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Based on observation and interview, the facility failed to protect a hazardous area in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.3.2.1, 19.3.2.1.3, & 19.3.2.1.5. This deficient practice could affect 1 of 8 inpatients, as well as an undetermined number of staff and visitors.

Findings include:

On 01/15/2020 at 10:00 am, observation in the Radiology Work Room revealed that the room was being used for the storage of combustible records. The Work Room, of an area greater than 50 square feet, is a hazardous area due to the room size and the amount of unprotected combustible material. The Work Room was accessible from the corridor through two Radiology Rooms. The corridor and the Radiology Rooms were not protected from the hazardous area by doors equipped with automatic door closing hardware.

This deficient condition was confirmed at the time of discovery by a concurrent interview with Staff O.

Based on observation, record review, and interview, the facility failed to install manual alarm boxes (pull stations) in locations per NFPA 101 (2012 edition) Sections 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5. This deficient practice has the potential to affect all of the inpatients, as well as an undeterminable number of staff and visitors.

Findings include:

On 01/15/2020 at 10:16 am, observation revealed that manual fire alarm pull stations were not installed in the basement. Review of fire alarm testing records, dated 06/28/19 by Ahern, confirmed that no pull stations were tested in the basement.

This deficient condition was confirmed at the time of discovery by a concurrent interview with Staff P.

Based on record review and interview, the facility did not perform the semi-annual testing and inspections of the fire alarm system in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.3.4 and 9.6.1.3 and NFPA 72 (2010 edition) Sections 14.3.1 and 14.4.5. This deficient practice could affect all inpatients, as well as an undetermined number of staff and visitors.

Findings include:

On 01/15/2020 at 1:01 pm, review of fire alarm inspection and testing documents revealed that the semi-annual visual inspection of alarm initiating devices for smoke detectors, heat detectors, duct detectors, electromechanical releasing devices (door hold opens), and manual fire alarm boxes (pull stations) were conducted once, on 06/28/2019 by Ahern, within the last year.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff O.

Based on observation and staff interview, the facility did not provide a sprinkler system as required by the code; with all spaces sprinkler protected in accordance with NFPA 101 (2012 edition) sections 19.3.5, 9.7; and NFPA 13 (2010 edition) sections 8.1 & 8.7. This deficient practice could affect an undetermined number of staff and visitors with access to the basement.

Findings include:

On 01/15/2020 at 10:14 am, observation revealed that basement room B144, Equipment Wash Room, was not sprinkler protected.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff P.

Based on observation and interview, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 101 (2012 edition) Sections 19.3.5.1, 9.7.1.1; NFPA 13 (2010 edition) Sections 8.6.5.3.2, 8.6.6.1. This deficient practice could affect 2 of 8 inpatients, as well as an undetermined number of staff and visitors.

Findings include:

1. On 01/15/2020 at 11:32 am, observation in OB Supply Closet 1, next to Room 104, revealed the storage of medical supplies 12-inches below a pendant sprinkler head.

2. On 01/15/2020 at 11:33 am, observation in OB Supply Closet 2, next to Room 106, revealed the storage of medical supplies 12-inches below a pendant sprinkler head.

These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staff O.

Based on observation and staff interview, the facility failed to maintain corridor doors in accordance with NFPA 101(2012 edition) Sections 19.3.6.3. This deficient practice could affect 6 of 8 inpatients, as well as an undetermined number of staff and visitors.

Findings include:

On 01/15/2020 at 11:46 am, observation revealed that the corridor door to the Med Surge Closet, across from the Nurses Station, did not positively latch. Inspection of the latching mechanism revealed that the latch was locked in the open position, which required a key to do so. The closet was not in use at the time of discovery.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff P.

Based on observation, record review, and interview, the facility did not ensure that the heating, ventilation, and air conditioning (HVAC) system was installed and maintained in accordance with NFPA 101 (2012 edition) Sections 19.5.2.1, 9.2.1, 9.2.2; NFPA 90A (2012 edition), 5.4.8.1, 5.4.8.2; NFPA 80 (2010 edition) 19.4.1, 19.4.1.1; NFPA 105 (2010 edition), 6.5.2; NFPA 211 (2010), 10.7.3.6. This deficient practice could affect all inpatients, as well as an undetermined number of staff and visitors.

Findings include:

1. On 01/15/2020 at 10:00 am, observation in the basement revealed a clothes dryer with flexible exhaust ducting. This deficient condition was confirmed at the time of discovery by a concurrent interview with Staff P.

2. On 01/15/2020 at 1:18 pm, record review of construction plans revealed the locations of the fire dampers in the HVAC system. Interview with Staff O revealed that the facility was constructed in 2016. Fire and smoke damper testing was required in 2017, one year after initial installation. The facility was unable to produce documentation verifying damper functional testing was performed, aside from the initial installation test. This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff O.

Based on observation and interview, the facility failed to test electrical receptacles in accordance with the requirements of NFPA 99 (2012 edition) Sections 6.3.3.2, 6.3.3.2.1, 6.3.3.2.2, 6.3.3.2.3, & 6.3.3.2.4. This deficient practice could affect all inpatients.

Findings include:

On 01/15/2020 at 11:40 am, observation revealed hospital grade electrical outlets located in patient care areas. Interview with Staff O confirmed that the facility had no documentation of testing for the continuity of ground in circuit, polarity, or retention strength of the electrical outlets.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff O & Staff P.

Based on observations and staff interview, the facility failed to properly maintain electrical devices in accordance with NFPA 101 (2012 edition), Sections 19.5.1.1 and 9.1.2, and NFPA 70 (2011 edition) Sections 400.8, 590.2(B). This deficient practice could affect 1 of 8 inpatients, as well as an undetermined number of staff and visitors.

Findings include:

1. On 01/15/2020 at 10:03 am, observation in basement room B154 revealed a flexible extension cord, powering a flexible cord multi-outlet strip device (power strip), powering office equipment. This deficient condition was confirmed at the time of discovery by a concurrent interview with Staff P.

2. On 01/15/2020 at 10:06 am, observation in the Radiology Staff Lounge revealed a power strip, powering a microwave. This deficient condition was confirmed at the time of discovery by a concurrent interview with Staff O.