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Based on record review and interview, the facility failed to have the diesel fuel tested annually for quality. This deficient practice increased the probability that the generator would fail to run during an emergency loss of power, which would affect the emergency systems in the facility. The facility has the capacity for 24 beds with a census of 0 on the day of survey.

Findings are:
Record review of on 3-25-19 at 10:38 am revealed, that there was no documentation that the diesel fuel for the generator was tested for quality.

During an interview on 3-25-19 at 10:38 am, Maintenance Staff B confirmed the lack of fuel testing.

NFPA Standard:
NFPA 110, 2010, 8.3.8
A fuel quality test shall be performed at least annually using tests approved by ASTM standards.

Based on observation and interview, the facility failed to maintain the doors and ceilings in hazardous areas. This deficient practice would allow smoke to migrate into the exit corridor. The facility has the capacity for 24 beds with a census of 0 on the day of survey.

Findings are:
Observation on 3-25-19 between 9:25 am and 10:29 am revealed:
1. The door to the CNO and Night Supervisor Room was equipped a self-closing device, the door failed to close and latch within the doorframe.
2. The door to the Soiled Linen Room, equipped with a self-closing device in the Material Management corridor was obstructed by a two wheeled cart with a 64 gallon trash can on it.
3. The ceiling in the IT Room failed to be smoke tight, numerous unsealed penetrations and missing ceiling tile.

During an interview on 3-25-19 between 9:25 am and 10:29 am, Maintenance Staff A confirmed the findings.

Based on observation and interview, the facility failed to ensure that the corridor room doors would latch and resist the passage of smoke. This deficient practice would not prevent the spread of fire and smoke into the exit corridors. The facility has the capacity for 24 beds with a census of 0 on the day of survey.

Findings are:
Observation on 3-25-19 at 10:03 am revealed, Patient Room 204 door failed to close and latch within the doorframe.

During an interview on 3-25-19 at 10:03 am, Maintenance Staff A confirmed the door failed to latch.

Based on observation and interview, the facility allowed storage to obstruct access to the electrical disconnect boxes. This deficient practice could cause a delay and injury when turning off the power during an electrical issue emergency. The facility has the capacity for 24 beds with a census of 0 on the day of survey.

Findings are:
Observations on 3-25-19 at 9:48 am and 10:28 am revealed:
1. Equipment stored in front of electrical panel boxes ALA and ALAE in the electrical room adjacent to the dining room.
2. Rolling cart and cardboard box stored in front of the electrical panel box in the IT Room.

During an interview on 3-25-19 at 9:48 am and 11:28 am, Maintenance Staff A confirmed the items stored in front of the electrical panel box.

NFPA Standard:
2011 NFPA 70, 110.26
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.

Based on record review and staff interview, the facility failed to inspect and test all fire rated doors annually throughout the facility as required by the code. This deficient practice could allow the spread of fire through faulty fire doors that would otherwise contain a fire. The facility has a capacity of 24 and a census of 0 at the day of the survey.

Findings are:
Record review on 3-25-19 at 11:31 am revealed a preventative maintenance plan to inspect and test fire rated doors annually failed to include all fire rated doors throughout the facility and were only inspecting the fire rated smoke doors.

During an interview on 3-25-19 at 11:31 am, Administration Staff B confirmed the fire door testing was not complete.

NFPA 80, 2010, 5.2* Inspections.
5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.

5.2.4 Swinging Doors with Builders Hardware or Fire Door
Hardware.
5.2.4.1 Fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly.
5.2.4.2 As a minimum, the following items shall be verified:
(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.

Based on record review and interview, the facility failed to have the diesel fuel tested annually for quality. This deficient practice increased the probability that the generator would fail to run during an emergency loss of power, which would affect the emergency systems in the facility. The facility has the capacity for 24 beds with a census of 0 on the day of survey.

Findings are:
Record review of on 3-25-19 at 10:38 am revealed, that there was no documentation that the diesel fuel for the generator was tested for quality.

During an interview on 3-25-19 at 10:38 am, Maintenance Staff B confirmed the lack of fuel testing.

NFPA Standard:
NFPA 110, 2010, 8.3.8
A fuel quality test shall be performed at least annually using tests approved by ASTM standards.

Based on observation and interview, the facility failed to prohibit the use of electrical power strips and extension cords as a substitute for adequate wiring. This deficient practice would create electrical injury and increase a fire hazard. The facility has a capacity of 24 and a census of 0 at the day of the survey.

Findings are:
Observation on 3-25-19 at 10:00 am and 10:14 am revealed:
1. An extension cord in Room 206.
2. A non-hospital grade power strip within six foot of patient care area in the Mammography Room.

During an interview on 3-25-19 at 10:00 am and 10:14 am, Maintenance Staff B confirmed the findings.