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Based on observation and staff interview the facility to maintain a hazardous storage room in accordance with the 2012 Life Safety Code (NFPA 101) section 19.3.2.1.3. This deficient condition could allow smoke or fire to enter the corridor making it untenable and affect the quick and efficient exiting for all of the 18 patients and an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 9:00 am to 4:00 pm on 05-03-2017 observations and staff interview revealed the soiled utility room door in the northeast corridor does not positively latch.

This deficient condition was confirmed by the Environmental Services Manager.

Based on observations and staff interview the facility failed to install the smoke detection in accordance with NFPA 101 Life Safety Code (2012) section 19.3.4.1, 9.6.1.3 and NFPA 72 National Fire Alarm Code (2010) section 17.7.4.1. This deficient practice could affect the ability of the alarm system to sound in a timely manner during a fire event which could affect an undetermined amount of patients, staff and visitors.

Findings include:

On the facility tour between 9:00 am to 4:00 pm on 05-03-2017 observations and staff interview revealed a smoke detector in the E.R. corridor is within 36 inches of a heat diffuser.

This deficient condition was confirmed by the Environmental Services Manager.

Based on observation and staff interview, the facility failed to test and maintain the sprinkler system in accordance with the 2012 Life Safety Code (NFPA 101) and NFPA 25 section 5.2.1.1.2. The standard for testing and maintenance of sprinkler systems. This deficient condition could cause the sprinkler system not to function properly and allow for the spread of fire. This could affect all of the 18 patients and an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 9:00 am to 4:00 pm on 05-03-2017 record review and staff interview revealed the sprinkler system has not had a visual obstruction inspection inspection since its installation over 5 years ago.

This deficient condition was confirmed by the Environmental Services Manager.

Based on observation and staff interview the facility failed to maintain a smoke barrier as required by the 2012 Life Safety Code (NFPA 101) section 19.3.7.3, 8.8.7.1 (1). This deficient practice could allow smoke to transfer from one smoke compartment to another affecting the exiting of all patients, staff and visitors.

Findings include:

On the facility tour between 9:00 am to 4:00 pm on 05-03-2017 observations and staff interview revealed penetrations without the proper fire stopping above the ceiling of the smoke barrier adjacent to the clinic in the following areas.
1. A 3x3 on the corridor side next to the east exit.
2. A pipe penetration on the room side of the break room, above the door.
3. A 3x3 on the corridor side on the left side of the radiology door.
4. A 1 inch open hole on the corridor side next to the west office.
5. A cable bundle on the south side of the west cross corridor doors.
6. A pipe penetration on both sides of the east cross corridor doors.

This deficient condition was confirmed by the Environmental Services Manager.

Based on record review and staff interview the facility failed to provide documentation of the alarm transmission on the fire drills reports as required required by the Life Safety Code (NFPA 101) 2012 edition, section 19.7.1.4 to 19.7.1.7. This deficient practice could reduce the ability of staff to conduct a safe and timely response to a fire emergency, which would affect all 18 patients and an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 9:00 am to 4:00 pm on 05-03-2017 record review and staff interview revealed the fire drill reports did not document the integrity of the alarm transmission.

This deficient condition was confirmed by the Environmental Services Manager.

Based on record review, observation and staff interview the facility failed to provide a proper policy for the use of portable heaters and ensure they met the requirements based on the 2012 edition of the Life Safety Code (NFPA 101) section 19.7.8. This deficient practice could cause injury to an undetermined amount of staff.

Findings include:

On the facility tour between 9:00 am to 4:00 pm on 05-03-2017 record review, observations and staff interview revealed two portable space heaters were being used, one in the clinic reception area and one in human resources without a policy in place.

This deficient conditions was confirmed by the Environmental Services Manager.

Based on observation and staff interview the facility failed to install a remote annunciator for the generator as required by the Health Care Facilities Code 2012 edition sections 6.4.1.1.17 & 6.4.1.1.17.5. This deficient practice could allow for the generator to fail while operating in a troubled condition. This could negatively affect all patients, staff and visitors.

Findings include:

On the facility tour between 9:00 am to 4:00 pm on 05-03-2017 observations and staff interview revealed there was no generator remote annunciator.

This deficient condition was confirmed by the Environmental Services Manager.

Based on record review and staff interview the facility failed to provide test documentation in accordance with the 2012 edition of the Life Safety Code (NFPA 101) section 9.1.3.1 and the 2010 edition of NFPA 110 the Standard for Emergency and Standby Power Systems. This deficient practice could affect the safety of all 18 patients and an undetermined amount of staff and visitors if the generator failed to operate during a power outage.

Findings include:

On the facility tour between 9:00 am to 4:00 pm on 05-03-2017 record review and staff interview revealed the monthly generator log did not address the required testing data.

This deficient condition was confirmed by the Environmental Services Manager.

Based on observation and staff interview the facility failed to ensure multiple outlet adapters are in accordance with the 2012 edition of NFPA 99 section 10.2..4.2.1 and the use of power strips comply with 10.2.3.6. This deficient practice could affect and an undetermined amount of patients, staff and visitors.

Findings include:

On the facility tour between 9:00 am to 4:00 pm on 05-03-2017 observations and staff interview revealed a power strip in a storage room in the north wing of the hospital had several battery chargers plugged into it which exceeded its amperage limit and a small handmade extension cord was being used in the IT room in lieu of permanent wiring.

This deficient condition was confirmed by the Environmental Services Manager.