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Based on observation, the facility failed to maintain the emergency exit and enclosed stairwell door with a 1.5-hour fire rated door. With the door removed, during a fire event resulting in a smoke filled enviroment ,a patient or staff could fall down the stairs. This could result in injury or death. Failing to maintain fire barriers could allow smoke to enter the stairwell and a fire to spread more rapidly through the two-hour fire barrier and give staff and patients less time to evacuate the building.

NFPA 101 Life Safety Code, 2012, Chapter 7, Sub-Section 7.2.2.5.1.1. All inside stairs serving as an exit or exit component shall be enclosed in accordance with Section 7.1.3.2 Exits, Sub-Section 7.1.3.2.1. Where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following:
(1) * The separation shall have a minimum 1-hour fire resistance rating where the exit connects three or fewer stories.
(2) The separation specified in 7.1.3.2.1(1), other than an existing separation, shall be supported by construction having not less than a 1-hour fire resistance rating.
(3) * The separation shall have a minimum 2-hour fire resistance rating where the exit connects four or more stories, unless one of the following conditions exists:
(a) In existing non-high-rise buildings, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating.
(b) In existing buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating.
(c) The minimum 1-hour enclosures in accordance with 28.2.2.1.2, 29.2.2.1.2, 30.2.2.1.2, and 31.2.2.1.2 shall be permitted as an alternative to the requirement of 7.1.3.2.1(3).

Findings include:

Observations while on tour revealed the fire rated door at the top of the stairwell had been removed by the facility due to damage. The stairwell does not have a safety landing at the top of the stairwell with the door removed, and any person entering the stairwell intentionally or by accident in a smoke filled enviroment could fall down the stairs.

Employee #1 and #4 confirmed during the exit conference on October 13 and 14, 2020 that the door at the top of the stairwell had been removed by the facility.

Based on observation it was determined that the facility failed to keep the sprinkler heads clean. Failing to maintain the sprinkler heads which are part of the entire sprinkler assembly could cause harm to the patients and staff by allowing a fire to spread before the temperature is reached to set off the sprinkler head.

NFPA 101 Life Safety Code, 2012 edition, 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 19.3.5.5. Chapter 9, Section 9.7.1 "Each automatic sprinkler system required by another section of this Code shall be in accordance with on of the following." " NFPA 13, Standard for the Installation of Sprinkler Systems." Chapter 26, Section 26.1 "General." "A sprinkler system installed in accordance with standard shall be properly inspected, tested, and maintained by the property owner or their authorized representative in accordance with NFPA 25. NFPA 25, Section 5.2.1 "Sprinklers, Section 5.2.1.1.1 "Sprinklers shall not show signs of leakage, shall be free of corrosion, foreign materials, paint and physical damage." Section 5.2.1.1.2 Any sprinkler that shows the signs of any of the following shall be replaced. 1. leakage
2. Corrosion 3. Physical damage 4. Loss of fluid in the glass bulb heat responsive element
5. * Loading See A.5.2.1.1.2 (5) In lieu of replacing sprinklers that are loaded with a coating of dust , it is permitted to clean sprinklers with compressed air or by a vacuum provided that the equipment does not touch the sprinkler. 6. Painting unless painted by the manufacturer. Section 5.2.1.1.4 Any sprinkler shall be replaced that has signs of leakage, is painted other than by the manufacturer, corroded, damaged, or loaded, is in the improper orientation. Annex E Examples of Classification of needed repairs Sprinklers and Escutcheon plates that are missing, painted or rusted.

Findings Include:

Observations while on tour revealed that greater than fifty (50) percent of the sprinkler heads were coated with dust.

Employee# 1 and 4 confirmed during the exit conference on October 14 2020 that greater than fifty (50) percent of the sprinkler heads were coated with dust.

#918
Based on Record Review and Interview the facility failed to perform or document the required weekly continuity or specific gravity testing of the emergency generator. Failure to perform weekly testing could allow the batteries to drop below the required amperage to start the generator which could result in harm to patients during emergency system failures.

NFPA 99 Health Care Facilities Code, 2012 Edition - Chapter 6 Electrical Systems
Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110, Chapter 6, Section 8.4.1 "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 8, Section 8.3.7 *
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.

Findings Include:

Observations while on tour revealed the generator batteries were not being tested for specific gravity. Conversations with employee# 4 indicated the facility was not aware of the requirement for the facility to perform weekly specific gravity or conductance testing. The facility was performing this task during monthly testing.

Employee# 1 and 4 confirmed during the exit conference on October 13 and 14, 2020 the generator batteries were not being tested for conductance or specific gravity. Conversations with employee# 4 indicated the facility was not aware of the requirement for the facility to perform weekly specific gravity or conductance testing.

Based on Observation it was determined the facility allowed the use of power strips and extension cords and did not use the wall outlet receptacles for appliances. Failure to maintain and utilize electrical equipment properly could cause the cords or receptacles to overload which would result in an electrical 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:

Observations while on tour revealed the following locations with power strips plugged into power strips (Daisy Chained), improper use of extension cords as permanent equipment and heavy load drawing appliance (refrigerators, microwaves) plugged into power strips
1. The main IT room had a daisy chained power strip.
2. The Laboratory had a refrigerator plugged into a power strip.
3. The Surgical Office had a refrigerator and microwave plugged into a power strip.
4. The Pharmacy had a microwave plugged into a power strip.
5. The ED Managers Office had a daisy chained power strip.
6. The Laboratory was using an extension cord and a permanent power source.
7. The Radiology area had one non-UL rated UPS used in a patient care area.

Employee# 1 and 4 confirmed during the exit conference on October 13 and 14, 2020 the following locations had power strips plugged into power strips (Daisy Chained), improper use of extension cords as permanent equipment and heavy load drawing appliance (refrigerators, microwaves) plugged into power strips.
1. The main IT room had a daisy chained power strip.
2. The Laboratory had a refrigerator plugged into a power strip.
3. The Surgical Office had a refrigerator and microwave plugged into a power strip.
4. The Pharmacy had a microwave plugged into a power strip.
5. The ED Managers Office had a daisy chained power strip.
6. The Laboratory was using an extension cord and a permanent power source.
7. The Radiology area had one non-UL rated UPS in use in a patient care area.

Based on Observation the facility failed to properly store full oxygen (O2) cylinders five (5) ft. from combustible items. This could result in the combustible items becoming oxygen saturated and easily ignitable which could cause a fire to start prematurely.

NFPA 99: Health Care Facilities Code, 2012 Edition - Chapter 11 Gas Equipment Section 11.3.2.3
Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following:
(1) Minimum distance of 6.1 m (20 ft)
(2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems
(3) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1/ 2 hour

Findings include:

Observations while on tour revealed the three (3) full O2 cylinders being stored next to combustible materials in the storage room in the Surgery wing.


Employee# 1 and 4 confirmed during the exit conference on October 14 and 15 2020 three (3) full O2 cylinders being stored next to combustible materials in the storage room in the Surgery wing.

Based on Observation the facility failed to secure CO2 gas cylinders in the kitchen. Failing to secure compressed gas cylinders could cause harm to patients and staff.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 11 Section 11.6.2.3 (11) Free standing cylinders shall be properly chained or supported in a proper cylinder stand or cart."

Findings include:

Observations while on tour revealed three (3) CO2 gas cylinder in the kitchen. The cylinders were attached to fountain drink system but not secured to a cart or chained to the wall.

Employee# 1 and 2 confirmed during the exit conference on October 13 and 14, 2020 three (3) CO2 gas cylinder in the kitchen. The cylinders were attached to fountain drink system but not secured to a cart or chained to the wall.