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Based on observation, staff interview and record review this facility is not providing unobstructed corridors that provides a clear path of egress. This facility has a capacity of 99 with a census of 34.

Findings include:

1. Observation and interview on 4-17-18 at 10:50 a.m., revealed the exit door from E Ray was locked. The corridor was not maintained to be clear and unobstructed.

2. Observation and interview on 4-17-18 at 10:56 a.m., revealed the exit corridor was blocked by wheelchairs. The corridor was not maintained to be clear and unobstructed.

Maintenance Staff (B) verified the observation. According to the facility layout, this was a required exit.

Based on observation and interview, the facility failed to maintain the emergency egress lighting system in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 7.9.2.1 and 19.2.9.1, by not ensuring emergency illumination be provided for a minimum of 1 1/2 hours in the event of failure of normal lighting. The facility has a capacity of 99 and a census of 34.

Findings include:

1. Observation and interview on 04-17-18, revealed the battery backup emergency lighting in the Manning Clinic Corridor failed to illuminate when tested. The Maintenance Supervisor verified this observation at the time of the survey process.

2. Observation and interview on 04-19-18, revealed the battery backup emergency lighting in the Breda Clinic Corridor failed to illuminate when tested. The Maintenance Supervisor verified this observation at the time of the survey process.

Based on observation and interview, the facility did not provide an approved sign that is readily visible from any direction of exit access for one of three exit doors in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.2.10.1 and 7.10. This deficient practice affects patients, staff, and visitors in the patient corridor. The facility had a capacity of 99 and a census of 34 patients at the time of the survey.

Findings include:

Observation and interview on 4-17-18 at 10:50 a.m., revealed the directional exit signs located in the North Surgery Corridor were obstructed by ceiling headers projecting down from the ceiling. Maintenance Staff A verified this observation during the survey.

Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.3.2.1.3. This deficient practice affects one of twelve smoke zones and could affect 6 staff within the affected zone. The facility had a capacity of 99 residents and a census of 34.

Findings include:

Observation and interview on 4-17-18 at 11:03 a.m., revealed the Storage Closet in the Administrative Corridor exceeded 50 square feet in size and did not positive latch with in the door frame with the self-closure devices on the closet door. The Maintenance Supervisor confirmed this observation at the time of the survey process.

(A)
Based on interview and record review, the facility did not provide and maintain complete documentation or provide 100% semi-annual testing of the fire alarm system as required by NFPA 72. The deficient practice of not providing complete and verifiable documentation on the inspection, testing, and maintenance of the fire alarm system did not ensure proper operation and prompt repair affecting all occupants. This facility had a capacity of 99 and a census of 34 residents at the time of the survey.

Findings include:

Record review and interview on 4-17-18, of the fire alarm inspection forms dated 3-23-18 revealed the device list was incomplete. The device list was missing the following items: magnetic hold opens and dampers. According to the facility's semi-annual fire alarm testing reports, 100% of the fire alarm system was not tested, and the documentation did not include all of the required testing and information required by NFPA 72.

This deficient practice was confirmed by Maintenance Staff A at the time of exit.

(B)
Based on observation and interview, this facility is not assuring that the fire alarm system is installed in accordance with NFPA 72, 2010 Edition, which requires that smoke detectors are not placed within direct airflow, nor closer that three feet to air supply or air return. Installation of a smoke detector close to a ceiling fan or air diffusers can impede the operation of the smoke detector and can affect all occupants of the building. This facility has a capacity of 99 and a census of 34 residents.

Findings include:

Observation and interview on 4-17-18 at approximately 11:10 a.m., revealed in the Administration North Hall there was a smoke detector within 3 feet of the air diffuser (located next to the Computer Room).

Maintenance Staff (A) verified the observation.

Based on observation and interview, the facility is not maintaining the sprinkler system in accordance with the 2011 edition of NFPA 25, by ensuring that sprinkler piping are free of foreign material. This deficient practice affects all occupants including staff, visitors and residents in one of nine smoke zones. The facility had a capacity of 99 and a census of 34 at the time of survey.

Findings include:

1. Observation and interview on 4-17-18 at approximately 10:44 a.m., revealed in the 3rd floor Same Day Surgery Lobby the sprinkler pipe located on the ceiling contained a white communication wire zip tide to the sprinkler pipe.

2. Observation and interview on 4-17-18 at approximately 11:01 a.m., revealed the 1st Floor TECH AREA OFFICE was missing the sprinkler head escutcheon ring.


Maintenance Staff (B) verified these observations.

Based on interview and record review, this facility did not assure that a complete policy is in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than ten hours in any twenty-four hour period. Lack of complete written policies and procedures could result in staff failing to implement interim safety measures in the event of an emergency. This deficient practice affected all occupants of the building. This facility had a capacity of 99 and a census of 34 residents at the time of the survey.

Findings include:

1. Record review on 4-17-18, of the fire watch procedures revealed the facility did not have a complete policy regarding the procedures to be taken in the event that the sprinkler system was out of service for more than ten hours in a twenty-four hour period. The policy did include phone numbers and a call list of the appropriate Authorities Having Jurisdiction. The plan was missing the contacting of the above Authorities Having Jurisdiction after the sprinkler system is back in service.

2. Record review on 4-17-18, of the fire watch procedures revealed the facility did not have a complete policy regarding the procedures to be taken in the event that the sprinkler system was out of service. The policy failed to address the supervisors in the areas to be affected have notification of the sprinkler impairment.

3. Record review on 4-17-18, of the fire watch procedures revealed the facility did not have a complete policy regarding the procedures to be taken in the event that the sprinkler system was out of service. The policy failed to address a tag impairment system during sprinkler impairment.

4. Record review on 4-17-18, of the fire watch procedures revealed the facility did not have a complete policy regarding the procedures to be taken in the event that the sprinkler system was out of service. The policy failed to address the interruption of the water supply and equipment failures.

5. Record review on 4-17-18, of the fire watch procedures revealed the facility did not have a complete policy regarding the procedures to be taken in the event that the sprinkler system was out of service. The policy failed to include areas or buildings involved have been inspected and increased risks determined.

6. Record review on 4-17-18, of the fire watch procedures revealed the facility did not have a complete policy regarding the procedures to be taken in the event that the sprinkler system was out of service. The policy failed to address the recommendations have been submitted to management or the property owner.

7. Record review on 4-17-18, of the fire watch procedures revealed the facility did not have a complete policy regarding the procedures to be taken in the event that the sprinkler system was out of service. The policy failed to address System Leakage and Ruptured Piping.

8. Record review on 4-17-18, of the fire watch procedures revealed the facility did not have a complete policy regarding the procedures to be taken in the event that the sprinkler system was out of service. The policy failed to address the designation of an Impairment Coordinator.


Administrative Staff A confirmed the findings during the exit conference.

Based on observations and interview, the facility is not ensuring resident room doors, office doors, and other ancillary area doors to the corridor resist the passage of smoke in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.3.6.3.1. This deficient practice would not prevent the spread of smoke, affecting one of four smoke compartments and could affect all residents, staff, and visitors in the affected zone. This facility has a capacity of 99 with a census of 34.

Findings include:

1. Observation and interview on 4-17-18 at 8:49 a.m., revealed the door to Room #415 in the MHU was held open with a door hold open device.

2. Observation and interview on 4-17-18 at 8:55 a.m., revealed the door to Room #412 in the MHU contained three holes that compromised the fire rating of the door.

3. Observation and interview on 4-17-18 at 8:59 a.m., revealed the MHU Basement door contained a gap greater than 1/2 inch on the handle side of the door.

4. Observation and interview on 4-17-18 at 9:20 a.m., revealed the OB door #367 contained a gap greater than 1/4 inch gap on the top of the door.

5. Observation and interview on 4-17-18 at 9:23 a.m., revealed the OB Addition separation doors contained a gap greater than 1/2 inch.

6. Observation and interview on 4-17-18 at 9:55 a.m., revealed the CCU door #304 failed to close and positive latch with in the door frame.

7. Observation and interview on 4-17-18 at 11:04 a.m., revealed the 1st Floor Radiology Storage Room door did not contain a door closure.


The Maintenance Director (B) confirmed these observations during the survey process.

(A)
Based on observation and interview, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 2011 edition, placing the Staff and Residents of the facility at risk in the event of a fire. The facility had a capacity of 99 and a census of 34 at the time of the survey.

Findings Include:

1. Observation and interview on 4-17-18 at 11:20 p.m., revealed the facility failed to maintain the electrical system in the 4NL2 electrical panel in the Administration Pent House. Electrical breakers #25 and 40 were in the on positions, charged and not labeled.

2. Observation and interview on 4-17-18 at 11:20 p.m., revealed the facility failed to maintain the electrical system in the 4CL2 electrical panel in the Administration Pent House. Electrical breakers #14, 16, 18 and 20 were in the on positions, charged and not labeled.

Maintenance Staff (A) verified this observation.


(B)
Based on observation and interview, the facility failed to maintain the building's electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 2011 edition, by allowing the use of non-approved electrical devices or adapters within the facility. This deficient practice affects one resident in one of seven smoke zones. The facility has a capacity of 99 and a census of 34.

Findings include:

Observation and interview on 4-17-18 at 10:46 a.m., revealed the facility failed to maintain the electrical system in 1st Floor OB #5. This room contained a three way adapter supplying electrical power to inappropriate appliances. The Maintenance Director (B) verified this observations.

Based on observation and interview, the facility failed to maintain the building's electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 2011 edition, by failing to use general precautions with power strips and surge protectors and allowing the use of non-approved electrical devices or adapters within the facility. These deficient practices affect one in one of twelve smoke departments. The facility had a capacity of 99 and a census of 34 residents at the time of the survey.

Findings include:

Observation and interview on 09/

1. Observation and interview on at 10:38 a.m., revealed a surge protector providing power to a refrigerator in Room #1, on the 1st floor of OB. Maintenance Staff B verified this observation at the time of the survey process.

2. Observation and interview on at 10:41 a.m., revealed a surge protector providing power to a sense pot in Room # 3 on the 1st Floor of OB. Maintenance Staff B verified this observation at the time of the survey process.

Based on observation and interview, the facility is not following specific procedures for oxygen cylinders in accordance with National Fire Protection Association (NFPA) Standard 99, Health Care Facilities Code, 2012 edition, 11.6.2.3, to ensure cylinders are protected from damage. This deficient practice occurred in one of nine smoke compartments and could affect one resident, staff, and visitors in the resident room. This facility has a capacity of 99 and a census of 34 residents.

Findings include:

1. Observation and interview on 04-17-18 at 1:41 p.m., at Manning Clinic revealed a freestanding "E" sized oxygen cylinder on the floor of Suite 4. The tank was not properly chained or supported in a proper cylinder stand or cart.

1. Observation and interview on 04-19-18 at 1:41 p.m., revealed at Breda Clinic freestanding "E" sized oxygen cylinder on the floor of Treatment room. The tank was not properly chained or supported in a proper cylinder stand or cart.