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Based on record review and interview with staff, it was determined the facility failed to complete smoke detector sensitivity testing on all the facilities smoke detectors. Failure to test and maintain the fire alarm systems smoke detectors could result in harm to the patients.

NFPA 101, Life Safety Code, 2012 Chapter 19, Section 19.1.1.1.1, "The requirements of this chapter apply to existing buildings or portions thereof currently occupied as health care. Existing health care facilities shall comply with the provisions of this chapter" Chapter 19, Section 19.3.4.1 "General" "Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.", Chapter 9, Section 9.6.1.3. A fire alarm system required for life safety shall be installed, tested and maintained in accordance with the applicable requirements of NFPA 70. National Electrical code, and NFPA 72, National fire Alarm Code. NFPA 101, Chapter 4, Section 4.6.12.3, " 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 72 National Fire Alarm Code, Chapter 14 Inspection Testing, and Maintenance Paragraph Section 14.4.5 Testing Frequency Unless otherwise permitted by other sections of this Code testing shall be performed in accordance with the schedules in Table 14.4.5. or more often if required by the authority having jurisdiction. Section 14.4.5.3.1 Sensitivity shall be checked within 1 year after installation. Sensitivity test shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3. Section 14.4.5.3.3. After the second required calibration test, if sensitivity tests indicate that the device has remained within its listed and marked sensitivity range the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years.

Findings include:

The Facilities Manager and the surveyor reviewed the facilitys' documentation on August 28, 2018, the annual fire alarm documentation did not indicate that the facility completed the smoke detector sensitivity testing. No past records were found if the testing has been completed.

The Chief Executive Officer, Chief Nursing Officer, Director of Quality, and Facilities Manager acknowledged during the exit conference on August 28, 2018, that the facility failed to complete smoke detector sensitivity testing on all the facilities smoke detectors.

Based on observation and interview with staff it was determined, the facility failed to provide automatic sprinkler protection throughout the facility. Failing to provide automatic sprinklers to all areas of the facility could cause harm to the patients in time of a fire.

NFPA 101 Life Safety Code 2012, Chapter 19, Section 19.3.5.3 "Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by Section 19.3.5.5. Section 19.3.5.5 In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where the authority having jurisdiction has prohibited sprinklers , without causing the building to be classified as non-sprinklered. Section 9.7."

Findings include:

The Facilities Manager, Director of Quality, and the surveyor observed on August 28, 2018, that the facility was not provided automatic sprinkler protection throughout the facility. The janitor closet in the East Wing was missing an automatic sprinkler protection.

The Chief Executive Officer, Chief Nursing Officer, Director of Quality, and the Facilities Manager acknowledged in the exit conference on August 28, 2018, that the facility was not provided automatic sprinkler protection throughout the facility.

Based on record review and interview with staff, it was determined that the facility failed to have the 5 year internal inspection of the automatic sprinkler piping. Failing to conduct the 5 year internal inspection of sprinkler piping could allow build-up of foreign material which will affect the operation of the automatic sprinklers and may cause harm to patients and staff.

NFPA 101 Life Safety Code, 2012 Edition, Chapter 19, Section 19.1.1.1.3. General "The provisions of Chapter 4, General, shall apply." Chapter 4, Section 4.6.12.3, "Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed." Section 4.6.12.4, "Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction. NFPA 13, "Installation of Sprinkler Systems." Chapter 26, Section 26.1, General, "A sprinkler system installed in accordance with this standard shall be properly inspected, tested and maintained by the property owner or their authorized representative in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed." NFPA 25, Chapter 14, Section 14.2 "Internal Inspection of Piping" "Except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and be removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material."

Findings Include:

The Facilities Manager and the surveyor reviewed the facilitys documentation on August 28, 2018. During the review of the automatic sprinkler inspection, testing, and maintenance documentation indicated that a 5 year internal inspection of the sprinkler piping was last conducted on August 15, 2012.

The Chief Executive Officer, Chief Nursing Officer, Director of Quality, and the Facilities Manager acknowledged during the exit conference on August 28, 2018, that the 5 year internal inspection of the sprinkler piping was last conducted on August 15, 2012.

Based on observation and staff interview, it was determined the facility failed to fill penetrations in two (2) of the smoke barriers in the facility. Failing to seal the penetrations, holes, and openings in the smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility, which could cause harm to the patients in the time of a fire.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of at least ½ hour." Chapter 8, Section 8.5.6.2 Penetrations for cables cable trays, conduits, pipes, tubes, vents wires and similar items to accommodate electrical, plumbing and communications systems that pass through a wall , floor or /ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof /ceiling of a smoke barrier assembly shall be protected by a system or material capable of restricting the transfer of smoke.

Findings include:

The Facilities Manager and the surveyor observed on August 28, 2018, unsealed penetrations in the smoke barriers in the following locations:

1. By room 110 conduit penetrated the smoke barrier and was not sealed.
2. By room 114 multiple penetrations in the smoke barrier and was not sealed.

The Chief Executive Officer, Chief Nursing Officer, Director of Quality, and the Facilities Manager acknowledged during the exit conference on August 28, 2018, unsealed penetrations in the smoke barriers.

Based on record review and interview with staff, it was determined that the facility failed to have a wet procedure location risk assessment for the procedure room. Failure to perform a risk assessment could cause harm to the patient, if the facility does not identify areas where they are at risk related to electricity.

NFPA 99 2012 Edition, section 6.3.2.2.8.4* "Operating rooms shall be considered to be a wet procedure location, unless a risk assessment conducted by the health care governing body determines otherwise." Section 6.3.2.2.8.7* "Operating rooms defined as wet procedure locations shall be protected by either isolated power or ground-fault circuit interrupters."

Findings include:

The Facilities Manager, Director of Quality, and the surveyor reviewed the facilities documentation related to wet procedure location on August 28, 2018. It was determined that the procedure rooms did not have isolated power or ground-fault circuit interrupters, and no risk assessment conducted by the governing body.

The Chief Executive Officer, Chief Nursing Officer, Director of Quality, and Facilities Manager acknowledged during the exit conference on August 28, 2018, that the facility did not have a wet procedure risk assessment conducted by the governing body.

Based on observation and staff interview, it was determined the facility allowed the use of an appliance plugged into a powerstrip and did not use the wall outlet receptacle. The use of an appliance into a powerstrip could overload the allowable wattage causing a fire.

NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , "All Patient Care Areas," Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings include:

The Facilities Manager and the surveyor observed on August 28, 2018, the microwave located at the Nurse's Station in the Emergency Department plugged into a powerstrip, and not directly into a wall receptacle.

The Chief Executive Officer, Chief Nursing Officer, Director of Quality, and the Facilities Manager acknowledged during the exit conference on August 28, 2018, that the microwave located at the Nurse's Station in the Emergency Department was plugged into a powerstrip and not directly into a wall receptacle as required.