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Based on Fire Alarm Inspection Report review and interview, it was determined the facility did not take corrective action when inspection of the Sprinler Water Flow Valve failed. The failed practice had the potential to affect all patients, staff, and visitors because the full functioning of all fire alarm system devices was not maintained to provide occupant notification of a fire event. The facility had a census of two patients on 02/02/15. The findings follow:

A. Review of the most recent Fire Alarm Inspection Report dated 03/21/14 at 0935 on 02/04/15 revealed the Sprinkler Water Flow Valve failed inspection. The report noted "The new sprinkler system covering the front lobby doesn't have a tamper switch monitoring the isolation valves. They are 4 ball type valves. The flow switch is installed but is not wired into the fire alarm panel either. Wire will have to be run and a zone card will have to be added to the panel to monitor this."
B. In an interview on 02/04/15 at 1025 the Maintenance Director verified the failed Sprinkler Water Flow Valve had not been repaired or corrected.

Based on Sprinkler Inspection Report review and interview, it was determined the facility did not take corrective action when the inspection failed due to the installed flow switch not connected, no tamper switch installed and the valves were not locked. The failed practice had the potential to affect all patients, staff, and visitors because the full functioning of all sprinkler system devices was not maintained to provide occupant notification of a fire event. The facility had a census of two patients on 02/02/15. The findings follow:

A. Review of the most recent Report of Sprinkler Inspection dated 03/21/14 at 0925 on 02/04/15 revealed the "flow switch installed, but not connected. No tamper switch installed and valves are not locked."
B. In an interview on 02/04/15 at 1025, the Maintenance Director verified corrective action had not been taken to correct the sprinkler system deficiencies.

Based on observation and interview, it was determined the facility allowed portable heating devices as evidenced by four heaters discovered in patient care areas (Emergency Department and Patient Room 18, 21 and 26) while touring the facility. The failed practice created a fire hazard that had the potential to affect all patients, staff, and visitors. The facility had a census of two patients on 02/02/15. The findings follow:

A. On a tour of the facility with the Maintenance Director on 02/03/15 at 0900 electric space heaters were observed as follows:
1) In the Emergency Department waiting room.
2) In Patient Room 26.
3) In Patient Room 19.
4) In Patient Room 21.
B. The Maintenance Director verified the observed portable heaters in the Emergency Department and Patient Rooms as each heater was observed on tour.

Based on observation and interview, it was determined the facility did not maintain the egress in the Nursing Unit corridor free from obstructions to provide instantaneous use in the event of a fire or other emergency. Failure to maintain egress corridors free from obstructions had the potential to affect the health and safety of all patients, staff, and visitors due to limiting the full use of the egress corridor to provide a path to safety in the event of a fire or other emergency. The facility had a census of two patients on 02/02/15. The findings follow

(Reference: NFPA 101 Sections 20.2.1 and Section 7.1.10.1)

A. Observation of the egress corridor near the Nurse Station revealed the corridor was obstructed as follows:
1) On 02/02/15 at 1420, four computer carts and two pieces of biomedical equipment were observed in the Nursing Unit corridor plugged into corridor electrical outlets.
2) On 02/02/15 at 1515, four computer carts and two pieces of biomedical equipment were observed in the Nursing Unit corridor plugged into corridor electrical outlets.
B. In an interview on 02/03/15 at 0930, the Maintenance Technician verified the carts and biomedical equipment was located in the corridor.

Based on interview it was determined the facility failed to inspect fire dampers every 4 years (or every six years under CMS Waiver per Survey and Certification Letter 10-04-LSC dated October 30, 2009). Failure to inspect fire and smoke dampers prevents the facility from ensuring the reliability of the dampers to close in the event of a fire or smoke event. The failed practice had the potential to affect all patients, staff, and visitors. The findings follow:

In an interview conducted on 02/03/15 at 1430 the Maintenance Director verified there was no documentation of fire and smoke damper inspection available for review.

(Reference NFPA 90A, Section 3-4.7)

Based on Fire Alarm Inspection Report review and interview, it was determined the facility did not take corrective action when inspection of the Sprinler Water Flow Valve failed. The failed practice had the potential to affect all patients, staff, and visitors because the full functioning of all fire alarm system devices was not maintained to provide occupant notification of a fire event. The facility had a census of two patients on 02/02/15. The findings follow:

A. Review of the most recent Fire Alarm Inspection Report dated 03/21/14 at 0935 on 02/04/15 revealed the Sprinkler Water Flow Valve failed inspection. The report noted "The new sprinkler system covering the front lobby doesn't have a tamper switch monitoring the isolation valves. They are 4 ball type valves. The flow switch is installed but is not wired into the fire alarm panel either. Wire will have to be run and a zone card will have to be added to the panel to monitor this."
B. In an interview on 02/04/15 at 1025 the Maintenance Director verified the failed Sprinkler Water Flow Valve had not been repaired or corrected.

Based on Sprinkler Inspection Report review and interview, it was determined the facility did not take corrective action when the inspection failed due to the installed flow switch not connected, no tamper switch installed and the valves were not locked. The failed practice had the potential to affect all patients, staff, and visitors because the full functioning of all sprinkler system devices was not maintained to provide occupant notification of a fire event. The facility had a census of two patients on 02/02/15. The findings follow:

A. Review of the most recent Report of Sprinkler Inspection dated 03/21/14 at 0925 on 02/04/15 revealed the "flow switch installed, but not connected. No tamper switch installed and valves are not locked."
B. In an interview on 02/04/15 at 1025, the Maintenance Director verified corrective action had not been taken to correct the sprinkler system deficiencies.

Based on observation and interview, it was determined the facility allowed portable heating devices as evidenced by four heaters discovered in patient care areas (Emergency Department and Patient Room 18, 21 and 26) while touring the facility. The failed practice created a fire hazard that had the potential to affect all patients, staff, and visitors. The facility had a census of two patients on 02/02/15. The findings follow:

A. On a tour of the facility with the Maintenance Director on 02/03/15 at 0900 electric space heaters were observed as follows:
1) In the Emergency Department waiting room.
2) In Patient Room 26.
3) In Patient Room 19.
4) In Patient Room 21.
B. The Maintenance Director verified the observed portable heaters in the Emergency Department and Patient Rooms as each heater was observed on tour.

Based on observation and interview, it was determined the facility did not maintain the egress in the Nursing Unit corridor free from obstructions to provide instantaneous use in the event of a fire or other emergency. Failure to maintain egress corridors free from obstructions had the potential to affect the health and safety of all patients, staff, and visitors due to limiting the full use of the egress corridor to provide a path to safety in the event of a fire or other emergency. The facility had a census of two patients on 02/02/15. The findings follow

(Reference: NFPA 101 Sections 20.2.1 and Section 7.1.10.1)

A. Observation of the egress corridor near the Nurse Station revealed the corridor was obstructed as follows:
1) On 02/02/15 at 1420, four computer carts and two pieces of biomedical equipment were observed in the Nursing Unit corridor plugged into corridor electrical outlets.
2) On 02/02/15 at 1515, four computer carts and two pieces of biomedical equipment were observed in the Nursing Unit corridor plugged into corridor electrical outlets.
B. In an interview on 02/03/15 at 0930, the Maintenance Technician verified the carts and biomedical equipment was located in the corridor.

Based on interview it was determined the facility failed to inspect fire dampers every 4 years (or every six years under CMS Waiver per Survey and Certification Letter 10-04-LSC dated October 30, 2009). Failure to inspect fire and smoke dampers prevents the facility from ensuring the reliability of the dampers to close in the event of a fire or smoke event. The failed practice had the potential to affect all patients, staff, and visitors. The findings follow:

In an interview conducted on 02/03/15 at 1430 the Maintenance Director verified there was no documentation of fire and smoke damper inspection available for review.

(Reference NFPA 90A, Section 3-4.7)