigerator" was plugged into a power strip.

This deficient practice was verified by Maintenance Manager (JV).

Based on observation and a staff interview, the facility failed to maintain one or more corridor doors in the means of egress in accordance with the requirements at NFPA 101 (2000) Chapter 19, Section 19.3.6.3. and Chapter 7, Section 7.2. In a fire emergency, this deficient practice could adversely affect any patients, staff or visitors within the affected smoke compartment.

Finding include:

On facility tour between 9:00 AM and 3:30 PM on 08/24/2015, it was observed the door to the Sprinkler Room did not latch in its frame.

This was confirmed by the Director Of Maintenance (JV).

Based on observation and a staff interview, the facility failed to maintain a hazardous area door in accordance with NFPA 101 (00), Chapter 19, Section 19.3.2.1 and 19.3.6.3.2, and Chapter 8, Section 8.2.3.2.3.2. In a fire emergency, this deficient practice could adversely affect any visitors, staff, or patients in that smoke compartment..

FINDINGS INCLUDE:

On 08/24/2015 between 9:00 Am and 3:30 PM, observation revealed, the IT Room door does not have automatic door closing hardware.

This finding was confirmed with the Maintenance Manager (JV) at the time of discovery.

Based on observation and a staff interview, it was confirmed the facility failed to conduct one or more fire drills on each shift, during each quarter of the previous year. This deficient practice was not in accordance with the requirements at NFPA 101 (2000) Chapter 18, Section 18.7.1.2, and CMS policy. In a fire emergency, this deficient practice could adversely affect all patients, staff and visitors.

Findings include:

On facility tour between 9:00 AM to 3:30 PM on 08/24/2015, during a documentation review of the available fire drill reports and interview with the Maintenance Manager (JV), it was revealed that the facility failed to conduct a fire drill during the following period:

1. 1st quarter 2nd shift
2. 2nd quarter 2nd shift
3 3rd quarter 2nd shift

This deficient practice was verified by the Maintenance Manager (JV).

This STANDARD is not met as evidenced by:

Based on review of reports, records and interview, it was determined that the facility failed vary the times of the fire drills and also failed to conduct the required number of fire drill in the last 12-month period. This deficient practice could affect how staff react in the event of a fire. Improper reaction by staff would affect the safety of all patients, visitors and staff.

Findings include:

On facility tour between 9:00 AM to 3:30 PM on 08/24/2015, during a documentation review of the available fire drill reports and interview with the Maintenance Manager (JV), it was revealed that the facility failed to conduct a fire drill during the following period:

1. 1st quarter 2nd shift
2. 2nd quarter 2nd shift
3 3rd quarter 2nd shift

This deficient practice was verified by the Maintenance Manager (JV).

Based on observation and staff interview, the facility failed to install and maintain the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 18.3.4.1 and 9.6, as well as 1999 NFPA 72, Sections 2-3.4.5.1.2, 2-3.5.1. These deficient practices could adversely affect the functioning of the fire alarm system that could delay the timely notification and emergency actions for the facility thus negatively affecting all patients, staff, and visitors of the facility.

Findings include:


On facility tour between 9:00 AM to 3:30 PM on 08/24/2015, observation revealed, that smoke detectors were located within 3 feet of air supply diffuser located in multiple areas of the hospital.


This deficient practice was verified by the Maintenance Manager (JV).

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to install and maintain the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1999 NFPA 72, Sections 2-3.4.5.1.2, 2-3.5.1. These deficient practices could adversely affect the functioning of the fire alarm system that could delay the timely notification and emergency actions for the facility thus negatively affecting all patients, staff, and visitors of the facility.


Findings include:


On facility tour between 9:00 AM to 3:30 PM on 08/24/2015, observation revealed, that smoke detectors were located within 3 feet of air supply diffuser located in multiple areas of the hospital.


This deficient practice was verified by the Maintenance Manager (JV).

Based on documentation review and staff interview revealed, that the automatic sprinkler system has not been installed in accordance with NFPA 13 Standard for the Installation of Sprinkler System 1999 edition. This deficient practice may allow a fire to grow uncontrolled which will negatively impact all the residents, visitors and staff.

Findings include:
Observations during the facility tour and documentation review on 08/24/2015, between 09:00 AM and 3:30 PM,revealed that:
1. IT cable trays in Health Information Services, Lower Level Administration Storage Area, Dietary Storage Area, Central Supply has boxes and other items with-in 18 inches of the sprinkler heads,
2. It could not be verified that the dumbwaiter was Sprinklered.



The Maintenance Manager (JV) Verified these findings during the facility tour.

Based on documentation review and staff interview, the facility failed to maintain the fire sprinkler system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1998 NFPA 25, section 2-3.3. This deficient practice could affect all patients, visitors and staff.


Findings include:

On facility tour between 9:00 AM and 3:30 PM on 08/24/2015, a review of the fire sprinkler annual reports shows that the last inspection was 05/13/2014.

This deficient practice was confirmed by the Maintenance Manager (JV) at the time of discovery.

Based on observation and staff interview, the facility failed to maintain the fire sprinkler system in accordance with the requirements of 2000 NFPA 101, Sections 18.3.4.1 and 9.6, as well as 1998 NFPA 25, section 2-2.1.1. The deficient practice could affect all patients, staff, and visitors.

Findings include:

On facility tour between 9:00 AM and 3:30 PM on 08/24/2015, a review of the fire sprinkler annual reports shows that the last inspection was 05/13/2014.

This deficient practice was confirmed by the Maintenance Manager (JV) at the time of discovery.

Based on documentation review and staff interview, it was determined that the facility has failed to ensure that 1 of 2 semi-annual inspections of the kitchen hood ventilation and fire suppression system protecting the cooking appliances have been completed. NFPA 96 8-3.1 per table 8-3.1, states that for moderate-volume cooking operations, the hood system and components shall be inspected and maintained semiannually by a properly trained, qualified, and certified company or person. This deficient practice could affect patients, all kitchen staff and visitors.

Findings Include:

On facility tour between 09:00 AM and 3:30 PM on 08/24/2015, the facility failed to provide bi-annual inspection reports showing that the kitchen hood ventilation and fire suppression system has been professionally inspected within the last 12 month time period. Last documented inspection was 05/13/2014.


This deficient practice was verified by the Maintenance Manager (JV).

Based on observation and interview, the facility failed to maintain the emergency generator in accordance with the requirements of NFPA 110-1999 edition, Section 6-4. This deficient practice could affect all residents.

Findings include:

On facility tour between 9:00 AM and 3:30 PM on 08/24/2015, At the time of the documentation review, weekly inspection logs of the diesel generator could not be located for August 2014 through August 2015.

This deficient practice was confirmed by the Maintenance Manager (JV) at the time of discovery.

Based on documentation review and staff interview, the facility failed to inspect the emergency generator in accordance with the requirements of 2000 NFPA 101 - 9.1.3 and 1999 NFPA 110 Chapter 6-4.1. The deficient practice could affect all patients, staff and visitors.

Findings include:

On facility tour between 09:00 AM and 3:30 PM on 08/24/2015, At the time of the documentation review, weekly inspection logs of the diesel generator could not be located for August 2014 through August 2015.

This deficient practice was confirmed by the Maintenance Manager (JV) at the time of discovery.

Based on observation and interview, electrical installations are not in accordance with NFPA 70 "The National Electrical Code 1999 edition. section 9.1.2. This deficiency could negatively effect the 10 of 20 residents.

Findings include:
On facility tour between 09:00 AM and 3:30 PM on 08/24/2015, it was observed that the "Placenta Refrigerator" was plugged into a power strip.

This deficient practice was verified by Maintenance Manager (JV).