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Based on observation it was determined the facility failed to fill penetrations in the first and second floors smoke barriers for the entire hospital.

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:

On May 16, 2017 the surveyor, accompanied by the Manager of Support Services observed unsealed penetrations, holes went through both sides of two smoke barriers located on the following floors of the hospital.

1. 1st floor by smoke barrier doors marked 1.135
2. 2nd floor by smoke barriers marked 2.148, 2.191 and 2.255

During the exit conference on May 16, 2017 the above findings were again acknowledged by the Chief Nursing Officer and Administrator, Director Support Services and Manager of Support Services.

Failing to the penetrations, holes 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 time of a fire.

Based on observation it was determined the facility failed to provide a protective guards on light bulbs located in a few areas of the entire seven story hospital.

NFPA 101 Life Safety Code, 2012, 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, 2011 Edition, "National Electrical Code." NEC, 2011, 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."

Findings include:

On May 16, 2017 the surveyor, accompanied by the Director of Support Services and Manager of Support Services observed the following areas in the hospital. The light ballasts light bulbs were exposed with no protective guards on the light bulbs. The following areas of the hospital are indicated below.

1. Communications room 3rd floor and first floor by the dock.
2. Emergency Management Supply and the floor cleaning room by the dock.
3. Maintenance shop.

During the exit conference on May 16, 2017 the above findings were again acknowledged by the Chief Nursing Officer and Administrator, Director Support Services and Manager of Support Services.

Failure to keep light guards on the light bulbs could cause accidental damage or possibly a fire, which could cause harm to the patients.

Based on interview with the nursing staff and the Director of Support Services it was determined upon interviews with the staff at the nursing stations on the 7th floor and the ICU, there was no written plan for the protection of all patients, and for their evacuation in the event of an emergency or the fire procedures plan manual available for review during the survey to be reviewed by the surveyor.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.7.1.1 "There is a written plan for the protection of all patients and for their evacuation in the event of an emergency. Employees are periodically instructed and kept informed with their duties under the plan, and a copy of the plan is readily available with telephone operator or with security. The plan addresses the basic response required of staff per 18/19.7.2.1.2 and provides for all of the fire safety plan components per 18/19.2.2. 19.7.1.1 through 19.7.1.3, 19.7.2.1.2, 19.7.2.2, 19.7.2.3."

Findings include:

On May 16, 2017 the surveyor accompanied by the Director of Support Services during questioning of the nursing staff on the seventh floor and ICU nurses stations, the surveyor asked for the written plan for the protection of all patients and for their evacuation in the event of an emergency or the fire procedures manual in case of a fire.

The Director of Support Services advised the staff it was called a safety manual for the hospital although the staff still could not locate the safety manual during the survey. Some nursing staff advised the surveyor, when questioned about the manual, the fire procedures were on the computer online.

During the exit conference on May 16, 2017 the above findings were again acknowledged by the Chief Nursing Officer and Administrator, Director Support Services and Manager of Support Services.

Failing to have a written plan for the protection of all patients and for their evacuation in the event of an emergency, could result in harm to patients and staff during an actual fire or emergency situation. .

Employees who are not periodically instructed and kept informed with their duties under the plan and if the plan is not readily available, could result in harm to patients and staff during a an actual fire or emergency situation.

Based on record review and interview with the Director of Support Services it was determined that the facility failed to test and document the Monthly testing of the line isolation monitoring panels in the hospital operating rooms.

NFPA 101, Life Safety Code, 2012 Edition, Maintenance and Testing (See 4.6.12) "Maintenance and Testing "Section 4.6.12.1, "Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction."

"NFPA 99 2012 Edition, Health Care Facilities Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system.

Findings include:

On May 16, 2017 the surveyor, accompanied by the Direct Support Services reviewed the line isolation testing of the operating rooms for the hospital. There was no documentation for line isolation testing for August and November of 2016 that identified to the surveyors while on site that the testing was done on those dates.

During the exit conference on May 16, 2017 the above findings were again acknowledged by the Chief Nursing Officer and Administrator, Director Support Services and Manager of Support Services.

Failing to test and maintain documentation on the line isolation monitor panel could cause harm to the patients in an emergency or power outage.

Based on record review and interview with the Director of Support Services and the hospital Plumber the facility failed to document the required testing of the emergency generator for Weekly and Monthly Testing of both generators for the hospital.

NFPA 101 Life Safety Code, 2012, 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 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 8.4.2 "Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes...."

Findings Include:

On May 16, 2017, the surveyors accompanied by the Director of Support Services and Plumber reviewed generator test records. During the review of the generator records that were available, the Director of Support Services advised the surveyors there was no documentation of weekly visual checks or monthly generator load tests documented for the years 2015 and 2016. In addition: January and February of 2017 were missing the weekly visual checks of both generators for the hospital.

The Month of March and April 2017 had a checklist the Plumber was using from NFPA 110 Emergency and Standby Power Systems (EPPS) Maintenance Log sheet for the weekly generator inspections.

The EPPS Maintenance Log sheets for March and April did not indicate if one or both generators were being inspected weekly. The NFPA 110 EPPS log sheets form only had a month, a date, and who performed the generator inspections.

During the exit conference on May 16, 2017 the above findings were again acknowledged by the Chief Nursing Officer and Administrator, Director Support Services and Manager of Support Services.

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

Based on observation it was determined the facility allowed the use of a six way multiple outlet adapters and extension cords, and did not use the wall outlet receptacles for appliances.

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:

On May 16, 2017 the surveyor, accompanied by the Director of Support Services observed the following locations in the hospital allowed the use of a six way multiple outlet adapter and extension cord, and did not use the wall outlet receptacles for appliances.

1. Gift shop-six way multiple outlet adapter in use on the 3rd floor, and laboratory bio-hazard room.
2. Microwave plugged into a power strip on the 3rd floor Access
3. Receiving Material area: Microwave and refrigerator was plugged into a power strip.
4. Main kitchen: extension cord in use for a refrigerator.

During the exit conference on May 16, 2017 the above findings were again acknowledged by the Chief Nursing Officer and Administrator, the Director of Support Services and Manager of Support Services.

The use of multiple outlet adapters and extension cords could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.