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Based on observation and testing, the facility failed to properly protect corridor openings as required by NFPA 101 Chapter 19 3.6.3.2. This deficiency practice had the potential to affect the entire facility on the day of survey.

Findings Include:

On October 4, 2016 between 11:00 AM and 1:00 PM, observation revealed Trauma Room doors were incapable of resisting the passage of smoke to the main corridor of the facility. It was also observed the dutch door to the Sterile Area lack a positive latching device (closer).

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.

Based on observations, the facility failed to properly maintain smoke barrier walls for the purpose of providing 1 half hour fire resistance. This deficiency practice had the potential to affect the entire facility on the day of survey.

Findings Include:

On October 4, 2016 at 11:50 AM, observation revealed open and unsealed penetrations in all the smoke barrier walls of the facility. These smoke barrier walls can be recognized by cross corridor doors in sync with the fire alarm system.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.

Based on observations, the facility failed to properly protect hazardous areas in accordance to NFPA 101 section 19.3.5.4. This deficiency practice had the potential to affect the entire facility on the day of survey.

Findings Include:

On October 4, 2016 between 10:00 AM and 1: 00 PM, observation revealed hazardous areas deficiencies in the following areas:

1) Junk Room door wedged open by piece of wood

2) Maintenance Shop ceiling contain open penetrations and was incapable of resisting the passage of smoke.

3) The Maintenance Electric Room ceiling and walls contain open penetrations and were incapable of resisting the passage of smoke.

4) Maintenance Storage Closet ceiling contain open penetrations and was incapable of resisting the passage of smoke The Maintenance Storage Closet door also lacked a positive latching device (closer).

5) EDS Supply Closet lacked a positive latching device (closer)

6) Respiratory Storage Room lacked a positive latching device (closer)

7) Main Boiler Room walls walls contain open penetrations and was incapable of resisting the passage of smoke

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.

Based on observations and testing, the facility failed to properly maintain the exit egress in accordance to NFPA 101 section 19.2.1. This deficiency practice had the potential to affect the entire facility on the day of survey.
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Findings Include:

While checking exit doors on October 4, 2016 at 1:00 PM, observation revealed the following deficiencies:

1) Double doors near the DON ' s office failed to release upon activation of the fire alarm

2) The exit doors at the Isolation Entrance failed to release upon activation of the fire alarm.

3)The exit door from the Maintenance Area was blocked by a wooden crate.

4) The Infusion Area was blocked by a temporary wall installed for construction purposes

5) Kitchen exit blocked by trash bins

6) Doors to the Mammogram Room, Ultra Sound Room, CT Room, and other doors had locks were installed greater than 48 inches from the finished floor. The other doors were mentioned to the Maintenance Supervisor during the survey.

7) All of the Patient Room doors had locks limited to means of egress travel to main corridor of the facility

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.

7.1.10.1*
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on observations, the facility failed to properly maintain fire extinguishers as per NFPA 10 4 - 4.3, and NFPA 10 4-4.4.2. This deficiency practice had the potential to affect the entire facility on the day of survey.

Findings Include:

On October 4, 2016 at 12:20 PM, observation revealed the K Class fire extinguisher in the Kitchen, the ABC fire extinguishers in the Dining Room, near Room 404, and in the Boiler Room were late and overdue for the 6 year inspection.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.

NFPA 10 4-4.3
Six-Year Maintenance.
Every 6 years, stored-pressure fire extinguishers that require a 12-year hydrostatic test shall be emptied and subjected to the applicable maintenance procedures. The removal of agent from halon agent fire extinguishers shall only be done using a listed halon closed recovery system. When the applicable maintenance procedures are performed during periodic recharging or hydrostatic testing, the 6-year requirement shall begin from that date.
4-4.4.2* Verification of Service (Maintenance or Recharging).
Each extinguisher that has undergone maintenance that includes internal examination or that has been recharged (see 4-5.5) shall have a " Verification of Service " collar located around the neck of the container. The collar shall contain a single circular piece of uninterrupted material forming a hole of a size that will not permit the collar assembly to move over the neck of the container unless the valve is completely removed. The collar shall not interfere with the operation of the fire extinguisher. The " Verification of Service " collar shall include the month and year the service was performed, indicated by a perforation such as is done by a hand punch.
Exception No. 1: Fire extinguishers undergoing maintenance before January 1, 1999.
Exception No. 2: Cartridge/cylinder-operated fire extinguishers do not require a " Verification of Service " collar.

Based on document review, the facility failed to properly maintain the emergency generator as per NFPA 110 A-6-3.1. This deficiency practice had the potential to affect the entire facility on the day of survey.

Findings include:

On October 4, 2016 at 1:40 AM, observation revealed the facility
was unable to provide last year's annual inspection documentation for the generator .

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.

Based on observation and testing, the facility failed to properly protect corridor openings as required by NFPA 101 Chapter 19 3.6.3.2. This deficiency practice had the potential to affect the entire facility on the day of survey.

Findings Include:

On October 4, 2016 between 11:00 AM and 1:00 PM, observation revealed Trauma Room doors were incapable of resisting the passage of smoke to the main corridor of the facility. It was also observed the dutch door to the Sterile Area lack a positive latching device (closer).

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.

Based on observations, the facility failed to properly maintain smoke barrier walls for the purpose of providing 1 half hour fire resistance. This deficiency practice had the potential to affect the entire facility on the day of survey.

Findings Include:

On October 4, 2016 at 11:50 AM, observation revealed open and unsealed penetrations in all the smoke barrier walls of the facility. These smoke barrier walls can be recognized by cross corridor doors in sync with the fire alarm system.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.

Based on observations, the facility failed to properly protect hazardous areas in accordance to NFPA 101 section 19.3.5.4. This deficiency practice had the potential to affect the entire facility on the day of survey.

Findings Include:

On October 4, 2016 between 10:00 AM and 1: 00 PM, observation revealed hazardous areas deficiencies in the following areas:

1) Junk Room door wedged open by piece of wood

2) Maintenance Shop ceiling contain open penetrations and was incapable of resisting the passage of smoke.

3) The Maintenance Electric Room ceiling and walls contain open penetrations and were incapable of resisting the passage of smoke.

4) Maintenance Storage Closet ceiling contain open penetrations and was incapable of resisting the passage of smoke The Maintenance Storage Closet door also lacked a positive latching device (closer).

5) EDS Supply Closet lacked a positive latching device (closer)

6) Respiratory Storage Room lacked a positive latching device (closer)

7) Main Boiler Room walls walls contain open penetrations and was incapable of resisting the passage of smoke

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.

Based on observations and testing, the facility failed to properly maintain the exit egress in accordance to NFPA 101 section 19.2.1. This deficiency practice had the potential to affect the entire facility on the day of survey.
.

Findings Include:

While checking exit doors on October 4, 2016 at 1:00 PM, observation revealed the following deficiencies:

1) Double doors near the DON ' s office failed to release upon activation of the fire alarm

2) The exit doors at the Isolation Entrance failed to release upon activation of the fire alarm.

3)The exit door from the Maintenance Area was blocked by a wooden crate.

4) The Infusion Area was blocked by a temporary wall installed for construction purposes

5) Kitchen exit blocked by trash bins

6) Doors to the Mammogram Room, Ultra Sound Room, CT Room, and other doors had locks were installed greater than 48 inches from the finished floor. The other doors were mentioned to the Maintenance Supervisor during the survey.

7) All of the Patient Room doors had locks limited to means of egress travel to main corridor of the facility

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.

7.1.10.1*
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on observations, the facility failed to properly maintain fire extinguishers as per NFPA 10 4 - 4.3, and NFPA 10 4-4.4.2. This deficiency practice had the potential to affect the entire facility on the day of survey.

Findings Include:

On October 4, 2016 at 12:20 PM, observation revealed the K Class fire extinguisher in the Kitchen, the ABC fire extinguishers in the Dining Room, near Room 404, and in the Boiler Room were late and overdue for the 6 year inspection.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.

NFPA 10 4-4.3
Six-Year Maintenance.
Every 6 years, stored-pressure fire extinguishers that require a 12-year hydrostatic test shall be emptied and subjected to the applicable maintenance procedures. The removal of agent from halon agent fire extinguishers shall only be done using a listed halon closed recovery system. When the applicable maintenance procedures are performed during periodic recharging or hydrostatic testing, the 6-year requirement shall begin from that date.
4-4.4.2* Verification of Service (Maintenance or Recharging).
Each extinguisher that has undergone maintenance that includes internal examination or that has been recharged (see 4-5.5) shall have a " Verification of Service " collar located around the neck of the container. The collar shall contain a single circular piece of uninterrupted material forming a hole of a size that will not permit the collar assembly to move over the neck of the container unless the valve is completely removed. The collar shall not interfere with the operation of the fire extinguisher. The " Verification of Service " collar shall include the month and year the service was performed, indicated by a perforation such as is done by a hand punch.
Exception No. 1: Fire extinguishers undergoing maintenance before January 1, 1999.
Exception No. 2: Cartridge/cylinder-operated fire extinguishers do not require a " Verification of Service " collar.

Based on document review, the facility failed to properly maintain the emergency generator as per NFPA 110 A-6-3.1. This deficiency practice had the potential to affect the entire facility on the day of survey.

Findings include:

On October 4, 2016 at 1:40 AM, observation revealed the facility
was unable to provide last year's annual inspection documentation for the generator .

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.