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Based on observation and interview, the facility failed to provide automatic sprinkler coverage required for Type
II(000) construction per the requirements of:

2012 NFPA 101, 19.1.6.1, and table 19.1.6.1

This deficiency could affect 20 patients.

Findings include:

On 01/25/2018, during a tour of the facility from 10:30 am to 3:15 pm, the Cardiac Rehab Restroom was observed without automatic sprinkler coverage.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the facility failed to maintain the stairway exit enclosure per the requirements of:

2012 NFPA 101, 19.2.2.3, and 7.2.2.5.3.1

This deficiency could affect 10 patients.

Findings include:

On 01/25/2018, during a tour of the facility from 10:30 am to 3:15 pm, the Cardiac Rehab stairwell was observed with a wheelchair stored on the first floor stairwell landing.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the facility failed to maintain the means of egress per the requirements of:

2012 NFPA 101, 19.2.3.4 (4) (c)

This deficiency could affect 26 patients.

Findings include:

On 01/24/2018, during a tour of the facility from 10:30 am to 3:15 pm, the surveyor observed the egress corridor at the Nurses' Station across from rooms 115/116 was obstructed with 3 computer on wheels with three chairs, narrowing the egress corridor down to approximately 3'-0". These were being used as stationary desks, as they were plugged into the Nurses' Station. Staff moved these items after being notified this was a problem.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the facility failed to maintain hazardous rooms per the requirements of:

2012 NFPA 101, 19.3.2.1.3

This deficiency could affect 2 out 7 smoke compartments.

Findings include:

On 01/24/2018, during a tour of the facility from 10:30 am to 3:15 pm, the following rooms were observed to be over 50 sq. ft. and without self-closing devices:

1. The Clean Linen Closet near room 110 (clean linen was observed on four shelves all around the room)
2. The Server Room next to Lobby (paper files were observed on three approximately 10'-0" long shelves on the back wall)

A member of the maintenance staff was present when this deficiency was identified.

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Based on review of documentation and interview, the facility failed to maintain the fire alarm system per the requirements of:

2012 NFPA 101, 19.3.4.1, and 9.6.1.3
2010 NFPA 72, 14.4.5.3.2, 14.4.5, Table 14.4.5, and 10.18.3.1

This deficiency could affect all patients.

Findings include:

On 01/24/2018, during a tour of the facility from 10:30 am to 3:15 pm, the facility failed to provide the following documentation:
1. The smoke detector sensitivity test within the past 2 years
2. The fire alarm system inspection report within the past 12 months

A member of the maintenance staff was present when this deficiency was found.

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Based on observation and interview, the facility failed to maintain the automatic sprinkler system per the requirements of:

2012 NFPA 101, 19.3.5.1, 9.7.5, and 9.7.8
2011 NFPA 25, Table 5.1.1.2, and 5.2.4.1
2011 NFPA 25, 5.3.2.1

Findings include:

On 01/24/2018, during a tour of the facility from 10:30 am to 3:15 pm, the facility failed to provide the following automatic sprinkler system documentation:

1. Monthly inspections of the wet sprinkler system riser gauges
2. Wet gauges have been replaced or re-calibrated within the last 5 years. The gauges were installed in 2011.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation and interview, the facility failed to maintain smoke barriers that would provide at least a half hour fire resistance rating and restrict the passage of smoke per the requirements of:

2012 NFPA 101, 19.3.7.3, 8.5.1, and 8.5.6.2

This deficiency could affect 3 out of 7 smoke compartments.

Findings include:

On 01/24/2018, during a tour of the facility from 10:30 am to 3:15 pm, the surveyor observed the following:

1. The smoke barrier at rooms 106/107 had an unsealed 2" square penetration with blue cables
2. The smoke barrier at rooms 109/110 had several penetrations filled with a non-fire rated foam sealant

A member of the maintenance staff was present when this deficiency was identified.

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Based on review of documentation and interview, the facility failed to maintain the diesel generator per the requirements of:

2012 NFPA 99, 6.4.4.1.1.3, and 6.5.4.2
2010 NFPA 110, 8.3.2.1, 8.3.8, 8.4.1, 8.4.2, and 8.4.2.3

Findings include:

On 01/24/2018, during a tour of the facility from 10:30 am to 3:15 pm, the facility failed to provide the following documentation:

1. Monthly 30 minute load test

2. Fuel quality test performed within the past 12 months using tests approved by ASTM standards

3. Weekly visual checks

4. The facility failed to provide documentation that the diesel generator was exercised once monthly for a minimum of 30 minutes with a load of not less than 30% of the diesel generator nameplate kW rating or the minimum manufacturer recommended exhaust temperature is met

OR

5. The facility failed to provide documentation of the annual 1.5 hour supplemental load bank test for the previous 12 months. A supplemental load bank test of not less than 50% of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75% of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours is required if the facility cannot not document item 4.

A member of the maintenance staff was present when this deficiency was identified.

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Based on review of documentation and interview, the facility failed to ensure continuing education on the handling and risks associated with oxygen cylinders and other medical gases stored in cylinders per the requirements of:

2012 NFPA 99, 11.5.2.1

This deficiency could affect all staff and patients.

Findings include:

On 01/24/2018, during the review of documentation from 10:30 am to 3:15 pm, the facility failed to provide documentation on the following:
1. The qualifications and training of the facility's training personnel on handling oxygen cylinders/medical gases and their cylinders.
2. Continuing education to include periodic review of safety guidelines and usage requirements for personnel that handle oxygen cylinders/medical gases and their cylinders, including new hires.

A member of the maintenance staff was present when this deficiency was identified.