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Based on observation and staff interview, the facility failed to provide vision panels in a set of smoke barrier doors that would allow occupants to see through the panel glass. This condition would prevent occupants from being able to check the environment on the other side of the smoke doors before evacuating through the doors during a fire.

Findings are:
Observation during the facility tour on 1/28/15, at 11:24 am revealed a frosted finish was applied over the vision panels in the newly installed Administration Corridor Smoke Doors. The vision panels failed to allow occupants to see through the glass.
In an interview conducted at the time of observation, (1/28/15, at 11:24 am), Maintenance A confirmed the other side of the corridor was not visible through the glass.

Based on observation and staff interview, the facility failed to mark exits by approved, readily visible signs in all cases where the exit or way to reach the exit was not readily apparent to the occupants. This condition would not allow occupants to efficiently evacuate the facility during a fire or other emergency.

Findings are:
Observations during the facility tour on 1/28/15, at 11:18 am revealed an exit sign failed to be visible when looking towards the smoke doors by Sharon ' s New Office when the smoke doors were closed.
In an interview conducted at the time of observations (1/28/15, at 11:18 am), Maintenance A acknowledged exit signs failed to be visible in two separate directions in this area.

Based on observation and staff interview, the facility failed to mark exits by approved, readily visible signs in all cases where the exit or way to reach the exit was not readily apparent to the occupants. This condition would not allow occupants to efficiently evacuate the facility during a fire or other emergency.

Findings are:
Observations during the facility tour on 1/28/15, from 11:19 am to 11:20 am revealed:
1. The internally illuminated exit sign above the Purchasing Exit Doors failed to be illuminated.
2. An exit sign failed to be visible when looking towards the Nursing Home Door in the Employee Hallway.
In an interview conducted at the time of observations (1/28/15, from 11:19 am to 11:20 am), Maintenance A acknowledged exit signs failed to be visible in two separate directions in these areas.

Based on observation and staff interview, the facility failed to provide smoke compartment doors that would resist the passage of smoke. This condition had the potential to allow smoke to migrate between smoke compartments.

Findings are:
Observations during the facility tour on 1/28/15, at 12:33 pm revealed the OR Fire Doors failed to fully close when auto-closed.
In an interview conducted at the time of observations (1/28/15, at 12:33 pm), Maintenance A confirmed the doors failed to fully close.

Based on observation and staff interview, the facility failed to separate hazardous areas from use areas. This condition had the potential to allow smoke and fire to migrate into other areas of the facility.

Findings are:
Observations during the facility tour on 1/28/15, from 11:40 am to 1:07 pm revealed:
1. The Pool Filter Room Door failed to latch when self-closed.
2. The Sterile Storage Room Door failed to latch when self-closed.
3. The door in the construction separation barrier by the Nurse Station failed to latch when self-closed.
4. The Soiled Utility Center Wing Storage Room Door failed to latch when self-closed.
In an interview conducted at the time of observations (1/28/15, from 11:40 am to 1:07 pm), Maintenance A acknowledged the findings.

Based on observation and staff interview, the facility failed to provide an exit that was accessible at all times. This condition would prevent the breakaway feature of powered horizontal sliding doors from functioning.

Findings are:
Observation during the facility tour on 1/28/15, at 12:35 pm revealed the Ambulance Entrance powered horizontal sliding doors had a lock operated by a thumb latch installed in the door. The doors would fail to breakaway to allow egress when the lock was engaged.
In an interview conducted at the time of observation, (1/28/15, at 12:35 pm), Maintenance A confirmed that the doors would fail to breakaway when the lock was engaged.

Based on record review and staff interview, the facility failed to conduct quarterly fire drills on each shift. This condition would not provide the required training for staff to respond to a fire emergency.

Findings are:
Record review of fire drills on 1/28/15, at 10:33 am revealed:
1. The facility failed to document a fire drill for the 2nd shift in the 4th Quarter of 2014.
2. The facility failed to document a fire drill for the 3rd shift in the 3rd Quarter of 2014.
In an interview conducted at the time of record review (1/28/15, at 10:33 am), Maintenance A acknowledged the missing fire drills.

Based on observation and staff interview, the facility failed to maintain a sprinkler head. This condition would prevent a fire from being suppressed by the sprinkler system.

Findings are:
Observations during the facility tour on 1/28/15, at 11:37 am revealed a missing sprinkler head escutcheon plate failed to be replaced on the flush-type sprinkler head in the Weight Room.
In an interview conducted at the time of observations, (1/28/15, at 11:37 am), Maintenance A confirmed the findings.

NFPA 13, 1999, 3-2.7.2*
Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

Based on record review and staff interview, the facility failed to maintain operating room humidity levels at a minimum of 35% during procedures. This condition increased the potential of a fire during procedures.

Findings are:
Record review on 1/28/15, at 10:51 am during the facility tour revealed that the humidity levels failed to be maintained at a minimum of 35% during procedures for the last year.
In an interview conducted at the time of record review, (1/28/15, at 10:51 am), Maintenance A confirmed the findings.

Based on record review and staff interview, the facility failed to maintain the emergency generator in accordance with the National Fire Protection Association (NFPA), 110. This condition increased the potential that the generator would fail to run during loss of power.

Findings are:
Record review on 1/28/15, at 10:44 am of emergency generator maintenance revealed generator battery levels were inspected monthly, and failed to be inspected weekly.
In an interview conducted at the time of record review, (1/28/15, at 10:44 am), Maintenance A confirmed that the generator battery levels were only inspected monthly.

Actual NFPA Standard:
NFPA 110, 1999, 6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.
6-4.2*
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.

Based on observation and staff interview, the facility failed to maintain clearances around electrical equipment in accordance with the National Fire Protection Association (NFPA), 70. This condition had the potential to prevent an occupant from exiting the room.

Findings are:
Observation during the facility tour on 1/28/15, at 11:03 am revealed bundles of electrical wire and conduit obstructed electrical panels, and the egress path from the Main Electrical Room. The storage failed to be removed prior to the survey.
In an interview conducted at the time of observation (1/28/15, at 11:03 am), Maintenance A acknowledged the findings.

NFPA 70, 1999, (B) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.

Based on observation and staff interview, the facility failed to provide vision panels in a set of smoke barrier doors that would allow occupants to see through the panel glass. This condition would prevent occupants from being able to check the environment on the other side of the smoke doors before evacuating through the doors during a fire.

Findings are:
Observation during the facility tour on 1/28/15, at 11:24 am revealed a frosted finish was applied over the vision panels in the newly installed Administration Corridor Smoke Doors. The vision panels failed to allow occupants to see through the glass.
In an interview conducted at the time of observation, (1/28/15, at 11:24 am), Maintenance A confirmed the other side of the corridor was not visible through the glass.

Based on observation and staff interview, the facility failed to mark exits by approved, readily visible signs in all cases where the exit or way to reach the exit was not readily apparent to the occupants. This condition would not allow occupants to efficiently evacuate the facility during a fire or other emergency.

Findings are:
Observations during the facility tour on 1/28/15, at 11:18 am revealed an exit sign failed to be visible when looking towards the smoke doors by Sharon ' s New Office when the smoke doors were closed.
In an interview conducted at the time of observations (1/28/15, at 11:18 am), Maintenance A acknowledged exit signs failed to be visible in two separate directions in this area.

Based on observation and staff interview, the facility failed to mark exits by approved, readily visible signs in all cases where the exit or way to reach the exit was not readily apparent to the occupants. This condition would not allow occupants to efficiently evacuate the facility during a fire or other emergency.

Findings are:
Observations during the facility tour on 1/28/15, from 11:19 am to 11:20 am revealed:
1. The internally illuminated exit sign above the Purchasing Exit Doors failed to be illuminated.
2. An exit sign failed to be visible when looking towards the Nursing Home Door in the Employee Hallway.
In an interview conducted at the time of observations (1/28/15, from 11:19 am to 11:20 am), Maintenance A acknowledged exit signs failed to be visible in two separate directions in these areas.

Based on observation and staff interview, the facility failed to provide smoke compartment doors that would resist the passage of smoke. This condition had the potential to allow smoke to migrate between smoke compartments.

Findings are:
Observations during the facility tour on 1/28/15, at 12:33 pm revealed the OR Fire Doors failed to fully close when auto-closed.
In an interview conducted at the time of observations (1/28/15, at 12:33 pm), Maintenance A confirmed the doors failed to fully close.

Based on observation and staff interview, the facility failed to separate hazardous areas from use areas. This condition had the potential to allow smoke and fire to migrate into other areas of the facility.

Findings are:
Observations during the facility tour on 1/28/15, from 11:40 am to 1:07 pm revealed:
1. The Pool Filter Room Door failed to latch when self-closed.
2. The Sterile Storage Room Door failed to latch when self-closed.
3. The door in the construction separation barrier by the Nurse Station failed to latch when self-closed.
4. The Soiled Utility Center Wing Storage Room Door failed to latch when self-closed.
In an interview conducted at the time of observations (1/28/15, from 11:40 am to 1:07 pm), Maintenance A acknowledged the findings.

Based on observation and staff interview, the facility failed to provide an exit that was accessible at all times. This condition would prevent the breakaway feature of powered horizontal sliding doors from functioning.

Findings are:
Observation during the facility tour on 1/28/15, at 12:35 pm revealed the Ambulance Entrance powered horizontal sliding doors had a lock operated by a thumb latch installed in the door. The doors would fail to breakaway to allow egress when the lock was engaged.
In an interview conducted at the time of observation, (1/28/15, at 12:35 pm), Maintenance A confirmed that the doors would fail to breakaway when the lock was engaged.

Based on record review and staff interview, the facility failed to conduct quarterly fire drills on each shift. This condition would not provide the required training for staff to respond to a fire emergency.

Findings are:
Record review of fire drills on 1/28/15, at 10:33 am revealed:
1. The facility failed to document a fire drill for the 2nd shift in the 4th Quarter of 2014.
2. The facility failed to document a fire drill for the 3rd shift in the 3rd Quarter of 2014.
In an interview conducted at the time of record review (1/28/15, at 10:33 am), Maintenance A acknowledged the missing fire drills.

Based on observation and staff interview, the facility failed to maintain a sprinkler head. This condition would prevent a fire from being suppressed by the sprinkler system.

Findings are:
Observations during the facility tour on 1/28/15, at 11:37 am revealed a missing sprinkler head escutcheon plate failed to be replaced on the flush-type sprinkler head in the Weight Room.
In an interview conducted at the time of observations, (1/28/15, at 11:37 am), Maintenance A confirmed the findings.

NFPA 13, 1999, 3-2.7.2*
Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

Based on record review and staff interview, the facility failed to maintain operating room humidity levels at a minimum of 35% during procedures. This condition increased the potential of a fire during procedures.

Findings are:
Record review on 1/28/15, at 10:51 am during the facility tour revealed that the humidity levels failed to be maintained at a minimum of 35% during procedures for the last year.
In an interview conducted at the time of record review, (1/28/15, at 10:51 am), Maintenance A confirmed the findings.

Based on record review and staff interview, the facility failed to maintain the emergency generator in accordance with the National Fire Protection Association (NFPA), 110. This condition increased the potential that the generator would fail to run during loss of power.

Findings are:
Record review on 1/28/15, at 10:44 am of emergency generator maintenance revealed generator battery levels were inspected monthly, and failed to be inspected weekly.
In an interview conducted at the time of record review, (1/28/15, at 10:44 am), Maintenance A confirmed that the generator battery levels were only inspected monthly.

Actual NFPA Standard:
NFPA 110, 1999, 6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.
6-4.2*
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.

Based on observation and staff interview, the facility failed to maintain clearances around electrical equipment in accordance with the National Fire Protection Association (NFPA), 70. This condition had the potential to prevent an occupant from exiting the room.

Findings are:
Observation during the facility tour on 1/28/15, at 11:03 am revealed bundles of electrical wire and conduit obstructed electrical panels, and the egress path from the Main Electrical Room. The storage failed to be removed prior to the survey.
In an interview conducted at the time of observation (1/28/15, at 11:03 am), Maintenance A acknowledged the findings.

NFPA 70, 1999, (B) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.