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Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients adjacent to the areas, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the building's exit access corridors.

Findings include:
A. At 2:00pm on 12/15/14 it was observed that the 1 1/2-hour rated indoor generator room door noted on the reviewed Life Safety Plans to be in a 2-hour rated wall was not self closing to a latched condition to comply with 19.3.2.1, 8.4.1, 8.2.3.2.1 and NFPA 80.

B. At 2:45pm on 12/15/14 the lower level Janitor room adjacent to Stair #1 was observed to have an unsealed hole in the ceiling in non-compliance with 19.3.2.1, 8.4.1.2 and 8.2.4.2.

Based on observation during the survey walk-through, not all stairs are constructed and maintained in accordance with 19.2.1, 19.2.2.2, 19.2.2.3 and 7.7.3. These deficiencies could affect all persons required to utilize the exit components by preventing those occupants from safely reaching the public way from an exit from the building.

Findings include:
A. At 1:40pm on 12/15/14 it was observed that the interrupter gates installed at the discharge land level of Stair #3 & #4 were resting in the open position which does not provide the intended purpose of preventing unintended movement to the lower level past the level of exit discharge to comply with 7.7.3.

B. At 3:30pm on 12/15/14 it was observed that the double egress cross corridor smoke barrier doors between the radiology area and the emergency room area were provided with latching hardware on one door which prevented the use of the other door swinging in the direction of exit travel. When on the ER side of the doors, the arrangement forces the user of the "outswinging" door which is marked with an exit sign above the door to operate the latch located on the adjacent 'in-swinging' door to release the 'out-swinging' door. This arrangement does not comply with 7.2.1.5.4 relative to the latch not being located on the door panel and not having an obvious method of operation to release the door panel.

Based on observation and staff interview during the survey walk-through on 12/15/14, not all exit discharge locations are provided with illumination to comply with 19.2.8, 7.8 and 7.9. This deficiency could affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:
A. At 1:45pm on 12/15/14 it was observed that the lighting provided at the Stair #3 exterior exit door and the corridor exit door which discharge under canopies at and between the hospital and the Rural Health Clinic building were not provided with emergency power to comply with 7.9.2.1. The Director of Support Services could not confirm that the hospital canopy lighting was served by the generator system and indicated that the lighting under the canvas canopy was served from the Rural Health Clinic building which does not have an emergency generator.

Emergency lighting is not provided in accordance with 19.2.9.1 and 7.9.

Findings include:

A. The facility utilizes a generator system for emergency power and battery powered emergency lighting. During document review at 10:00am on 12/15/14, records to document that monthly and annual inspection/testing is done for the battery powered emergency lighting systems to comply with 7.9.3 was not available. Required battery powered emergency lighting systems were observed at the interior generator location and at the Operating rooms. A list to identify the locations of all battery powered emergency lighting systems was not available.

1. Battery powered emergency lighting system were not documented to be tested every 30 days for a duration of 30 seconds.

2. Battery powered systems were not documented to be tested annually for a duration of 90 minutes.

Based on observation during the 12/15/14 survey walk-through and document review, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1. These deficiencies could affect any patients, staff, or visitors in the building because the failure to identify key life safety components could result in the failure to protect them properly.

Findings include:
A. During the survey walk-through and document review of the available Life Safety Plans, it was observed that the plans are not sufficiently accurate to comply with 19.7.1.1.
1. The IT server room was indicated on the Life Safety Plans as being 1-hour enclosed. Staff indicated that the room was to be considered 2-hour enclosed. Upon inspection at 3:00pm on 12/15/14, the labeling provided at the penetrations identified the penetrations to be protected for 1-hour rating. The door for this room was labeled as meeting the requirements for only 20 minutes rather than 3/4-hour to comply with 8.2.3.2.3.1. The rating designation for the door did not match the designated rating shown on the Life Safety Plan.

2. The kitchen pantry/storage room was indicated on the Life Safety Plans as being 2-hour enclosed. Upon inspection at 4:00pm of 12/15/14, the door for this room was labeled as meeting the requirements for only 1-hour rather than 1 1/2-hours to comply with 8.2.3.2.3.1. The rating designation for the door did not match the designated rating shown on the Life Safety Plan.

Based on record review and staff interview it was determined that the facility did not conduct fire drills in accordance with 19.7.1.2. Drills were not conducted at least quarterly on each shift under varied conditions to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action as required.

Findings include:
A. Fire Drills conducted for the 2nd shift (6:30pm-7:00am) employees include the following dates and times:

1st Quarter: 1/20/14 at 16:59 (4:59pm)
2nd Quarter: 4/29/14 at 19:20 (7:20pm)
3rd Quarter: 9/9/14 at 20:17 (8:17pm)
4th Quarter: 12/2/14 at 20:01 (8:01pm)

The fire drills conducted for the 2nd shift (6:30pm-7:00am) employees had all of the last 3 drills occurring within the same 1-hour period of the day within the first 2 hours of the shift and not at varying times during the normal shift. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

B. Fire Drills conducted for the 1st shift (6:30am-7:00pm) employees include the following dates and times:

1st Quarter: 12/30/14 at 13:40 (1:40pm)
2nd Quarter: 4/16/14 at 10:06am
2nd Quarter: 6/26/14 at 11:43am
3rd Quarter: 8/29/14 at 10:55am
4th Quarter: 12/20/14 at 10:30am

The fire drills conducted for the 1st shift (6:30am-7:00pm) employees had all of the last 4 drills occurring within the same 1-hour period of the day at approximately mid-morning and not at varying times during the normal shift. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

C. During document review, it was observed that the facility does not document that the fire alarm signal has been successfully transmitted to the monitoring agency as part of the drill activities to comply with 19.7.2.2.

Based on observation during the survey walk through while accompanied by the Director of Support Services, the surveyor found that the fire alarm installation did not meet all of the requirements of NFPA 72-1999. This could affect all occupants of the Four Seasons Long Term Care Unit if the fire alarm system does not operate properly during a fire emergency.

Findings include:
A. At 1:45pm on 12/15/14 it was observed that the smoke detector located in the "MCC" room (accessed from the garage space) was not mounted at the ceiling junction box. The detector was hanging from coiled wire 12" or more from the ceiling surface and not in compliance with NFPA 72-1999, 2-3.4.3.1.

Based on observation during the survey walk-through, the facility failed to install and maintain automatic sprinkler protection in accordance with the requirements of NFPA 101-2000, 19.3.5, NFPA 13-1999, Chapter 5 and NFPA 25-1998, 2-2.1.1. Lack of maintenance for fire protection system could result in delayed response of those systems to provide required protection.

Findings include:

A. At 4:10pm on 12/15/14 it was observed that the sprinkler protection provided at the lower level laundry room was compromised by the lack of ceiling tile intended to be in place and was open to the above ceiling space. The open ceiling can compromise the activation of the sprinkler protection provided for the room. (Surveyor notes that tile was removed due to water damage from a leak which does not have a permanent repair but rather a trough and container collection system.)

Ventilation systems are not maintained in accordance with 19.5.2.1, 9.2 and NFPA 90A. Lack of maintenance for components required for the protection of occupants during a fire condition could result in personal injury.

Findings include:
A. Upon review of the fire and smoke damper inspection dated 9/17/13 there was no evidence to indicate deficiencies cited in that inspection have been corrected. Although work order and invoice information was reviewed to indicate that a portion of the cited damper deficiencies had been addressed, others could not be confirmed to be corrected. Those on the list which remain unresolved due to lack of access panel, unable to reach link from access panel or the damper was observed to be closed and needing repair include:

1. FD109-Kitchen Server Line
2. FD113-Business Office
3. FD112-Kitchen Storage room

Based on observation during the survey walk-through, not all portions of the facilities commercial cooking equipment is installed and maintained in accordance with NFPA 96 1998. Lack of proper installation of the system could result in unnecessary property damage and expose the occupants to hazardous conditions when immediate notification of a fire hazard is not made.

Findings include:

A. During document review at 10:30am on 12/15/14 it was noted that the hood fire suppression system inspection identified the system being tied to the fire alarm system as "N/A". The fire alarm testing documentation dated 8/29/14 and 2/20/14 did not include the hood suppression system as a monitored point to comply with NFPA 69-1998, 7-6.2.

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate Interim Life Safety Measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the Interim Life Safety Measures to remain in place as work toward the completion of its PoC progresses.

The emergency generator systems are not documented to be inspected and tested in accordance with NFPA 99-1999, 3-4.4.1 and NFPA 110-1999, Chapter 6. Failure to maintain periodic inspection and records for the condition of the generator could result in unexpected failure of the generator to perform as required.

Findings include:
A. Documents available for review at 11:45am on 12/15/14 did not included forms for the weekly visual inspection and monthly testing-under-load of the diesel generator systems to provide required information.

1. Recorded information for the monthly run-under-load of the generators does not include amperage load values for each phase, therefore the ability to determine that the generator runs monthly under a load for a minimum 30 minutes to comply with NFPA 110-1999, 6-4.2 could not be verified. Surveyor notes that annual load bank testing is performed because available building loads are not sufficient to meet the 30% requirement.

2. Information for the weekly inspection and testing of the starting batteries to indicate that electrolyte levels are inspected and specific gravity testing is performed for each cell of the batteries was not recorded to comply with NFPA 110-1999, 6-3.6 and NFPA 99-1999, 3-4.4.1.3.

Based on observation during the survey walk through, the surveyor found that the electrical system installation did not meet all requirements of NFPA-70. This could affect any occupant of the facility if proper safety precautions are not met when electrical systems are installed.

Findings include:
A. At 2:00pm on 12/15/14 the surveyor observed that the panel schedule was not accurate or was not updated to meet the requirements of NFPA-70, Section 110-22, and Section 384-13. The LS panel located in the Outpatient Clinic area corridor did not have all circuits identified as to their use. Circuit breakers installed but turned "off" were not included on the directory. It could not be confirmed these were "spare" circuits.

Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients adjacent to the areas, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the building's exit access corridors.

Findings include:
A. At 2:00pm on 12/15/14 it was observed that the 1 1/2-hour rated indoor generator room door noted on the reviewed Life Safety Plans to be in a 2-hour rated wall was not self closing to a latched condition to comply with 19.3.2.1, 8.4.1, 8.2.3.2.1 and NFPA 80.

B. At 2:45pm on 12/15/14 the lower level Janitor room adjacent to Stair #1 was observed to have an unsealed hole in the ceiling in non-compliance with 19.3.2.1, 8.4.1.2 and 8.2.4.2.

Based on observation during the survey walk-through, not all stairs are constructed and maintained in accordance with 19.2.1, 19.2.2.2, 19.2.2.3 and 7.7.3. These deficiencies could affect all persons required to utilize the exit components by preventing those occupants from safely reaching the public way from an exit from the building.

Findings include:
A. At 1:40pm on 12/15/14 it was observed that the interrupter gates installed at the discharge land level of Stair #3 & #4 were resting in the open position which does not provide the intended purpose of preventing unintended movement to the lower level past the level of exit discharge to comply with 7.7.3.

B. At 3:30pm on 12/15/14 it was observed that the double egress cross corridor smoke barrier doors between the radiology area and the emergency room area were provided with latching hardware on one door which prevented the use of the other door swinging in the direction of exit travel. When on the ER side of the doors, the arrangement forces the user of the "outswinging" door which is marked with an exit sign above the door to operate the latch located on the adjacent 'in-swinging' door to release the 'out-swinging' door. This arrangement does not comply with 7.2.1.5.4 relative to the latch not being located on the door panel and not having an obvious method of operation to release the door panel.

Based on observation and staff interview during the survey walk-through on 12/15/14, not all exit discharge locations are provided with illumination to comply with 19.2.8, 7.8 and 7.9. This deficiency could affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:
A. At 1:45pm on 12/15/14 it was observed that the lighting provided at the Stair #3 exterior exit door and the corridor exit door which discharge under canopies at and between the hospital and the Rural Health Clinic building were not provided with emergency power to comply with 7.9.2.1. The Director of Support Services could not confirm that the hospital canopy lighting was served by the generator system and indicated that the lighting under the canvas canopy was served from the Rural Health Clinic building which does not have an emergency generator.

Emergency lighting is not provided in accordance with 19.2.9.1 and 7.9.

Findings include:

A. The facility utilizes a generator system for emergency power and battery powered emergency lighting. During document review at 10:00am on 12/15/14, records to document that monthly and annual inspection/testing is done for the battery powered emergency lighting systems to comply with 7.9.3 was not available. Required battery powered emergency lighting systems were observed at the interior generator location and at the Operating rooms. A list to identify the locations of all battery powered emergency lighting systems was not available.

1. Battery powered emergency lighting system were not documented to be tested every 30 days for a duration of 30 seconds.

2. Battery powered systems were not documented to be tested annually for a duration of 90 minutes.

Based on observation during the 12/15/14 survey walk-through and document review, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1. These deficiencies could affect any patients, staff, or visitors in the building because the failure to identify key life safety components could result in the failure to protect them properly.

Findings include:
A. During the survey walk-through and document review of the available Life Safety Plans, it was observed that the plans are not sufficiently accurate to comply with 19.7.1.1.
1. The IT server room was indicated on the Life Safety Plans as being 1-hour enclosed. Staff indicated that the room was to be considered 2-hour enclosed. Upon inspection at 3:00pm on 12/15/14, the labeling provided at the penetrations identified the penetrations to be protected for 1-hour rating. The door for this room was labeled as meeting the requirements for only 20 minutes rather than 3/4-hour to comply with 8.2.3.2.3.1. The rating designation for the door did not match the designated rating shown on the Life Safety Plan.

2. The kitchen pantry/storage room was indicated on the Life Safety Plans as being 2-hour enclosed. Upon inspection at 4:00pm of 12/15/14, the door for this room was labeled as meeting the requirements for only 1-hour rather than 1 1/2-hours to comply with 8.2.3.2.3.1. The rating designation for the door did not match the designated rating shown on the Life Safety Plan.

Based on record review and staff interview it was determined that the facility did not conduct fire drills in accordance with 19.7.1.2. Drills were not conducted at least quarterly on each shift under varied conditions to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action as required.

Findings include:
A. Fire Drills conducted for the 2nd shift (6:30pm-7:00am) employees include the following dates and times:

1st Quarter: 1/20/14 at 16:59 (4:59pm)
2nd Quarter: 4/29/14 at 19:20 (7:20pm)
3rd Quarter: 9/9/14 at 20:17 (8:17pm)
4th Quarter: 12/2/14 at 20:01 (8:01pm)

The fire drills conducted for the 2nd shift (6:30pm-7:00am) employees had all of the last 3 drills occurring within the same 1-hour period of the day within the first 2 hours of the shift and not at varying times during the normal shift. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

B. Fire Drills conducted for the 1st shift (6:30am-7:00pm) employees include the following dates and times:

1st Quarter: 12/30/14 at 13:40 (1:40pm)
2nd Quarter: 4/16/14 at 10:06am
2nd Quarter: 6/26/14 at 11:43am
3rd Quarter: 8/29/14 at 10:55am
4th Quarter: 12/20/14 at 10:30am

The fire drills conducted for the 1st shift (6:30am-7:00pm) employees had all of the last 4 drills occurring within the same 1-hour period of the day at approximately mid-morning and not at varying times during the normal shift. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

C. During document review, it was observed that the facility does not document that the fire alarm signal has been successfully transmitted to the monitoring agency as part of the drill activities to comply with 19.7.2.2.

Based on observation during the survey walk through while accompanied by the Director of Support Services, the surveyor found that the fire alarm installation did not meet all of the requirements of NFPA 72-1999. This could affect all occupants of the Four Seasons Long Term Care Unit if the fire alarm system does not operate properly during a fire emergency.

Findings include:
A. At 1:45pm on 12/15/14 it was observed that the smoke detector located in the "MCC" room (accessed from the garage space) was not mounted at the ceiling junction box. The detector was hanging from coiled wire 12" or more from the ceiling surface and not in compliance with NFPA 72-1999, 2-3.4.3.1.

Based on observation during the survey walk-through, the facility failed to install and maintain automatic sprinkler protection in accordance with the requirements of NFPA 101-2000, 19.3.5, NFPA 13-1999, Chapter 5 and NFPA 25-1998, 2-2.1.1. Lack of maintenance for fire protection system could result in delayed response of those systems to provide required protection.

Findings include:

A. At 4:10pm on 12/15/14 it was observed that the sprinkler protection provided at the lower level laundry room was compromised by the lack of ceiling tile intended to be in place and was open to the above ceiling space. The open ceiling can compromise the activation of the sprinkler protection provided for the room. (Surveyor notes that tile was removed due to water damage from a leak which does not have a permanent repair but rather a trough and container collection system.)

Ventilation systems are not maintained in accordance with 19.5.2.1, 9.2 and NFPA 90A. Lack of maintenance for components required for the protection of occupants during a fire condition could result in personal injury.

Findings include:
A. Upon review of the fire and smoke damper inspection dated 9/17/13 there was no evidence to indicate deficiencies cited in that inspection have been corrected. Although work order and invoice information was reviewed to indicate that a portion of the cited damper deficiencies had been addressed, others could not be confirmed to be corrected. Those on the list which remain unresolved due to lack of access panel, unable to reach link from access panel or the damper was observed to be closed and needing repair include:

1. FD109-Kitchen Server Line
2. FD113-Business Office
3. FD112-Kitchen Storage room

Based on observation during the survey walk-through, not all portions of the facilities commercial cooking equipment is installed and maintained in accordance with NFPA 96 1998. Lack of proper installation of the system could result in unnecessary property damage and expose the occupants to hazardous conditions when immediate notification of a fire hazard is not made.

Findings include:

A. During document review at 10:30am on 12/15/14 it was noted that the hood fire suppression system inspection identified the system being tied to the fire alarm system as "N/A". The fire alarm testing documentation dated 8/29/14 and 2/20/14 did not include the hood suppression system as a monitored point to comply with NFPA 69-1998, 7-6.2.

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate Interim Life Safety Measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the Interim Life Safety Measures to remain in place as work toward the completion of its PoC progresses.

The emergency generator systems are not documented to be inspected and tested in accordance with NFPA 99-1999, 3-4.4.1 and NFPA 110-1999, Chapter 6. Failure to maintain periodic inspection and records for the condition of the generator could result in unexpected failure of the generator to perform as required.

Findings include:
A. Documents available for review at 11:45am on 12/15/14 did not included forms for the weekly visual inspection and monthly testing-under-load of the diesel generator systems to provide required information.

1. Recorded information for the monthly run-under-load of the generators does not include amperage load values for each phase, therefore the ability to determine that the generator runs monthly under a load for a minimum 30 minutes to comply with NFPA 110-1999, 6-4.2 could not be verified. Surveyor notes that annual load bank testing is performed because available building loads are not sufficient to meet the 30% requirement.

2. Information for the weekly inspection and testing of the starting batteries to indicate that electrolyte levels are inspected and specific gravity testing is performed for each cell of the batteries was not recorded to comply with NFPA 110-1999, 6-3.6 and NFPA 99-1999, 3-4.4.1.3.

Based on observation during the survey walk through, the surveyor found that the electrical system installation did not meet all requirements of NFPA-70. This could affect any occupant of the facility if proper safety precautions are not met when electrical systems are installed.

Findings include:
A. At 2:00pm on 12/15/14 the surveyor observed that the panel schedule was not accurate or was not updated to meet the requirements of NFPA-70, Section 110-22, and Section 384-13. The LS panel located in the Outpatient Clinic area corridor did not have all circuits identified as to their use. Circuit breakers installed but turned "off" were not included on the directory. It could not be confirmed these were "spare" circuits.