HospitalInspections.org

Based on observation and interview, the facility failed to maintain fire doors in the two-hour fire barrier that separated two occupancies, the Hospital and Clinic. The facility census was 0 patients.

Findings are:
Observations on 11-10-15 at 12:35 pm revealed, the west 1 ½ hour fire rated door leading into the Clinic failed to latch within the door frame.

During an interview on 11-10-15 at 12:35 pm, Maintenance A confirmed the findings.

NFPA Standard:
Health care occupancies in buildings housing other occupancies shall be completely separated from them by construction having a fire resistance rating of not less than 2 hours. 2000 NFPA 101, 19.1.2.3, 19.1.1.4

Based on observation and interview, the facility failed to use materials in accordance with the interior finish requirements for walls in healthcare occupancies. Facility failed to provide documentation for the flame spread rating of the wood on the walls in the Data Room. The facility census was 0 patients.

Findings are:
Observations on 11-10-15 at 11:04 am revealed, 5 foot X 7 foot and 3 foot X 7 foot wood installed on the walls of the Data Room.

During an interview on 11-10-15 at 11:04 am, Maintenance A confirmed the wood on the walls and failed to provide any type of documentation for flame retardancy.

NFPA Standard:
Ceiling and wall materials shall be limited as specified in 2000 NFPA 101, 10.2.3 Existing materials may be Class A or Class B except that rooms protected by an approved, supervised automatic sprinkler system use of existing Class C finish shall be permitted within rooms separated from the exit access corridors in accordance with 19.3.6. New materials must be Class A except that new walls/ceilings shall be permitted to have Class A or Class B finish in individual rooms having a capacity of four persons. Newly installed corridor wall finish not exceeding 4 feet in height on the lower half of the wall shall be permitted to be Class A or Class B. 2000 NFPA 101, 19.3.3.

Based on observation and interview, the facility failed to assure that 1 of 3 Countryside Dining corridor doors would latch within the doorframe. This deficient practice would prevent containment of fire and smoke within the exiting corridor which could affect all residents in 1 of 6 smoke compartments based on the occupant load of the Countryside Dining and the adjacent Courtyard Dining Room. The facility has a census of 0 patients.

Findings are:
Observations on 11-10-15 between 10:32 am and 1:43 pm revealed:
1. The door to the Nursery was blocked open with a soiled linen cart.
2. Roller latches on the Supply Closet doors, next to Room 421.
3. The gap between the doors to the Supply Closet was greater than 1/8 inch.
4. Louver grill in the Data Closet door.
5. The corridor door to Radiology failed to provide a latching device, only a dead bolt lock was provided.
6. Roller latches on ER Storage room doors.
7. A metal kick down door stop on the Conference Room B door.

During an interview on 11-10-15 between 10:32 am and 1:43 pm, Maintenance A confirmed the findings.

NFPA Standard:
Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3 and CMS S&C Letter 07-1

Based on observation and interview, the facility failed to provide " No Exit " signs on the exterior door leading to the patio on the second floor. This deficient practice had the potential to allow the door to the patio to be mistaken as exit access from the building. The facility census was 0 patients.

Findings are:
Observations on 11-10-15 at 12:25 am revealed, 2 of 2 doors leading into the interior courtyard failed to provide " NO Exit " sign.

During an interview on 11-10-15 at 12:25 pm, Maintenance A confirmed that no signs were provided on the courtyard doors.

NFPA Standard:
Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows:
NO EXIT
Such sign shall have the word NO in letters 2 in. high with a stroke width of 3/8 in. and the word EXIT in letters 1 in. high, with the word EXIT below the word NO. 2000 NFPA 101, 7.10.4.1

Based on observation and interview, the facility failed to ensure that smoke separation doors were capable of resisting the passage of smoke as the doors would allow smoke and gasses to spread. The facility census was 0 patients.

Findings are:
Observations on 11-10-15 at 11:56 revealed, the smoke doors leading into Labor/Delivery were equipped with metal kick down door stops.

During an interview on 11-10-15 at 11:56, Maintenance A confirmed the findings.

NFPA Standard:
Requires doors in smoke barriers to be self-closing and resist the passage of smoke, NFPA 101, 19.3.7.6*.

Based on observation and interview, the facility failed to maintain the doors to hazardous areas so they would to latch within the door frame, allowed metal kick down on hazardous area doors and failed to install self-closing devices on rooms used as storage. These deficient practices would allow fire and smoke to migrate out of the hazard areas into the exiting corridors which would delay egress. The facility census was 0 patients.

Findings are:
Observations on 11-10-15 between 10:31 am and 1:47 pm revealed:
1. A metal kick down door stop on the Clean Hold door in Acute Care Wing.
2. A metal kick down door stop on the Medication Room door in Acute Care Wing.
3. Patient room 433 was used as a storage room, the door failed to provide a self-closing device.
4. The Surgery Equipment room door, equipped with a self-closing device failed to latch within the door frame.
5. Metal door kick down door stop on the Promotional Storage room door.
6. Promotional Storage room door failed to provide latching device, only a dead-bolt.
7. Double doors to Physical Therapy Storage room, failed to provide self-closing device.
8. A metal kick down door stop on the East Housekeeping door.
9. The undercut of the east Housekeeping door was greater than 1 inch.
10. A metal kick down door stop on the Auxiliary Storage room door.
11. Missing ceiling tile in the Auxiliary Storage room
12. A metal kick down door stop on the east wing Mechanical room door.
13. Equipment storage room door in Labor/Delivery area equipped with a self-closing device failed to close and latch within the door frame.
14. Utility room door in Labor/Delivery area equipped with a self-closing device failed to close and latch within the door frame.
15. Storage room located in the Labor/Delivery room failed to provide a self-closing device.
16. Double doors to Laundry room failed to latch within door frame.
17. The undercut of the south Mechanical Room door was greater than 1 inch.
18. File Room which measured approximately 196 square feet, failed to provide a self-closing device on the door.
19. Kitchen Pantry which measured over 100 square feet, failed to provide a self-closing device on the door.
20. The Purchasing Storage room door, equipped with a self-closing device failed to latch within the door frame.
21. A metal kick down door stop on the Purchasing Storage room door.

During an interview on 11-10-15 between 10:26 am and 1:47 pm, Maintenance A confirmed the findings.

NFPA Standard:
Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1, 19.3.6.2 and 19.3.6.3

Based on observation and interview, the facility failed to provide a sidewalk to a public way from the north exit door from the facility. This deficient practice would delay egress during an emergency. The facility census was 0 patients.

Findings are:
Observations on 11-10-15 at 10:15 am revealed:
1. No sidewalk from the exit on the north side of the building leading to a public way.
2. No sidewalk from the west storage exit door leading to a public way.

During an interview on 11-10-15 at 10:15 am, Maintenance A confirmed the lack of sidewalk to public way.

NFPA Standard:
Exits shall terminate directly at a public way or an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. 2000 NFPA 101, 7.7.1

Based on observation and interview, the facility failed to provide two-bulb illumination outside of an exit. This deficient practice would have the potential to leave occupants in darkness during an emergency. The facility census was 0 patients.

Findings are:
Observations on 11-10-15 at 10:42 am revealed, no egress lighting at the south exit by the nurse ' s station acute wing, across from the courtyard.

During an interview on 11-10-15 at 10:42 am, Maintenance A confirmed the lack of lighting.

NFPA Standard:
Required illumination shall be arranged so that the failure of any single bulb or unit does not result in less than .2 foot-candles of illumination in any designated area. 2000 NFPA 101, 7.8.1.4

Based on observation and interview, the facility failed to provide exit signs for the required second exit throughout the facility. This deficient practice would delay or cause confusion during an emergency as occupants would not be aware of the exits or they would reenter the building. The facility census was 0 patients.

Findings are:
Observations on 11-10-15 between 12:42 pm and 2:10 pm revealed:
1. No exit signage provided above the smoke doors near Medical Records.
2. Exit signage outside Lab failed to indicate the correct direction to an exit.
3. No exit signage provided above the smoke doors next to the Chapel.
4. No exit signage provided in the Laundry corridor.

During an interview on 11-10-15 between 12:42 pm and 2:10 pm, Maintenance A confirmed the lack of exit signage.

NFPA Standard:
Means of egress shall have signs in accordance with Section 7.10. 2000 NFPA 101, 19.2.10.1

Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs. 2000 NFPA 101, 7.10.1.4

Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access. 2000 NFPA 101, 7.10.1.2

Based on observations and interview, the facility failed to provide fire alarm notification devices in the interior courtyard and a sleeping room. The lack of fire alarm notification devices could cause a fire emergency to go undetected in those areas of the facility because of the inability to hear and see an alarm device. The facility census was 0 patients.

Findings are:
Observations on 11-10-15 between 10:42 am and 11:30 am revealed:
1. No audible visual device provided in the interior courtyard.
2. No audible visual device provided in the Doctor ' s sleeping room 35.
3. No smoke detection provided in the Doctor ' s sleeping room 35.

During an interview on 11-10-15 between 10:42 am and 11:30 am, Maintenance A confirmed the lack of notification devices.

NFPA Standard:
A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, and NFPA 72. 2000 NFPA 101, 9.6.1.4

Based on documentation review and interview, the facility failed to provide documentation for current testing and inspection of the facility fire alarm system. This deficient practice increased the potential that the fire alarm would fail to detect smoke. The facility census was 0 patients.

Findings are:
Documentation review on 11-10-15 at 2:39 pm revealed, the facility failed to provide current fire alarm testing reports, last report provided was dated 2013. The facility failed to have current sensitivity testing conducted, last report provided was dated 2012.

During an interview on 11-10-15 at 2:39 pm, Maintenance A confirmed the lack of documentation.

NFPA Standard:
1999 NFPA 72, 7-3.2.1
Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
a) Calibrated test method
b) Manufacturer ' s calibrated sensitivity test instrument
c) Listed control equipment arranged for the purpose
d) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
e) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.

Based on observation and interview, the facility failed to provide sprinkler coverage in 2 of 2 folding door storage locations and at the exterior dock. This deficient practice would allow fire and smoke to spread. The facility census was 0 patients.

Findings are:
Observations on 11-10-15 at 11:45 am and 1:39 pm revealed:
1. No sprinkler protection in two closets used as storage, where a folding door was to be stored in Physical Therapy.
2. No sprinkler protection in the dock area, where there were two large dumpsters.

During an interview on 7-14-14 at 11:45 am and 1:39 pm, Maintenance A confirmed the lack of sprinkler protection in the closets and stated doors were never installed and that the area was used for storage also confirmed the lack of protection in the dock.

NFPA Standard:
Where required by 19.1.6.1 health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. 2000 NFPA 101, 19.3.5

NFPA Standard:
Sprinklers shall be installed under exterior roofs or canopies exceeding 4 ft (1.2 m) in width.
Exception: Sprinklers are permitted to be omitted where the canopy or roof is of noncombustible or limited combustible construction. 1999 NFPA 13, 5-13.8.25-13.8.1

Sprinklers shall be installed under roofs or canopies over areas where combustibles are stored and handled. 1999 NFPA 13, 5-13.8.2*

Based on observation and interview, the facility failed to provide an unobstructed path to the K type fire extinguisher in the kitchen. The deficient practice would delay the attempt to extinguish a fire. The facility census was 0 patients.

Findings are:
Observations on 11-10-15 at 1:15 pm revealed the Class K fire extinguisher in the kitchen was obstructed with a cart.

During an interview on 11-10-15 at 1:15 pm, Maintenance A confirmed the extinguisher was blocked.

NFPA Standard:
Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas. 1998 NFPA 10, 1-6.3

Based on observation and interview, the facility failed to assure that the manual pull for the hood suppression system which was installed in 2012, was readily accessable and located in an accessible location on the path of egress or identified. This deficient practice could delay the response to extinguishing a fire under the hood. The facility census was 0 patients.

Findings are:
Observations on 11-10-15 at 1:20 pm revealed, the manual pull for the hood extinguishing system located on the control box which was above a microwave on a counter top. The manual pull was not located in the path to an exit and failed to be identified.

During an interview 11-10-15 at 1:20 pm, Maintenance A confirmed that the manual pull was not readily accessible or located near the kitchen exit, and stated the hood was installed in 2012.

NFPA Standard:
A readily accessible means for manual activation shall be located in a path of exit or egress no more than 5 ft (1.5 m) above the floor and shall clearly identify the hazard protected. 1998 NFPA 17, 3-7.1.3*

All remote manual actuators shall be identified as to the hazard they protect. 1998 NFPA 17, 3-7.1.4

Based on observation and interview the facility failed to provide documentation that the curtain in Conference Room B was flame resistant. The facility census was 0 patients.

Findings are:
Observations on 11-10-15 at 2:28 pm revealed the curtain in the doorway of a storage area in Conference Room B were not tagged as being flame retardant.

During an interview on 11-10-15 at 2:28 pm, Maintenance Manager A confirmed the curtain and did not have documentation regarding the flame resistance ratings.

NFPA Standard:
Draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701. 2000 NFPA 101, 10.3.

Based on observation, interview and documentation review, the facility failed to maintain signage on the bulk oxygen and failed to provide documentation of inspection. This practice would affect all patients in the facility. The facility census was 0 patients.

Findings are:
Observations on 11-10-15 at 12:34 pm revealed the " no smoking " signs on the bulk oxygen tank were weathered and peeling off, making them difficult to read.

During an interview on 11-10-15 at 12:34 pm, Maintenance A confirmed the signage was unreadable.

Documentation review on 11-10-15 at 2:40 pm revealed the facility failed to provide any type of maintenance records for the bulk oxygen system.

During an interview on 11-10-15 at 2:40 pm, Maintenance A confirmed the lack of records.

NFPA Standard:
The bulk oxygen storage location shall be permanently placarded to indicate " OXYGEN - NO SMOKING - NO OPEN FLAMES. " 2001 NFPA 50, 3.5.8

Each bulk oxygen system installed on consumer premises shall be inspected annually and maintained by a qualified representative of the equipment owner. 2001 NFPA 50, 4.2.1

Based on observation, interview and documentation review, the facility failed to maintain the emergency generator in accordance with the National Fire Protection Association (NFPA), 110. This deficient condition increased the potential that the generator would fail to run during loss of power. Facility census was 0 patients.

Findings are:
Observation on 11-10-15 at 1:24 pm revealed, the remote generator notification device audible alarm, was switched to the off position and the green indicator light failed to be illuminated.

During an interview on 11-10-15 at 11:24 pm, Maintenance A confirmed that the remote generator notification device may not be operational and failed to verify that it worked.

Documentation review on 11-10-15 at 2:20 pm of the provided emergency generator maintenance revealed the documentation failed to exhibit information for monthly and weekly testing in accordance with NFPA 110:
1. The percentage of KW that the generator ran at during monthly load testing failed to provide documentation that it reached 30 percent.
2. The fuel system failed to be inspected weekly.
3. The lubrication system failed to be inspected weekly.
4. The cooling system failed to be inspected weekly.
5. The exhaust system failed to be inspected weekly.
6. The battery system failed to be inspected weekly.
7. The electrical system failed to be inspected weekly.
8. The prime mover failed to be inspected weekly.
9. The belts and hoses failed to be inspected weekly.
10. No time to transfer was documented.

During an interview on 11-10-15 at 2:20 pm, Maintenance A confirmed that the generator testing documentation failed to be complete.

NFPA Standard:
NFPA 110, 1999, 6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.
6-4.2*
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations

Generator sets or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures. 1999 NFPA 99, 3-4.4.1.1

Based on interview and observation, the facility failed to provide a remote audible annunciator panel which was functional and failed to verify low fuel on the exterior fuel tank. This deficient practice would affect all smoke compartments of the building and all occupants, as it would delay the response to maintain the generator in the event of failure. The facility census was 0 patients.

Findings are:
Observation on 11-10-15 at 1:24 pm revealed, the remote generator notification device audible alarm, was switched to the off position and the green indicator light failed to be illuminated. The annunciator failed to indicate low battery.

During an interview on 11-10-15 at 1:24 pm, Maintenance A confirmed that the remote generator notification device may not be operational and failed to verify that it worked.

Observations on 11-10-15 at 1:40 pm revealed, the generator fuel tank located outside the facility.

During an interview on 11-10-15 at 1:24 pm, Maintenance A stated that the 1000 gallon exterior fuel tank supplied fuel for the generator and the boilers. Maintenance A failed to verify if the fuel tank was equipped with a low fuel sensor.

Based on observation, interview and documentation review, the facility failed to assure that power strips, extension cords and electrical adaptors were not used within the facility and failed to keep electrical panels free of obstructions. The facility failed to test and document retention for electrical outlets. These deficient practices increased the potential for electrical fire. The facility census was 0 patients.

Findings are:
Observations on 11-10-15 between 11:15 am and 1:18 pm revealed:
1. Non-hospital grade power strip used for medical equipment in Room 36.
2. Non-hospital grade power strip plugged into an extension cord used for medical equipment in Room 38.
3. Microwave and coffee pot plugged into a power strip and an extension cord.
4. Medication refrigerator in the Pharmacy plugged into a power strip.
5. Refrigerator and microwave plugged into a four way electrical adaptor, an extension cord and a power strip in the " old " Doctors lounge.
6. Reading light plugged into an extension cord in the Reading Room.
7. Outlet failed to provide a cover in the south-east corner of the Reading Room.
8. Obstruction to the transfer switches in the Mechanical room.
9. Obstruction in front of the electrical panel A in Medical records storage room.
10. 3-way electrical adaptor in the Chapel used for the Cross, radio and lamp.
11. Lamp plugged into an extension cord in the Chapel.
12. Microwave and toaster plugged into a power strip in the Dining Room.

During an interview on 11-10-15 between 11:15 am and 1:18 pm, Maintenance A confirmed the findings.

Documentation review on 11-10-15 at 2:49 pm revealed, that the facility failed to test and document retention of electrical outlets.

During an interview on 11-10-15 at 2:49 pm, Maintenance A confirmed the lack of retention testing.

NFPA Standard:
Sufficient access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment. 1999 NFPA 70, 110.26

Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8, 1999 NFPA 110, 6.4.1 and 6.4.2

Regulation:
Nebraska State Fire Marshal Official Interpretation 08-01
Nebraska State Fire Marshal Official Interpretation 87-11

NFPA Standard:
Receptacle Testing in Patient Care Areas
a) The physical integrity of each receptacle shall be confirmed by visual inspection.
b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). 1999 NFPA 99, 3-3.3.3

Testing Interval for Receptacles in Patient Care Areas
1. Testing shall be performed after initial installation, replacement, or servicing of the device.
2. Additional testing shall be performed at intervals defined by documented performance data.
Exception: Receptacles not listed as hospital-grade shall be tested at intervals not exceeding 12 months.1999 NFPA 99, 3-3.4.2.3

Based on record review and interview, the facility failed to assure that a policy was in place regarding the procedures to be taken in the event that the sprinkler system was out of service for more than 4 hours in a 24-hour period. The lack of procedures could affect the actions taken by staff in the event of an emergency. The facility census was 0 patients.

Findings are:
Documentation review on 11-10-15 at 2:47 pm revealed:
1. The facilities policy failed to include directions to notify local fire department immediately.
2. The facilities policy failed to include that the individual conducting the fire watch shall have no other assigned duties.
3. The facilities policy failed to include that the individual conducting the fire watch shall have access to all portions of the building.
4. The facilities policy failed to include that individuals conducting fire watch shall walk through the affected areas at intervals not exceeding 30 minutes.

During an interview on 11-10-15 at 2:47, Maintenance A confirmed the lack of information on the policy.

NFPA Standard:
When a required sprinkler system is out of service for more than 4 hours in a 24-hour period, the AHJ shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties until the fire alarm system has been returned to service. A fire watch should consist of trained personnel who continuously patrol the effected area, with ready access to fire extinguishers and the ability to promptly notify the fire department. During the patrol of the area, the person should look for fire, and that other fire protection features of the building such as egress routes and alarm systems are available and functioning properly. 2000 NFPA 101, 9.6.1.8

Based on record review and interview, the facility failed to assure that a policy is in place regarding the procedures to be taken in the event that the fire alarm system is out of service for more than 4 hours in a 24-hour period. The lack of procedures could affect the actions taken by staff in the event of an emergency.The facility census was 0 patients.

Findings are:
Documentation review on 11-10-15 at 2:47 pm revealed:
1. The facilities policy failed to include to notify local fire department immediately.
2. The facilities policy failed to include that the individual conducting the fire watch shall have no other assigned duties.
3. The facilities policy failed to include that the individual conducting the fire watch shall have access to all portions of the building.
4. The facilities policy failed to include that individuals conducting fire watch shall walk through the affected areas at intervals not exceeding 30 minutes.

During an interview on 11-10-15 at 2:47, Maintenance A confirmed the lack of information on the policy.

NFPA Standard:
When a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the AHJ shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties until the fire alarm system has been returned to service. A fire watch should consist of trained personnel who continuously patrol the effected area, with ready access to fire extinguishers and the ability to promptly notify the fire department. During the patrol of the area, the person should look for fire, and that other fire protection features of the building such as egress routes and alarm systems are available and functioning properly. 2000 NFPA 101, 9.6.1.8

Based on observation and interview, the facility failed to maintain fire doors in the two-hour fire barrier that separated two occupancies, the Hospital and Clinic. The facility census was 0 patients.

Findings are:
Observations on 11-10-15 at 12:35 pm revealed, the west 1 ½ hour fire rated door leading into the Clinic failed to latch within the door frame.

During an interview on 11-10-15 at 12:35 pm, Maintenance A confirmed the findings.

NFPA Standard:
Health care occupancies in buildings housing other occupancies shall be completely separated from them by construction having a fire resistance rating of not less than 2 hours. 2000 NFPA 101, 19.1.2.3, 19.1.1.4

Based on observation and interview, the facility failed to use materials in accordance with the interior finish requirements for walls in healthcare occupancies. Facility failed to provide documentation for the flame spread rating of the wood on the walls in the Data Room. The facility census was 0 patients.

Findings are:
Observations on 11-10-15 at 11:04 am revealed, 5 foot X 7 foot and 3 foot X 7 foot wood installed on the walls of the Data Room.

During an interview on 11-10-15 at 11:04 am, Maintenance A confirmed the wood on the walls and failed to provide any type of documentation for flame retardancy.

NFPA Standard:
Ceiling and wall materials shall be limited as specified in 2000 NFPA 101, 10.2.3 Existing materials may be Class A or Class B except that rooms protected by an approved, supervised automatic sprinkler system use of existing Class C finish shall be permitted within rooms separated from the exit access corridors in accordance with 19.3.6. New materials must be Class A except that new walls/ceilings shall be permitted to have Class A or Class B finish in individual rooms having a capacity of four persons. Newly installed corridor wall finish not exceeding 4 feet in height on the lower half of the wall shall be permitted to be Class A or Class B. 2000 NFPA 101, 19.3.3.

Based on observation and interview, the facility failed to assure that 1 of 3 Countryside Dining corridor doors would latch within the doorframe. This deficient practice would prevent containment of fire and smoke within the exiting corridor which could affect all residents in 1 of 6 smoke compartments based on the occupant load of the Countryside Dining and the adjacent Courtyard Dining Room. The facility has a census of 0 patients.

Findings are:
Observations on 11-10-15 between 10:32 am and 1:43 pm revealed:
1. The door to the Nursery was blocked open with a soiled linen cart.
2. Roller latches on the Supply Closet doors, next to Room 421.
3. The gap between the doors to the Supply Closet was greater than 1/8 inch.
4. Louver grill in the Data Closet door.
5. The corridor door to Radiology failed to provide a latching device, only a dead bolt lock was provided.
6. Roller latches on ER Storage room doors.
7. A metal kick down door stop on the Conference Room B door.

During an interview on 11-10-15 between 10:32 am and 1:43 pm, Maintenance A confirmed the findings.

NFPA Standard:
Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3 and CMS S&C Letter 07-1

Based on observation and interview, the facility failed to provide " No Exit " signs on the exterior door leading to the patio on the second floor. This deficient practice had the potential to allow the door to the patio to be mistaken as exit access from the building. The facility census was 0 patients.

Findings are:
Observations on 11-10-15 at 12:25 am revealed, 2 of 2 doors leading into the interior courtyard failed to provide " NO Exit " sign.

During an interview on 11-10-15 at 12:25 pm, Maintenance A confirmed that no signs were provided on the courtyard doors.

NFPA Standard:
Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows:
NO EXIT
Such sign shall have the word NO in letters 2 in. high with a stroke width of 3/8 in. and the word EXIT in letters 1 in. high, with the word EXIT below the word NO. 2000 NFPA 101, 7.10.4.1

Based on observation and interview, the facility failed to ensure that smoke separation doors were capable of resisting the passage of smoke as the doors would allow smoke and gasses to spread. The facility census was 0 patients.

Findings are:
Observations on 11-10-15 at 11:56 revealed, the smoke doors leading into Labor/Delivery were equipped with metal kick down door stops.

During an interview on 11-10-15 at 11:56, Maintenance A confirmed the findings.

NFPA Standard:
Requires doors in smoke barriers to be self-closing and resist the passage of smoke, NFPA 101, 19.3.7.6*.

Based on observation and interview, the facility failed to maintain the doors to hazardous areas so they would to latch within the door frame, allowed metal kick down on hazardous area doors and failed to install self-closing devices on rooms used as storage. These deficient practices would allow fire and smoke to migrate out of the hazard areas into the exiting corridors which would delay egress. The facility census was 0 patients.

Findings are:
Observations on 11-10-15 between 10:31 am and 1:47 pm revealed:
1. A metal kick down door stop on the Clean Hold door in Acute Care Wing.
2. A metal kick down door stop on the Medication Room door in Acute Care Wing.
3. Patient room 433 was used as a storage room, the door failed to provide a self-closing device.
4. The Surgery Equipment room door, equipped with a self-closing device failed to latch within the door frame.
5. Metal door kick down door stop on the Promotional Storage room door.
6. Promotional Storage room door failed to provide latching device, only a dead-bolt.
7. Double doors to Physical Therapy Storage room, failed to provide self-closing device.
8. A metal kick down door stop on the East Housekeeping door.
9. The undercut of the east Housekeeping door was greater than 1 inch.
10. A metal kick down door stop on the Auxiliary Storage room door.
11. Missing ceiling tile in the Auxiliary Storage room
12. A metal kick down door stop on the east wing Mechanical room door.
13. Equipment storage room door in Labor/Delivery area equipped with a self-closing device failed to close and latch within the door frame.
14. Utility room door in Labor/Delivery area equipped with a self-closing device failed to close and latch within the door frame.
15. Storage room located in the Labor/Delivery room failed to provide a self-closing device.
16. Double doors to Laundry room failed to latch within door frame.
17. The undercut of the south Mechanical Room door was greater than 1 inch.
18. File Room which measured approximately 196 square feet, failed to provide a self-closing device on the door.
19. Kitchen Pantry which measured over 100 square feet, failed to provide a self-closing device on the door.
20. The Purchasing Storage room door, equipped with a self-closing device failed to latch within the door frame.
21. A metal kick down door stop on the Purchasing Storage room door.

During an interview on 11-10-15 between 10:26 am and 1:47 pm, Maintenance A confirmed the findings.

NFPA Standard:
Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1, 19.3.6.2 and 19.3.6.3

Based on observation and interview, the facility failed to provide a sidewalk to a public way from the north exit door from the facility. This deficient practice would delay egress during an emergency. The facility census was 0 patients.

Findings are:
Observations on 11-10-15 at 10:15 am revealed:
1. No sidewalk from the exit on the north side of the building leading to a public way.
2. No sidewalk from the west storage exit door leading to a public way.

During an interview on 11-10-15 at 10:15 am, Maintenance A confirmed the lack of sidewalk to public way.

NFPA Standard:
Exits shall terminate directly at a public way or an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. 2000 NFPA 101, 7.7.1

Based on observation and interview, the facility failed to provide two-bulb illumination outside of an exit. This deficient practice would have the potential to leave occupants in darkness during an emergency. The facility census was 0 patients.

Findings are:
Observations on 11-10-15 at 10:42 am revealed, no egress lighting at the south exit by the nurse ' s station acute wing, across from the courtyard.

During an interview on 11-10-15 at 10:42 am, Maintenance A confirmed the lack of lighting.

NFPA Standard:
Required illumination shall be arranged so that the failure of any single bulb or unit does not result in less than .2 foot-candles of illumination in any designated area. 2000 NFPA 101, 7.8.1.4

Based on observation and interview, the facility failed to provide exit signs for the required second exit throughout the facility. This deficient practice would delay or cause confusion during an emergency as occupants would not be aware of the exits or they would reenter the building. The facility census was 0 patients.

Findings are:
Observations on 11-10-15 between 12:42 pm and 2:10 pm revealed:
1. No exit signage provided above the smoke doors near Medical Records.
2. Exit signage outside Lab failed to indicate the correct direction to an exit.
3. No exit signage provided above the smoke doors next to the Chapel.
4. No exit signage provided in the Laundry corridor.

During an interview on 11-10-15 between 12:42 pm and 2:10 pm, Maintenance A confirmed the lack of exit signage.

NFPA Standard:
Means of egress shall have signs in accordance with Section 7.10. 2000 NFPA 101, 19.2.10.1

Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs. 2000 NFPA 101, 7.10.1.4

Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access. 2000 NFPA 101, 7.10.1.2

Based on observations and interview, the facility failed to provide fire alarm notification devices in the interior courtyard and a sleeping room. The lack of fire alarm notification devices could cause a fire emergency to go undetected in those areas of the facility because of the inability to hear and see an alarm device. The facility census was 0 patients.

Findings are:
Observations on 11-10-15 between 10:42 am and 11:30 am revealed:
1. No audible visual device provided in the interior courtyard.
2. No audible visual device provided in the Doctor ' s sleeping room 35.
3. No smoke detection provided in the Doctor ' s sleeping room 35.

During an interview on 11-10-15 between 10:42 am and 11:30 am, Maintenance A confirmed the lack of notification devices.

NFPA Standard:
A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, and NFPA 72. 2000 NFPA 101, 9.6.1.4

Based on documentation review and interview, the facility failed to provide documentation for current testing and inspection of the facility fire alarm system. This deficient practice increased the potential that the fire alarm would fail to detect smoke. The facility census was 0 patients.

Findings are:
Documentation review on 11-10-15 at 2:39 pm revealed, the facility failed to provide current fire alarm testing reports, last report provided was dated 2013. The facility failed to have current sensitivity testing conducted, last report provided was dated 2012.

During an interview on 11-10-15 at 2:39 pm, Maintenance A confirmed the lack of documentation.

NFPA Standard:
1999 NFPA 72, 7-3.2.1
Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
a) Calibrated test method
b) Manufacturer ' s calibrated sensitivity test instrument
c) Listed control equipment arranged for the purpose
d) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
e) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.

Based on observation and interview, the facility failed to provide sprinkler coverage in 2 of 2 folding door storage locations and at the exterior dock. This deficient practice would allow fire and smoke to spread. The facility census was 0 patients.

Findings are:
Observations on 11-10-15 at 11:45 am and 1:39 pm revealed:
1. No sprinkler protection in two closets used as storage, where a folding door was to be stored in Physical Therapy.
2. No sprinkler protection in the dock area, where there were two large dumpsters.

During an interview on 7-14-14 at 11:45 am and 1:39 pm, Maintenance A confirmed the lack of sprinkler protection in the closets and stated doors were never installed and that the area was used for storage also confirmed the lack of protection in the dock.

NFPA Standard:
Where required by 19.1.6.1 health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. 2000 NFPA 101, 19.3.5

NFPA Standard:
Sprinklers shall be installed under exterior roofs or canopies exceeding 4 ft (1.2 m) in width.
Exception: Sprinklers are permitted to be omitted where the canopy or roof is of noncombustible or limited combustible construction. 1999 NFPA 13, 5-13.8.25-13.8.1

Sprinklers shall be installed under roofs or canopies over areas where combustibles are stored and handled. 1999 NFPA 13, 5-13.8.2*

Based on observation and interview, the facility failed to provide an unobstructed path to the K type fire extinguisher in the kitchen. The deficient practice would delay the attempt to extinguish a fire. The facility census was 0 patients.

Findings are:
Observations on 11-10-15 at 1:15 pm revealed the Class K fire extinguisher in the kitchen was obstructed with a cart.

During an interview on 11-10-15 at 1:15 pm, Maintenance A confirmed the extinguisher was blocked.

NFPA Standard:
Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas. 1998 NFPA 10, 1-6.3

Based on observation and interview, the facility failed to assure that the manual pull for the hood suppression system which was installed in 2012, was readily accessable and located in an accessible location on the path of egress or identified. This deficient practice could delay the response to extinguishing a fire under the hood. The facility census was 0 patients.

Findings are:
Observations on 11-10-15 at 1:20 pm revealed, the manual pull for the hood extinguishing system located on the control box which was above a microwave on a counter top. The manual pull was not located in the path to an exit and failed to be identified.

During an interview 11-10-15 at 1:20 pm, Maintenance A confirmed that the manual pull was not readily accessible or located near the kitchen exit, and stated the hood was installed in 2012.

NFPA Standard:
A readily accessible means for manual activation shall be located in a path of exit or egress no more than 5 ft (1.5 m) above the floor and shall clearly identify the hazard protected. 1998 NFPA 17, 3-7.1.3*

All remote manual actuators shall be identified as to the hazard they protect. 1998 NFPA 17, 3-7.1.4

Based on observation and interview the facility failed to provide documentation that the curtain in Conference Room B was flame resistant. The facility census was 0 patients.

Findings are:
Observations on 11-10-15 at 2:28 pm revealed the curtain in the doorway of a storage area in Conference Room B were not tagged as being flame retardant.

During an interview on 11-10-15 at 2:28 pm, Maintenance Manager A confirmed the curtain and did not have documentation regarding the flame resistance ratings.

NFPA Standard:
Draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701. 2000 NFPA 101, 10.3.

Based on observation, interview and documentation review, the facility failed to maintain signage on the bulk oxygen and failed to provide documentation of inspection. This practice would affect all patients in the facility. The facility census was 0 patients.

Findings are:
Observations on 11-10-15 at 12:34 pm revealed the " no smoking " signs on the bulk oxygen tank were weathered and peeling off, making them difficult to read.

During an interview on 11-10-15 at 12:34 pm, Maintenance A confirmed the signage was unreadable.

Documentation review on 11-10-15 at 2:40 pm revealed the facility failed to provide any type of maintenance records for the bulk oxygen system.

During an interview on 11-10-15 at 2:40 pm, Maintenance A confirmed the lack of records.

NFPA Standard:
The bulk oxygen storage location shall be permanently placarded to indicate " OXYGEN - NO SMOKING - NO OPEN FLAMES. " 2001 NFPA 50, 3.5.8

Each bulk oxygen system installed on consumer premises shall be inspected annually and maintained by a qualified representative of the equipment owner. 2001 NFPA 50, 4.2.1

Based on observation, interview and documentation review, the facility failed to maintain the emergency generator in accordance with the National Fire Protection Association (NFPA), 110. This deficient condition increased the potential that the generator would fail to run during loss of power. Facility census was 0 patients.

Findings are:
Observation on 11-10-15 at 1:24 pm revealed, the remote generator notification device audible alarm, was switched to the off position and the green indicator light failed to be illuminated.

During an interview on 11-10-15 at 11:24 pm, Maintenance A confirmed that the remote generator notification device may not be operational and failed to verify that it worked.

Documentation review on 11-10-15 at 2:20 pm of the provided emergency generator maintenance revealed the documentation failed to exhibit information for monthly and weekly testing in accordance with NFPA 110:
1. The percentage of KW that the generator ran at during monthly load testing failed to provide documentation that it reached 30 percent.
2. The fuel system failed to be inspected weekly.
3. The lubrication system failed to be inspected weekly.
4. The cooling system failed to be inspected weekly.
5. The exhaust system failed to be inspected weekly.
6. The battery system failed to be inspected weekly.
7. The electrical system failed to be inspected weekly.
8. The prime mover failed to be inspected weekly.
9. The belts and hoses failed to be inspected weekly.
10. No time to transfer was documented.

During an interview on 11-10-15 at 2:20 pm, Maintenance A confirmed that the generator testing documentation failed to be complete.

NFPA Standard:
NFPA 110, 1999, 6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.
6-4.2*
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations

Generator sets or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures. 1999 NFPA 99, 3-4.4.1.1

Based on interview and observation, the facility failed to provide a remote audible annunciator panel which was functional and failed to verify low fuel on the exterior fuel tank. This deficient practice would affect all smoke compartments of the building and all occupants, as it would delay the response to maintain the generator in the event of failure. The facility census was 0 patients.

Findings are:
Observation on 11-10-15 at 1:24 pm revealed, the remote generator notification device audible alarm, was switched to the off position and the green indicator light failed to be illuminated. The annunciator failed to indicate low battery.

During an interview on 11-10-15 at 1:24 pm, Maintenance A confirmed that the remote generator notification device may not be operational and failed to verify that it worked.

Observations on 11-10-15 at 1:40 pm revealed, the generator fuel tank located outside the facility.

During an interview on 11-10-15 at 1:24 pm, Maintenance A stated that the 1000 gallon exterior fuel tank supplied fuel for the generator and the boilers. Maintenance A failed to verify if the fuel tank was equipped with a low fuel sensor.

Based on observation, interview and documentation review, the facility failed to assure that power strips, extension cords and electrical adaptors were not used within the facility and failed to keep electrical panels free of obstructions. The facility failed to test and document retention for electrical outlets. These deficient practices increased the potential for electrical fire. The facility census was 0 patients.

Findings are:
Observations on 11-10-15 between 11:15 am and 1:18 pm revealed:
1. Non-hospital grade power strip used for medical equipment in Room 36.
2. Non-hospital grade power strip plugged into an extension cord used for medical equipment in Room 38.
3. Microwave and coffee pot plugged into a power strip and an extension cord.
4. Medication refrigerator in the Pharmacy plugged into a power strip.
5. Refrigerator and microwave plugged into a four way electrical adaptor, an extension cord and a power strip in the " old " Doctors lounge.
6. Reading light plugged into an extension cord in the Reading Room.
7. Outlet failed to provide a cover in the south-east corner of the Reading Room.
8. Obstruction to the transfer switches in the Mechanical room.
9. Obstruction in front of the electrical panel A in Medical records storage room.
10. 3-way electrical adaptor in the Chapel used for the Cross, radio and lamp.
11. Lamp plugged into an extension cord in the Chapel.
12. Microwave and toaster plugged into a power strip in the Dining Room.

During an interview on 11-10-15 between 11:15 am and 1:18 pm, Maintenance A confirmed the findings.

Documentation review on 11-10-15 at 2:49 pm revealed, that the facility failed to test and document retention of electrical outlets.

During an interview on 11-10-15 at 2:49 pm, Maintenance A confirmed the lack of retention testing.

NFPA Standard:
Sufficient access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment. 1999 NFPA 70, 110.26

Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8, 1999 NFPA 110, 6.4.1 and 6.4.2

Regulation:
Nebraska State Fire Marshal Official Interpretation 08-01
Nebraska State Fire Marshal Official Interpretation 87-11

NFPA Standard:
Receptacle Testing in Patient Care Areas
a) The physical integrity of each receptacle shall be confirmed by visual inspection.
b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). 1999 NFPA 99, 3-3.3.3

Testing Interval for Receptacles in Patient Care Areas
1. Testing shall be performed after initial installation, replacement, or servicing of the device.
2. Additional testing shall be performed at intervals defined by documented performance data.
Exception: Receptacles not listed as hospital-grade shall be tested at intervals not exceeding 12 months.1999 NFPA 99, 3-3.4.2.3

Based on record review and interview, the facility failed to assure that a policy was in place regarding the procedures to be taken in the event that the sprinkler system was out of service for more than 4 hours in a 24-hour period. The lack of procedures could affect the actions taken by staff in the event of an emergency. The facility census was 0 patients.

Findings are:
Documentation review on 11-10-15 at 2:47 pm revealed:
1. The facilities policy failed to include directions to notify local fire department immediately.
2. The facilities policy failed to include that the individual conducting the fire watch shall have no other assigned duties.
3. The facilities policy failed to include that the individual conducting the fire watch shall have access to all portions of the building.
4. The facilities policy failed to include that individuals conducting fire watch shall walk through the affected areas at intervals not exceeding 30 minutes.

During an interview on 11-10-15 at 2:47, Maintenance A confirmed the lack of information on the policy.

NFPA Standard:
When a required sprinkler system is out of service for more than 4 hours in a 24-hour period, the AHJ shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties until the fire alarm system has been returned to service. A fire watch should consist of trained personnel who continuously patrol the effected area, with ready access to fire extinguishers and the ability to promptly notify the fire department. During the patrol of the area, the person should look for fire, and that other fire protection features of the building such as egress routes and alarm systems are available and functioning properly. 2000 NFPA 101, 9.6.1.8

Based on record review and interview, the facility failed to assure that a policy is in place regarding the procedures to be taken in the event that the fire alarm system is out of service for more than 4 hours in a 24-hour period. The lack of procedures could affect the actions taken by staff in the event of an emergency.The facility census was 0 patients.

Findings are:
Documentation review on 11-10-15 at 2:47 pm revealed:
1. The facilities policy failed to include to notify local fire department immediately.
2. The facilities policy failed to include that the individual conducting the fire watch shall have no other assigned duties.
3. The facilities policy failed to include that the individual conducting the fire watch shall have access to all portions of the building.
4. The facilities policy failed to include that individuals conducting fire watch shall walk through the affected areas at intervals not exceeding 30 minutes.

During an interview on 11-10-15 at 2:47, Maintenance A confirmed the lack of information on the policy.

NFPA Standard:
When a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the AHJ shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties until the fire alarm system has been returned to service. A fire watch should consist of trained personnel who continuously patrol the effected area, with ready access to fire extinguishers and the ability to promptly notify the fire department. During the patrol of the area, the person should look for fire, and that other fire protection features of the building such as egress routes and alarm systems are available and functioning properly. 2000 NFPA 101, 9.6.1.8