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Based on observation and interview, the facility failed to provide means of egress with sufficient headroom in accordance with the requirements of NFPA 101 (2012 edition), 7.1.5. This deficient practice could affect an undetermined number of out-patients in 2 of 8 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:

On 07/26/2018 at 1:09 pm, it was observed that the headroom, in the exit stairwell (near the Boiler room), was less than the 6'-8" minimum from a plane parallel and tangent to the foremost portion of the stair tread measured vertically to the ceiling surface.

This finding was confirmed at the time of discovery by an interview with staff O, staff U and staff V.

Based on record review and interview, the facility failed to maintain the fire alarm system in accordance with the requirements of NFPA 101 - 2012 edition, Sections 9.7.5, 9.7.7, 9.7.8 and NFPA 25. This deficient practice could affect approximately 1 of 1 patients, as well as an undetermined number of staff and visitors.

Findings include:

On 07/26/2018 at 11:55 am, it was noted during a review of the Fire Alarm Inspection Reports that the last annual inspection was dated as 03/15/2017, which makes the annual inspection more than 4 months overdue. Additional there was no record of the smoke detectors being sensitivity tested.

This finding was confirmed at the time of discovery by an interview with staff O, staff U and staff V.

Based on record review and interview, the facility failed to provide a fire alarm system out of service procedure as required by NFPA 101 (2012 edition), 19.3.4.1 and 9.6.1.6. This deficient practice could affect approximately 1 of 1 patients, as well as an undetermined number of staff and visitors.

Findings include:

On 07/26/2018 at 1:00 pm, it was noted during review of documents that there was no fire alarm out of service procedure.

This finding was confirmed at the time of discovery by an interview with staff O, staff U and staff V.

Based on observations 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 13 (2010 edition), 8.7. This deficient practice could affect approximately 1 of 1 patients, as well as an undetermined number of staff and visitors.

Findings include:

On 07/26/2018 at 1:40 pm, observation revealed that the central supply suite housekeeping closet did not have sprinkler coverage for the entire room.

This finding was confirmed at the time of discovery by an interview with staff O, staff U and staff V.

Based on observationm record review and interview, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 101 - 2012 edition, Sections 19.3.5, 9.7 and NFPA 25 - 2011 edition, Sections 4.4, 5.1, Table 5.1.1.2 and 5.2.1. This deficient practice could affect approximately 1 of 1 patients, as well as an undetermined number of staff and visitors.

Findings include:

1. On 07/26/2018 at 11:39 am, it was noted during a review of the fire sprinkler system inspection/test reports that there was no record of the last five year inspection and testing.
2. On 07/26/2018 at 11:45 am, it was noted during a review of the fire sprinkler system inspection/test reports that there was no record of quarterly inspection and testing.
3. On 07/26/2018 at 2:17 pm, observation revealed that a sprinkler in the old dictation room was not kept free of dust, lint and other foreign material.
4. On 07/26/2018 at 2:33 pm, observation revealed that a sprinkler in the large nurses locker room was not kept free of dust, lint and other foreign material.
5. On 07/26/2018 at 2:48 pm, observation revealed that a sprinkler in the X-ray reading room was not kept free of dust, lint and other foreign material.

This finding was confirmed at the time of discovery by an interview with staff O, staff U and staff V.

Based on record review and interview, the facility failed to provide a sprinkler system out of service procedure as required by NFPA 101 (2012 edition), 19.3.5.1 and 9.7.6; and NFPA 25 (2011 edition), 15.5.2. This deficient practice could affect approximately 1 of 1 patients, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

On 07/26/2018 at 1:00 pm, it was noted during review of documents that there was no sprinkler out of service procedure.

This finding was confirmed at the time of discovery by an interview with staff O, staff U and staff V.

Based on observation and staff interview, the facility failed to maintain corridor doors in accordance with NFPA 101(2012 ed.) 19.3.6.3. This deficient practice could affect approximately 1 of 1 patients, as well as an undetermined number of staff and visitors.

Findings include:

1. On 07/26/2018 at 1:15 pm, observation revealed that the corridor door to the Marshfield Clinic- Orthopedic clinic did not fully close and latch.
2. On 07/26/2018 at 2:14 pm, observation revealed that the corridor doors to the ICU suite did not fully close and latch.
3. On 07/26/2018 at 2:31 pm, observation revealed that the corridor doors to the small nurses' locker room did not fully close and latch.
4. On 07/26/2018 at 2:56 pm, observation revealed that the corridor door to the X-Ray RF1 room did not fully close and latch.

This finding was confirmed at the time of discovery by an interview with staff O, staff U and staff V.

Based on record review and interview the facility failed to conduct fire drills in accordance with the requirements of NFPA 101 - 2012 edition, Sections 4.7.1, 4.7.2, 4.7.6, 19.7.1, 19.7.1.4 and 19.7.1.6. This deficient practice could affect approximately 1 of 1 patients, as well as an undetermined number of staff and visitors.

Findings include:

On 07/26/2018 at 1:15 pm, it was noted during review of the facility fire drills for the last 12 months that there was no fire drill conducted on the third shift during the fourth quarter of 2017. It was also noted that 5 of 7 2nd and 3rd shift drills were held between 7:00pm and 7:31pm and were not varied throughout the shifts. Additional there was no recorded of the transmission of the fire alarm signal to the facility monitoring company for any of the fire drills.

This finding was confirmed at the time of discovery by an interview with staff O, staff U and staff V.

Based on record review and interview, the facility failed to inspect door assemblies at least annually, with written record of inspection and testing in accordance with NFPA 101(2012 edition), sections 19.7.6, 4.6.12, 7.2.1.15, 8.3.3. This deficient practice could affect 1 of 1 patients as well as an undetermined number of staff and visitors.

Findings include:

On 07/26/2018 at 12:45 pm, it was noted during record review the facility had no documentation that door assemblies had been inspected or tested in the last year. Additional there was no policy on what doors should be annually inspected and what criteria should be verified during testing for the door assemblies.

This finding was confirmed at the time of discovery by an interview with staff O, staff U and staff V.

Based on record review and interview, the facility did not perform testing of the emergency generator in accordance with the requirements of NFPA 101 (2012 edition), 19.5.1 and 9.1.3; and NFPA 110 (2010 edition), sections 8.3.7 & 8.4.2. This deficient practice could affect 1 of 1 patients as well as an undetermined number of staff and visitors.

Findings include:

On 07/26/2018 at 12:45 pm, it was noted during a review of the generator records for the last 12 months that there was no written record of weekly inspections. It was also noted that there was no record of the time for the transfer switch to engage after the generator started during the monthly load test. Additionally the facility failed to provide documentation for the monthly specific gravity testing of the generator batteries.

This finding was confirmed at the time of discovery by an interview with staff O, staff U and staff V.