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Based on observation and staff interview, the facility failed to correct fire system defects in accordance with NFPA 72-2010 Edition, Section 14.2.1.2.2. This had the potential to affect 12 patients.

Findings include:

During an initial tour of the facility on 08/19/19 at 8:08 A.M. the fire alarm was observed in use. During observation ma 08/19/19 at 3:00 P.M. with the Director of Plant Operations (DPO) #1, revealed the fire alarm system stated "TROUBLE". The fire alarm panels showed "TROUBLE" on 08/19/19, 08/20/19, 08/21/19 and 08/22/19. A test of the fire alarm was conducted on 08/22/19 at the system worked as it should.

Interview with the DPO #1 verified the deficient practice at the time of the discovery by stating they were in the process of switching six smoke detectors over.

Based on observation and interview, the facility failed to install sprinkler protection at the bottom of elevator shafts when using hydraulic oil as required by NFPA 13-2010 Edition, Section 8.15.5.1* for the protection of the compartments. This had the potential to affect 12 patients currently at the facility.

Findings include:

During observation on 08/22/19 at 10:31 A.M. revealed there was no sidewall sprinkler head installed in the elevator shaft in the elevator by the kitchen. There also was no sidewall sprinkler head installed in the bottom of elevator shaft located in the medical office building side by the oncology conference room.

The Director of Plant Operations #1 verified the deficient practice during interview at the time of the observation.

Based on observation and staff interview, the facility failed to ensure fire/smoke barriers were maintained in accordance with NFPA 101 - 2012 Edition, Sections 19.3.7.3(2), 8.3.5 through 8.3.5.6.2. This deficient practice had the potential to affect 12 patients and staff's ability to respond in an emergency.

Finding include:

During observation on 08/20/19 at 9:23 A.M., two three-quarter inch copper pipes and one bundle of network cable was penetrating the corridor wall located in the medical-surgical hall by the storage room. There was one 10-inch exhaust that was unsealed from the same wall. There was a one-inch pipe that was unsealed by the Social Services Office and a six-inch linear hole in the wall located in the kitchen by the dishwashing machine.

The Director of Plant Operations #1 verified the deficient practice during interview at the time of the observation.

Based on record review and staff interview, the facility failed to maintain the generator in accordance with NFPA 110-2010 Edition, Section 8.4.2.

Findings include:

Review of the hospital generator test logs revealed two columns were allotted on a chart for each generator to denote if a load was placed on the generators. The columns read "Line Load (Amps) Leg 1" and Line Load (Amps) Leg 2". A load was documented on a monthly basis, however, there was no calculation to show what percentage of the load was placed on the generator. There was no documentation that an annual load bank test had been completed.

Interview with Director of Plant Operations (DPO) #1 on 08/20/19 at 10:30 A.M. stated that the previous Biomed Engineer told him that the load they do on a monthly basis is always at 80 to 90 percent capacity of the generator, and they didn't need to bring in an outside contractor to do a load bank to verify the load placed on the two generators.

Based on record review and staff interview, the facility failed to establish a policy to designate a threshold when a oxygen cylinder is considered empty. This had the potential to affect 12 patients.

Findings include:

During a review of the facility's life safety code documentation revealed there was no policy that established a threshold pressure at which a oxygen cylinder is considered empty.

Interview with the Director of Respiratory Therapy and EEG (DRTE) #1 on 08/21/19 at approximately 10:00 A.M. verified the facility did not have a policy.