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Based on observation and staff interview, the facility failed to ensure the means of egress is continuously maintained free of all obstructions to full use in case of emergency in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 10.

Findings include:

1. An observation on 11/13/17 at approximately 2:20 p.m., revealed a gate on both door frames of the Clinic Patient Scheduling area, which reduced the acceptable doorway width and presented a tripping hazard at the floor level.

2. This finding was verified with the Facilities Services Director at the time of discovery and again with the Administrator at the time of exit.

Based on observation and staff interview, the facility failed to ensure appropriate fire protection of fire barriers and fire doors within the facility in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 10.

Findings include:

1. An observation on 11/14/17 at approximately 2:12 p.m., revealed a penetration above the ceiling in the the 1-hour rated fire/smoke barrier of the Clinic in the vicinity of the restroom in the Human Resources hallway.

2. An observation on 11/14/17 at approximately 2:15 p.m., revealed a penetration above the ceiling in the the 1-hour rated fire/smoke barrier of the Clinic near Registration 4.

3. An observation on 11/14/17 at approximately 2:18 p.m., revealed two (2) penetrations above the ceiling in the 1-hour rated fire/smoke barrier between the corridor and Physical Therapy near the exit sign.

4. An observation on 11/14/17 at approximately 2:30 p.m., revealed two (2) penetrations above the ceiling in the 1-hour rated fire/smoke barrier near the Lab door.

5. An observation on 11/14/17 at approximately 2:35 p.m., revealed an approximately three (3) inch penetration above the ceiling in the 1-hour rated fire/smoke barrier near X-Ray 2.

6. An observation on 11/14/17 at approximately 2:40 p.m., revealed two (2) penetrations above the ceiling in the 1-hour rated fire/smoke barrier separating Clinic B and the waiting area.

7. Record review on 11/15/17 at approximately 11:37 a.m., revealed no documentation of annual inspection and testing of fire door assemblies for the facility.

8. These findings were verified with the Facilities Services Director at the time of discovery and again with the Administrator at the time of exit.

Based on observation and staff interview, the facility failed to ensure that hazardous areas are protected and separated from other spaces in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 10.

Findings include:

1. An observation on 11/13/17 at approximately 2:28 p.m., revealed two (2) penetrations near the ceiling in the Clinic Electrical Room C75.

2. An observation on 11/14/17 at approximately 1:44 p.m., revealed two (2) penetrations around the sprinkler piping in the wall separating the Boiler Room and the Clinic Break Room.

3. An observation on 11/14/17 at approximately 1:47 p.m., revealed a penetration around the sprinkler piping in the wall separating the Boiler Room and the Vacuum Pump Room.

4. An observation on 11/14/17 at approximately 1:50 p.m., revealed penetrations in the wall separating the the Transfer Switch Gear Room and the Main Electrical Room.

5. An observation on 11/14/17 at approximately 1:52 p.m., revealed a penetration in the wall separating the Main Electrical Room and the Sprinkler Riser Room.

6. An observation on 11/14/17 at approximately 2:00 p.m., revealed two (2) penetrations in the wall separating the Dock Med Gas Storage Room and the Morgue.

7. An observation on 11/14/17 at approximately 2:10 p.m., revealed two (2) penetrations in the wall separating the Dock Med Gas Storage Room and the Warehouse.

8. An observation on 11/15/17 at approximately 9:39 a.m., revealed two (2) penetrations above the ceiling in the Acute Care Electrical Room that were sealed with unapproved residential type expanding foam.

9. An observation on 11/15/17 at approximately 9:55 a.m., revealed two (2) penetrations above the ceiling of the Carbon Dioxide Manifold Room.

10. These findings were verified with the Facilities Services Director at the time of discovery and again with the Administrator at the time of exit.

Based on record review and staff interview, the facility failed to ensure that records of system testing for the fire alarm system were readily available in accordance with NFPA (National Fire Protection Association) 72. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 10.

Findings include:

1. Record review on 11/15/17 at approximately 9:10 a.m., revealed no documentation of location or testing of fire dampers located throughout the facility.

2. This finding was verified with the Facilities Services Director at the time of discovery and again with the Facilities Director at the time of exit.

Based on observation and staff interview, the facility failed to ensure that automatic sprinkler and standpipe systems were maintained in accordance with NFPA (National Fire Protection Association) 25. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 10.

Findings include:

1. An observation on 11/14/17 at approximately 1:02 p.m., revealed IT wiring laying on the sprinkler lines above the corridor ceiling near the Occupational Health Office.

2. An observation on 11/14/17 at approximately 1:06 p.m., revealed IT wiring laying on the sprinkler lines above the corridor ceiling near the Provider/Nursing Office.

3. An observation on 11/14/17 at approximately 1:10 p.m., revealed IT wiring laying on the sprinkler lines above the corridor ceiling near Exam Room D6.

4. An observation on 11/14/17 at approximately 1:15 p.m., revealed IT wiring laying on the sprinkler lines above the corridor ceiling near the Audiology Room.

5. An observation on 11/14/17 at approximately 1:20 p.m., revealed IT wiring laying on the sprinkler lines above the corridor ceiling near the Housekeeping Closet in the vicinity of Human Resources.

6. An observation on 11/15/17 at approximately 9:43 a.m., revealed flex conduit laying on the sprinkler lines above the corridor ceiling near X-Ray 1.

7. An observation on 11/15/17 at approximately 9:44 a.m., revealed flex conduit laying on the sprinkler lines above the corridor ceiling near the Respiratory Manager Office.

8. An observation on 11/15/17 at approximately 9:52 a.m., revealed flex conduit laying on the sprinkler lines above the corridor ceiling near the Electrical Room.

9. An observation on 11/15/17 at approximately 10:18 a.m., revealed IT wiring and flex conduit laying on the sprinkler lines above the corridor ceiling near the Pharmacy.

10. An observation on 11/15/17 at approximately 10:30 a.m., revealed IT wiring laying on the sprinkler lines above the corridor ceiling near room 112.

11. An observation on 11/15/17 at approximately 10:43 a.m., revealed IT wiring laying on the sprinkler lines above the corridor ceiling near the ICU doors.

12. An observation on 11/15/17 at approximately 10:49 a.m., revealed IT wiring laying on the sprinkler lines above the corridor ceiling near room 125.

13. An observation on 11/15/17 at approximately 10:50 a.m., revealed IT wiring laying on the sprinkler lines above the corridor ceiling near room 119.

14. An observation on 11/15/17 at approximately 10:54 a.m., revealed flex conduit laying on the sprinkler lines above the corridor ceiling near the Acute Care Nurse's Station.

15. An observation on 11/15/17 at approximately 10:59 a.m., revealed flex conduit laying on the sprinkler lines above the corridor ceiling near room 116.

16. These findings were verified with the Facilities Services Director at the time of discovery and again with the Administrator at the time of exit.

Based on record review and staff interview, the facility failed to ensure that fire drills were held at least quarterly on each shift in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 10.

Findings include:

1. Record review on 11/14/17 at approximately 11:40 a.m., revealed that the facility failed to record a fire drill during the first quarter of 2017.

2. Record review on 11/14/17 at approximately 11:45 a.m., revealed that the facility failed to record a fire drill during the second shift of the third quarter for 2017.

3. Record review on 11/14/17 at approximately 11:50 a.m., revealed that the facility failed to record a fire drill during the fourth quarter for 2017.

4. These findings were verified with the Facilities Services Director at the time of discovery and again with the Administrator at the time of exit.

Based on record review and staff interview, the facility failed to maintain and test electrical receptacles at patient bed locations in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 10.

Findings include:

1. Record review on 11/15/17 at approximately 9:04 a.m., revealed no documentation for testing of the physical integrity, continuity of the grounding circuit, correct polarity of the hot and neutral connections, or the retention force of the grounding blade for each electrical receptacle at the patient bed locations in the facility.

2. Record review on 11/15/17 at approximately 9:20 a.m., revealed no documentation for testing of line isolation monitors that are installed in the facility.

3. These findings were verified with the Facilities Services Director at the time of discovery and again with the Facilities Director at the time of exit

Based on observation, record review, and staff interview, the facility failed to ensure that maintenance and testing of the generator and associated equipment was performed in accordance with NFPA (National Fire Protection Association) 110. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 10.

Findings include:

1. Record review on 11/13/17 at approximately 3:10 p.m., revealed no documentation of monthly testing and recording of electrolyte specific gravity or battery conductance testing for each cell of the batteries of the emergency generators serving the facility.

2. Record review on 11/13/17 at approximately 3:15 p.m., revealed no documentation prior to 09/08/17 that the emergency generator serving the facility had been exercised under load monthly.

3. An observation on 11/13/17 at approximately 3:25 p.m., revealed no battery-powered emergency lighting located in the transfer switch-gear room.

4. These findings were verified with the Facilities Services Director at the time of discovery and again with the Administrator at the time of exit.

Based on record review and staff interview, the facility failed to maintain the testing and maintenance requirements for fixed and portable patient-care equipment in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 10.

Findings include:

1. Record review on 11/15/17 at approximately 8:40 a.m., revealed no documentation of electrical resistance, current leakage, or touch current testing for medical equipment used within the facility.

2. Record review on 10/15/17 at approximately 8:50 p.m., revealed no documentation of electrical resistance, current leakage, or touch current testing for patient beds used within the facility.

3. These findings were verified with the Facilities Services Director at the time of discovery and again with the Administrator at the time of exit

Based on record review and staff interview, the facility failed to ensure that personnel had received the appropriate medical gas equipment qualifications and training in accordance with NFPA (National Fire Protection Association) 99. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 10.

Findings include:

1. Record review on 11/14/17 at approximately 9:00 a.m., revealed no documentation that staff had been trained on the risk of handling medical gases and oxygen cylinders.

2. Record review on 11/14/17 at approximately 9:10 a.m., revealed that the facility failed to provide continuing education to all staff that handle medical gases and oxygen cylinders.

3. These findings were verified with the Facilities Services Director at the time of discovery and again with the Administrator at the time of exit.