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Based on observation and interview, the Facility failed to ensure that exit and directional signs are displayed in accordance with 7.10
Exit Signage.

2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)

FINDINGS INCLUDE:

On facility tour between 9:00 AM and 4:00 PM on 02/28/2017, doors were observed that lead directly to the outside. These doors are not considered an emergency exit. The courtyard access doors need to be labeled "Not An Exit" and the old exit door from the ED needs to be either removed or labeled "Not An Exit".

This deficient practice was verified by the Facility Maintenance Director.

Based on observation and interview, the Facility failed to maintain hazardous areas are protected by a fire barrier having 1-hour fire resistance rating.

Hazardous Areas - Enclosure
2012 EXISTING
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4-hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1

Area Automatic Sprinkler Seperation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K3220)

FINDINGS INCLUDE:

On facility tour between 9:00 AM and 4:00 PM on 02/28/2017, observation revealed penetrations around the conduit pipes in the wall of the Data Closet/Electrical Panel Room A.

This deficient practice was verified by the Facility Maintenance Director.

Based on documentation review and interview the Facility did not ensure that the cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.

Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2.

FINDINGS INCLUDE:

On facility tour between 9:00 AM and 4:00 PM on 02/28/2017, during documentation review, it was revealed that documentation could not be located to show that the kitchen fire suppression system was inspected on a semi-annual basis. The only inspection on record for 2016/2017 was conducted on 02/06/17.

This deficient practice was verified by the Facility Maintenance Director.

Based on documentation review and interview, the Facility failed to test and maintain the Fire Alarm System in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code.

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.7.5, 9.7.7, 9.7.8, and NFPA 25.


FINDINGS INCLUDE:

On facility tour between 9:00 AM and 4:00 PM on 2/28/2016, documentation reviewed revealed that the DACT System was not tested during the fire drills conducted on the night shift.

This deficient practice was verified by the Facility Maintenance Director.

Based on documentation review and interview, the Facility failed to provide a current and accurate Fire Alarm Out of Service Policy.

Fire Alarm - Out of Service
Where required fire alarm system is out of services for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.
9.6.1.6

FINDINGS INCLUDE:

On facility tour between 9:00 AM and 4:00 PM on 02/28/2017, documentation review revealed that the Out of Service Policy for the Fire Alarm System does not have current Staff/Fire Marshal contact information.

This deficient practice was verified by the Facility Maintenance Director.

Based on observation and interview, the Facility failed to maintain the ceiling in the Northest Corridor in accordance with 9.7.5, 9.7.7, 9.7.8, and NFPA 25.



Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

FINDINGS INCLUDE:

On facility tour between 9:00 AM and 4:00 PM on 02/28/2017, during the inspection and documentation review, the following concerns with the facility fire sprinklers system were observed:
1.) privacy curtains in the Imagining Changing Room were observed with mesh netting on the top of the curtain that would impede the flow of water from the fire sprinkler system.
2.) documentation could not be located to show corrective action was taken on 3 deficiencies that were noted on Annual Fire Sprinkler Inspection. This inspection was conducted on 12/21/2016. These items were:
a.) Pull station in ED entrance did not function
b.) Heat detector falling from ceiling in file storage room
c.) Horn/strobe in environmental services hallway did not function

This deficient practice was verified by the Facility Maintenance Director.

Based on documentation review and interview, the Facility failed to provide a current and accurate Fire Sprinkler Out of Service Policy.

Sprinkler System - Out of Service
Where the sprinkler system is impaired, the extent and duration of the impairment has been determined, areas or buildings involved are inspected and risks are determined, recommendations are submitted to management or designated representative, and the fire department and other authorities having jurisdiction have been notified. Where the sprinkler system is out of service for more than 10 hours in a 24-hour period, the building or portion of the building affected are evacuated or an approved fire watch is provided until the sprinkler system has been returned to service.
18.3.5.1, 19.3.5.1, 9.7.5, 15.5.2 (NFPA 25)

FINDINGS INCLUDE:

On facility tour between 9:00 AM and 4:00 PM on 02/28/2017, documentation review revealed that the Out of Service Policy for the Fire Sprinkler System does not have current Staff/ Fire Marshal contact information and the 10 hour out of service time needs to be updated.

This deficient practice was verified by the Facility Maintenance Director.

Based on documentation review and interview, the Facility failed to maintain a Evacuation and Relocation Plan according to the 2012 Life Safety Code.

Evacuation and Relocation Plan
There is a written plan for the protection of all patients and for their evacuation in the event of an emergency.
Employees are periodically instructed and kept informed with their duties under the plan, and a copy of the plan is readily available with telephone operator or with security. The plan addresses the basic response required of staff per 18/19.7.2.1.2 and provides for all of the fire safety plan components per 18/19.2.2.
18.7.1.1 through 18.7.1.3, 18.7.2.1.2, 18.7.2.2, 18.7.2.3, 19.7.1.1 through 19.7.1.3, 19.7.2.1.2, 19.7.2.2, 19.7.2.3

FINDINGS INCLUDE:

On facility tour between 9:00 AM and 4:00 PM on 02/28/2017, documentation review revealed the Emergency Fire Plan needs to be updated to ensure all the requirements of the 2012 Life Safety Code are addressed.

This deficient practice was verified by the Facility Maintenance Director.

Based on documentation review and interview, the Facility failed to conduct Fire Drills in accordnance with 18.7.1.4 through 18.7.1.7, 19.7.1.4 through 19.7.1.7.

Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
18.7.1.4 through 18.7.1.7, 19.7.1.4 through 19.7.1.7.

FINDINGS INCLUDE:

On facility tour between 9:00 AM and 4:00 PM on 02/28/2017, documentation reviewed revealed that a fire drills during 2016 were not conducted at unexpected times under varying conditions.
(11:24 AM, 11:31 AM and 4:10 AM, 4:30 AM)

This deficient practice was verified by the Facility Maintenance Director.

Based on documentation review and interview, the Facility failed to provide complete written records of Generator maintenance and testing are maintained and readily available.

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked and readily identifiable. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

FINDINGS INCLUDE:

On facility tour between 9:00 AM and 4:00 PM on 02/28/2017, documentation reviewed revealed that not all the required information is being documented during the Month Emergency Generator Load Test.The transfer time of how long it takes the emergency generator to assume power and the cool down time after the 30 minute monthly load test is not being recorded.

This deficient practice was verified by the Facility Maintenance Director.

Based on observation and interview, the Facility failed to comply with 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5.

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

FINDINGS INCLUDE:

On facility tour between 9:00 AM and 4:00 PM on 02/28/2017, observation during the inspection revealed:
1.) An extension cord being used as a source of fixed wiring in boiler room.
2.) A power strip being used as a source of fixed wiring in the nurses break room.
A microwave, toaster, plate cooker and pizza oven was observed plugged into a power strip.

This deficient practice was verified by the Facility Maintenance Director.

Based on observation and interview, the Facility failed to comply with 5.1.3.3.2 (NFPA 99).


Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)


FINDINGS INCLUDE:

On facility tour between 9:00 AM and 4:00 PM on 02/28/2017, oxygen cylinder tanks were observed nor secure properly to prevent them from falling over in the ambulance storage room and ambulance garage.

This deficient practice was verified by the Facility Maintenance Director.