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Based on observation the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."
Section 19.3.6.4 "Transfer grilles, regardless of whether they are protected by fusible link-operated dampers, shall not be used in these walls or doors.

Findings Include:

On January 27, 2014 the surveyor, accompanied by the Director of Maintenance, observed the following corridor doors would not tightly close when tested or have a transfer grill

1. Dialysis water purification room, door tested three of three times, will not positively latch
2. Employee break room, door has a transfer grill
3. Kitchen utility closet, door has a closing device, tested three of three times, will not positively latch
4. Respiratory office door, tested three of three times will not positively latch

During the exit conference on January 27, 2014, the above findings were again acknowledged by the Chief Clinical Officer, Director of Quality and the Director of Maintenance.

In time of a fire failing to protect patients from heat and smoke could cause harm to the patients.

Based on observation the facility failed to fill penetrations in the smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of at least ½ hour." (1 Hour New) Chapter 8, Section 8.3.6. "Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:"
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
(a) It shall be made on either side of the smoke barrier.
(b) It shall be made by an approved device that is designed for the specific purpose.

Findings include:

On January 27, 2014 the surveyor, accompanied by the Director of Maintenance, observed an approximate seven inch by three inch cut out of sheet rock in the smoke barrier by laundry.

During the exit conference on January 27, 2014, the above findings were again acknowledged by the Chief Clinical Officer, Director of Quality and the Director of Maintenance.

Failing to fill holes in smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility, which will cause harm to patients.

Based on record review the facility failed to conduct the required fire drills.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.7.1.2 Fire exit drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 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."

Findings include:

On January 27, 2014 the surveyor, accompanied by the Director of Maintenance, reviewed the facility's fire drill records. The surveyor reviewed the Fire drill reports from January 2013 to December 2013. The following Fire exit drills did not include the transmission of a fire alarm signal before 9:00 PM and after 6:00 AM.

1. May 22, 2013 at 3:00 PM, no activation of fire alarm
2. February 23. 2013 at 3:15 PM, no activation of fire alarm
3. January 31, 2013 at 7:15 AM, no activation of fire alarm

During the exit conference on January 27, 2014, the above findings were again acknowledged by the Chief Clinical Officer, Director of Quality and the Director of Maintenance.

Failure to train and drill the staff on fire procedures could result in harm to the patients.

Based on observation the facility failed to maintain the sprinkler heads and assure that all parts of the sprinkler system were in accordance with the UL Listing.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.5.1 "Buildings containing health care facilities shall be protected throughout by and approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection,
Testing, and Maintenance of Water-Based Fire Protection systems. NFPA 25, Section 2-2.1.1 "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign material , paint, and physical damage and shall be installed in the proper orientation..." NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, Chapter 3, Section 3-2.7.2, "Escutcheon Plates used with a recessed or flushed sprinkler shall be part of a listed sprinkler assembly."

Findings Include:

On January 27, 2014 the surveyor, accompanied by the Director of Maintenance, observed the following sprinkler assemblies have a cover of lint:

1. Kitchen walk in refrigerator, one of one sprinkler lint
2. Kitchen dish wash area, one of one sprinkler lint

During the exit conference on January 27, 2014, the above findings were again acknowledged by the Chief Clinical Officer, Director of Quality and the Director of Maintenance.

Failing to maintain sprinkler heads and keep the fusible link clean could allow a fire to burn longer before the sprinkler head will activate. Failing to maintain sprinkler heads, missing escutcheon plates, which are part of the UL Listing of the sprinkler assembly, could allow heat and smoke to effect other areas of the building. This could cause harm to the patients.

Based on record review, the facility failed to document the required testing of three emergency generators.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.7.6 " Maintenance and Testing (See 4.6.12) Section 4.6.12.2 " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 99 "HEALTH CARE FACILITIES". Chapter 3, Section 3-5.4.1.1 (a) and Section 3-4.4.1.1 (b) "Generator sets shall be tested twelve (12) times a year... Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Chapter 6, Section 6-4.1 "Level 1 and Level 2 EPSSs, including all appurtenant components shall be inspected weekly and shall be exercised under load at least monthly. NFPA 110, Chapter 6, Section 6-4.2 "Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes...
Chapter 3, Section 3-4.1.1.8. (Level/Type 1) "The generator sets shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power.
or Section 3-5.3.1 (Level/Type 2) "The emergency system shall be installed and connected to the alternate source of power specified in 3-4.1.1.2 and 3-4.1.1.3 so that all functions specified herein for the emergency system will be automatically restored to operation within 10 seconds after interruption of the normal source."

Findings Include:

On January 27, 2014 the surveyor, accompanied by the Director of Maintenance, reviewed the generator test records. The documentation of weekly inspections was incomplete. The weekly checklist stated "Test emergency generator". The facilities has three generators to be checked weekly and documented per NFPA 110 Standard for Emergency and Standby Power Systems 1999 Edition. The documentation does not indicate three generators. The preventive maintenance checklist does not include the following checks: Fuel, Lubrication system, Cooling system, Fan and alternator belt, Houses, Battery system, and general inspection per 1999 edition Appendix A Maintenance Schedule.(110-21)

During the exit conference on January 27, 2014, the above findings were again acknowledged by the Chief Clinical Officer, Director of Quality and the Director of Maintenance.

Failure to test the emergency generators under load, inspect weekly, and document time from normal power to emergency power could result in harm to patients during emergency system failures.

Based on observation the facility failed to provide protection from electrical shock, and the facility failed to provide a guard on the light bulbs.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19-5.1 "Utilities shall comply with the provisions of Section 9.1. Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70 "National Electrical Code. NEC, 1999, ARTICLE 110, SECTION 110-12 (a) Unused Openings. "Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment."
Section 9.1, Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, Article 110, Section 110-27 (b) Prevent Physical Damage. " In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage

On January 27, 2014 the surveyor, accompanied by the Director of Maintenance, observed the following:

1. Main Electrical room, Electrical panel EHB, missing one of eighteen blanks
2. Pharmacy, narcotics closet, missing one of one light cover
3. Central supply, missing six florescent light covers

During the exit conference on January 27, 2014, the above findings were again acknowledged by the Chief Clinical Officer, Director of Quality and the Director of Maintenance.

Failing to protect energized electrical equipment or wiring can cause a shock or fire. A fire could cause harm to the patient, and failure to keep light guards on the light could cause accidental damage or possibly a fire, which could cause harm to the patients.