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Based on interview and record review, the facility failed to develop and implement emergency preparedness (EP) policies and procedures, addressing the use of volunteers in an emergency.

This deficiency affects all staff and patients in the facility.

Findings include:

During an interview on 1/17/24 at 11:30 a.m., staff member C stated the facility's emergency preparedness plan did not include a policy for the use of volunteers in an emergency.

Review of the facility's Emergency Preparedness plan on 1/17/24 showed the facility did not include a policy and procedure for the use of volunteers in an emergency.

Based on observations, the facility failed to ensure corridor doors with automatic self-closing devices were maintained in accordance with NFPA 101-2012, Section 19.2.2.2.7.

This deficiency affects 1 of 3 lower level smoke compartments and 1 of 2 main floor smoke compartments in the facility.

Findings include:

1. During an observation on 1/17/24 at 12:44 p.m., the PT room was inspected. The corridor door was observed to have a magnetized hold-open device, which was not connected to the facility's fire panel, attached to the door. The door was fitted with a self-closure.

2. During an observation on 1/17/24 at 1:26 p.m., the ER soiled utility room had a kick-down door stop. This door was fitted with a self-closure. When the door stop is being used the door would not close under the power of the self-closure.

Based on observation and interview, the facility failed to ensure all vertical openings containing stairs and a penthouse were properly enclosed with 1 hour rated doors and other rated construction in accordance with NFPA 101, 2012 edition, section 19.3.1.1. This deficiency had the potential to affect 3 of 5 total smoke compartments (including the main level and the lower levels).

Findings include:

During an observation on 1/17/24 at 1:07 p.m. the stairwell connecting the east zones of the lower and upper levels and, serving the "communicating stairway" between the levels, were made of glass walls and door enclosures with metal framing. The glass structures at the main and the lower level were not of 1-hour fire rating for the vertical separation.

During an interview on 1/17/24 at 1:08 p.m. staff member A stated there had not been any changes to the stairwell since the last life safety code survey in 2015.

Based on an observation, the facility failed to assure hazardous rooms had doors which were able to close, and latch under the power of a self-closing device, in accordance with NFPA 101, 2012 Edition, Sections 19.3.2.1, 19.3.2.1.3. and 19.3.2.1.5.

This deficiency affects 1 of 3 lower-level smoke compartments in the facility.

Findings include:

1. During an observation on 1/17/24 at 10:05 a.m., the mechanical room was inspected. The corridor door to the mechanical room was fitted with self-closing devices and would not close under the power of the self-closure.

Based on observation the facility failed to:

a) maintain sprinkler heads free of foreign materials per NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.1.1.1, and

b) failed to ensure sprinkler piping was fee from external loads in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.2.2

c) ensure sprinkler systems maintained satisfactory performance with respect to activation time in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.1.1 (3).

This deficiency affects all smoke compartments at the facility.

Findings include:

1. During an observation on 1/17/24 at 12:46 p.m., the PT restroom was inspected. The sprinkler head was loaded with dust and debris.

2. During an observation on 1/17/24 at 12:48 p.m., the server room was inspected. Ceiling tiles were observed to be missing in the room.

3. During an observation on 1/17/24 at 1:09 p.m., the south awning was inspected. There were multiple zip ties with spikes attached to the sprinkler piping.

4. During an observation on 1/17/24 at 1:20 p.m., the radiology room was inspected. a ceiling tile was observed with a hole in it.

5. During an observation on 1/17/24 at 1:26 p.m., the ER bay was inspected. A sprinkler head was loaded with dust and debris.

6. During an observation on 1/17/24 at 1:29 p.m., the dea-con bay was inspected. There were cords hanging off the sprinkler piping.

7. During an observation on 1/17/24 at 1:32 p.m., the nursing area was inspected. A sprinkler head was loaded with dust and debris.

Based on interview, and record review the facility failed to ensure all employees were kept informed with respect to their duties during a fire drill, ensuring competency per NFPA 101. 2012 Edition, section 19.7.1.2., and 19.7.1.6.

This deficiency affects all facility occupants.

Findings include:

During an interview on 1/17/24 at 10:53 a.m. staff member B stated he just started completing sign-in seets for fire drills in November 2023.

Review of the facility fire drills on 1/17/24 showed, the following quarters did not have staff sign in sheets of who attended, to ensure competency with the fire drill protocol:

January - March 2023
April - June 2023
July - September 2023

Based on record review and interview, the facility failed to test the fire doors in fire assemblies annually in accordance with NFPA 101-2012, Sections 7.2.1.15.1, 4.6.12.1 and in accordance with NFPA 80-2010, Section 5.2.4.2 (written report).

This deficiency affects all smoke compartments at the facility.

Findings include:

Review of the fire safety maintenance records on 1/17/24, reflected the lack of the annual fire door assembly testing documentation. The facility must identify the required fire/smoke barriers, as well as electronically controlled doors and doors with special locking arrangement in the building and show inspections of all components of the doors in those barriers.

During an interview on 1/17/24 at 11:20 a.m., staff member B stated an outside vendor inspects the facility's doors annually, however the facility did not have documentation.

Based on interview and record review, the facility failed to have evidence of the generator weekly visual documentationin accordance with NFPA 110 Standard for Emergency and Standby Power Systems, 2010 Edition, Sections 8.4.1 and 8.4.2.4.

This deficiency affects all smoke compartments.

Findings include:

During an interview on 1/17/24 at 11:24 a.m., staff member B stated he did not have documentation of the weekly visual inspections of the generator.

Record review of the generator information on 1/17/24 did not include any weekly visual documentation of the generator in the last year.

Based on observation, the facility failed to keep the room housing the Emergency Power Supply System (EPSS) free from any other equipment per NFPA 110 2010 Edition, Section 7.2.1.2.

This deficiency affects 1 out of 3 main floor smoke compartments.

Findings include:

1. During an observation on 1/17/24 at 1:04 p.m., the generator room was inspected. The room housing the generator was also being used as a storage room for items such as a snow blower and a multiple gas cans. The room housing the generator can only be used to store items for maintaining the generator.