HospitalInspections.org

Based on observation and staff interview, the facility failed to provide walls free from holes and penetrations. This deficient practice would allow smoke products to travel from room to room and into the attic area, affecting 2 patients in 1 of 14 smoke zones. The facility has a capacity of 25 and census of 12 at the time of the survey.

Findings include:

During the survey on August 28, 2018 the following observations were made.

1) 9:35 a.m. It was observed in Labor Room 312 that there is a hole in the west wall behind the head of the bed.

Staff A was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: Any vertical opening shall be enclosed or protected in accordance with Section 8.6, unless otherwise modified by 19.3.1.1 through 19.3.1.8. (2012) NFPA 101, 19.3.1.

Review of the following NFPA Standard revealed: Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating. (2012) NFPA 101, 19.3.1.1

Review of the following NFPA Standard revealed: Unprotected vertical openings in accordance with 8.6.9.1 shall be permitted. (2012) NFPA 101, 19.3.1.2

Review of the following NFPA Standard revealed: 8.4.4 Penetrations. The provisions of 8.4.4 shall govern the materials and methods of construction used to protect through penetrations and membrane penetrations of smoke partitions.

Review of the following NFPA Standard revealed: .4.4.1 Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a smoke partition shall be protected by a system or material that is capable of limiting the transfer of smoke.

Based on observation and staff interview the facility fails to ensure that all means of egress are free of all obstructions or impediments to a full instant use. This deficient practice could impede occupants from exiting in the event of a fire or other emergency situation, affecting staff and visitors in 2 of 14 smoke zones. The facility has a capacity of 25 with a census of 12 at the time of survey.

Findings include:

During the survey on August 28, 2018 the following is observed:

1) 10:55 a.m. PBX exit path is blocked by four items; recycling bin, wagon, janitors floor sign, and wheelchair.

2) 10:50 a.m. Exit door from old EMS living quarters takes more than 30 pounds to set into motion.

3) 12:45 p.m. The floor rug in the breeze way of main entrance restricted the inside doors from opening 90 degrees with breakaway test.

4) 11:05 a.m. The exit path from surgery east exit has an elevation change in the means of egress exceeding .25 inches.

Staff B was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: Any required aisle, corridor, or ramp shall be not less than 48 in. (1220 mm) in clear width where serving as means of egress from patient sleeping rooms, unless otherwise permitted by one of the following:

(1) Aisles, corridors, and ramps in adjunct areas not intended for the housing, treatment, or use of inpatients shall be not less than 44 in. (1120 mm) in clear and unobstructed width.
(2) Where corridor width is at least 6 ft (1830 mm), noncontinuous projections not more than 6 in. (150 mm) from the corridor wall, above the handrail height, shall be permitted.
(3) Exit access within a room or suite of rooms complying with the requirements of 19.2.5 shall be permitted.
(4) Projections into the required width shall be permitted for wheeled equipment, provided that all of the following conditions are met:
(a) The wheeled equipment does not reduce the clear unobstructed corridor width to less than 60 in. (152.5 mm).
(b) The health care occupancy fire safety plan and training program address the relocation of the wheeled equipment during a fire or similar emergency.
(c) The wheeled equipment is limited to the following:
i. Equipment in use and carts in use
ii. Medical emergency equipment not in use
iii. Patient lift and transport equipment
(5) Where the corridor width is at least 8 ft (2440 mm), projections into the required width shall be permitted for fixed furniture, provided that all of the following conditions are met:
(a) The fixed furniture is securely attached to the floor or to the wall.
(b) The fixed furniture does not reduce the clear unobstructed corridor width to less than 6 ft (1830 mm), except as permitted by 19.2.3.4(2).
(c) The fixed furniture is located only on one side of the corridor.
(d) The fixed furniture is grouped such that each grouping does not exceed an area of 50 ft2 (4.6 m2).
(e) The fixed furniture groupings addressed in 19.2.3.4(5) (d) are separated from each other by a distance of at least 10 ft (3050 mm).
(f) The fixed furniture is located so as to not obstruct access to building service and fire protection equipment.
(g) Corridors throughout the smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the fixed furniture spaces are arranged and located to allow direct supervision by the facility staff from a nurses' station or similar space.
(h) The smoke compartment is protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.8. 2012 NFPA 101, 19.2.3.4

Review of the following NFPA Standard revealed: Changes in Elevation. Abrupt changes in elevation of walking surfaces shall not exceed 1/4 in. (6.3 mm). Changes in elevation exceeding 1/4 in. (6.3 mm), but not exceeding 1/2 in. (13 mm), shall be beveled with a slope of 1 in 2. Changes in elevation exceeding 1/2 in. (13 mm) shall be considered a change in level and shall be subject to the requirements of 7.1.7. 2012 NFPA 101, 7.1.6.2

Based upon observation and staff interview, the facility fails to assure that smoke barrier doors self-close. The deficient practice would not prevent products of fire or smoke from passing to other areas of the building affecting all patients, visitors and staff in 4 of 14 smoke zones. The facility has a capacity of 25 with a census of 12 at the time of this survey.

Findings include:

During the survey on Aug 28, 2018 the following observations were made:

1. 11:00 a.m. Closure has been made inoperable for the surgery family conference room.

2. 12:00 a.m. Data processing door to the corridor has had closure removed.

3. 1:35 p.m. The closer has been removed from the marketing door, the education office door, and the biomed door.

4. 1:30 a.m. The 3rd floor the east leaf of the south fire doors hits in the west leaf and won't shut to form a barrier.

5. 10:45 a.m. Coordinator to EMS room rated doors failed to operate correctly stopping the doors from closing and latching.

6. 1:15 p.m. Door in 3-hour rated wall has been removed between x-ray and mammogram/bone density offices.

7. 1:20 p.m. Closure has been removed from fire rated door in 3-hour rated wall between x-ray reception and x-ray staff lounge.

8. 12:05 p.m. Fire rated doors outside laundry, outside CEO office, and outside surgery failed to close and latch when drop tested due to manual operation needed of flush bolt on one leaf of each set of doors.

Maintenance Staff A and B were present and acknowledged the findings.

NFPA Standard: Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system;
* Automatic sprinkler system, if installed; and
* Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Review of the NFPA code revealed: A door leaf normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2, unless otherwise permitted by 7.2.1.8.3. 7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, door leaves shall be permitted to be automatic-closing, provided that all of the following criteria are met:
(1) Upon release of the hold-open mechanism, the leaf becomes self-closing.
(2) The release device is designed so that the leaf instantly releases manually and, upon release, becomes self closing, or the leaf can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door leaf release service in NFPA 72, National Fire Alarm and Signaling Code.
(4) Upon loss of power to the hold-open device, the hold open mechanism is released and the door leaf becomes self-closing.
(5) The release by means of smoke detection of one door leaf in a stair enclosure results in closing all door leaves serving that stair.

Based upon a review of records and staff interview, the facility fails to assure that emergency lighting of at least 1-1/2-hour duration is automatically provided. The deficient practice could result in a failure to provide illumination in the event of a power failure, affecting all residents, visitors and staff in all smoke zones. The facility has a capacity of 25 beds with a census of 12.

Findings include:

During the survey on August 28, 2018 the following is observed::

1. Documentation for monthly 30-second functional testing of the emergency lighting units through August 2018 does not include detailed information of each unit that was tested, only a summary that groups of units were tested.

2. Documentation for monthly 30-second functional testing of the emergency lighting units through August 2018 does not include dates that devices were tested only initials that they were tested within the month.

3. Annual 90-minute testing of the emergency lighting units showed no date for testing only initials of the staff.

Maintenance Staff A was present and acknowledged the results of the records review.

NFPA Standard: A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 and 1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 2012 NFPA 101, 7.9.3

Based on observation and staff interview the facility failed to mark doors that are not an exit with the appropriate signage. The deficient practice of failing to mark doors with the appropriately signage may delay exiting affecting 8 patients in 4 of 14 smoke zones. The facility has a capacity of 25 with a census of 12 at the time of the survey.

Findings include:

During the survey on August 28th, 2018 the following is observed:

1.12:30 p.m. West basement stairwell door is not marked with a "NO Exit" sign

The Maintenance staff B was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: 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

The NO EXIT sign shall have the word NO in letters 2in. (51 mm) high, with a stroke width of 3/8 in. (9.5mm), and the word EXIT in letters 1 in. (25 mm) high, with the word EXIT below the word NO, unless such sign is an approved existing sign. 2012 NFPA 101, 7.10.8.3.1 and 7.10.8.3.2

Based on observation and staff interview the facility fails to ensure proper separation of hazardous areas from other spaces. This deficient practice would not prevent the passage of smoke and fire into other areas of the building, affecting all patients, visitors and staff in 2 of 14 smoke zones. The facility has a capacity of 25 and at the time of the survey the census was 12.

Findings include:

During the survey on August 28, 2018 the following is observed:

1.10:48 a.m. It was observed in room 327 this is a patient room that is being used as a storage room; there is no auto closure.

2. 11:23 a.m. It was observed patient room 270 has been made into a storage room; no auto closure.

3. 11:47 a.m. It was observed patient room 243 has been made into a storage room; no auto closure.

4. 11:50 a.m. It was observed that the storage room across from 235 has a 3/4 hole in the door and (2) 1/4 I inch penetration holes through the door.

Maintenance Staff A was present and acknowledged the findings.

NFPA Standard: Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. 2012 NFPA 101, 19.3.2.1

NFPA Standard: Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. 19.3.2.1

Based on staff interview and observation, the facility fails to install and maintain their alcohol based hand rub dispensers in accordance with NFPA 101. The deficient practice would affect staff and visitors in 2 of 14 smoke zones. The facility has a capacity of 25 with a census of 12 at the time of the survey.

Findings include:

During the survey on August 28, 2018 the following is observed::

1. 12:05 p.m. An alcohol based hand sanitizer dispenser is installed directly above light switch in soil utility outside of the laundry area on the first floor.

2. 1:05 p.m. An alcohol based hand sanitizer dispenser is installed directly above light switch in Ultrasound room.

Maintenance staff B was present and acknowledged these findings.

NFPA Standard: Life Safety Code 101 2012 19.3.2.6* Alcohol-Based Hand-Rub Dispensers. Alcohol-based hand-rub dispensers shall be protected in accordance with 8.7.3.1, unless all of the following conditions are met: (8) Dispensers shall not be installed in the following locations: (a) Above an ignition source within a 1 in. (25 mm) horizontal distance from each side of the ignition source (b) To the side of an ignition source within a 1 in. (25mm) horizontal distance from the ignition source (c) Beneath an ignition source within a 1 in. (25 mm) vertical distance from the ignition source.

Based on observation and record review the facility failed to provide complete documentation of annual inspection and testing of the fire alarm system as required by NFPA 72. The absence of complete, verifiable documented maintenance and repair history on the fire alarm system fails to ensure reliability of the alarm system in the event of an emergency, affecting all residents in all smoke zones. The facility has a capacity of 25 residents and census of 12 at the time of the survey.

Findings include:

During the survey on August 27, 2018 the following is observed:

1. No documentation is available for review showing that deficiencies on fire alarm inspection report from 4/3/18 have been corrected. Deficiencies are as listed "1. NAC Panel Battery (6.2 Amps, 12V) on the 3rd Floor- Hospital in closet by receptions failed load test customer will replace them" "2. Gamewell Panel in Mechanical room in Clinic basement failed- expired manufacturers date. 6.2 Amps. 12 V Customer will replace"

2. No complete list of smoke detector sensitively documentation for entire facility is available for review.

3. No complete device list of fire alarm annual inspection testing and maintenance available for 2017

4. No documentation is available for review showing that deficiencies listed on inspection report dated 7/27/18 for the fire alarm inspection form have been corrected. Deficiencies are as listed "1. Pavilion- main fire panel batteries failed, 10 amps 12 v Fire Panel is located d at the main entrance of the building." 2. "Nac batteries failed in the hospital. Panel is located on the 3rd FL, furthest end- West of the building, closet by nursing station batteries size 6.2 Amps 12 V. This was a previous deficiency from 4/3/18.


During the survey on August 28, 2018 the following is observed:

5. At 11:25 a.m. It was observed that the "dock exit" has a fire alarm pull station that is loose from wall.

Facility maintenance staff A and B were present and acknowledged the finding.

Review of the following NFPA Standard revealed: Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 2012 NFPA 101, 19.3.4.1

Review of the following NFPA Standard revealed: Any device, equipment, system, condition, arrangement, level of protection, fire resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected, or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction. 2012 NFPA 101, 4.6.12.4.

Review of the following NFPA Standard revealed: To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. 2012 NFPA 101, 9.6.1.5

Review of the following NFPA Standard revealed: 14.6.2.4* A record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 14.6.2.4: (1) Date, (2) Test frequency, (3) Name of property, (4) Address, (5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number. (6) Name, address, and representative of approving agency(ies), (7) Designation of the detector(s) tested, (8) Functional test of detectors, (9)Functional test of required sequence of operations, (10) Check of all smoke detectors, (11) Loop resistance for all fixed temperature, line type heat detectors, (12) Functional test of mass notification system control units, (13) Functional test of signal transmission to mass notification systems, (14) Functional test of ability of mass notification system to silence fire alarm notification appliances, (15) Test of intelligibility of mass notification system speakers, (16) Other tests as required by the equipment manufacturer's published instructions, (17) Other tests as required by the authority having jurisdiction, (18) Signatures of tester and approving agency notified, problem corrected/successfully retested, device abandoned in place proved authority representative, (19) Disposition of problems identified during test (e.g., system owner).

Based on observation, record review and interview the facility fails to assure that the facility' automatic sprinkler system is installed, maintained and tested in accordance with NFPA 25. This deficient practice fails to assure that the sprinkler system will be properly prepared in the event of a fire, affecting all residents in all smoke zones. The facility has a capacity of 25 and census of 12 at the time of the survey.

Findings include:

During the survey on August 28, 2018 the following is observed:

1. It was observed during the documentation review of the sprinkler inspection testing and maintenance there is no documentation available for review of the 4th quarter 2017 sprinkler.

2. It was observed during the documentation review of the sprinkler inspection testing and maintenance there is no documentation available for review for the 2017 annual sprinkler.

The Maintenance staff A and B were present and acknowledged the findings.

NFPA Standard: Automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25 per 2012 NFPA 101, 9.7.5.

NFPA Standard: Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. 2012 NFPA 101 4.6.12.1

NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 2012 NFPA 101, 4.6.12.1

Based upon observation and staff interview, the facility fails to assure that corridors are separated from use areas. The deficient practice would not prevent the passage of smoke or other products of fire from other areas of the building, affecting 8 patients, staff and visitors in 1 of 14 smoke zones. The facility has a capacity of 25 with a census of 12 at the time of this survey.

Findings include:

During the survey conducted on 8/28/18, at approximately 11:10 a.m. It was observed in the hall between rooms 251 and 249 that there are (3) 1/8 dia. penetration holes in the east wall.

Maintenance staff A was present and acknowledged the finding.

NFPA Standard: Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5 (see also 19.2.5.4), unless otherwise permitted by one of the following: (1) Smoke compartments protected throughout by an approved supervised automatic sprinkler system in accordance with 19.3.5.8 shall be permitted to have spaces that are unlimited in size and open to the corridor, provided that all of the following criteria are met: (a)*The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas. 2012 NFPA 101, 19.3.6.1

NFPA Standard: Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code. Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames. 2012 NFPA 101, 19.3.6.2

Based on observation and staff interview the facility has penetrations in corridor doors. The deficient practice of not ensuring that corridor doors have no penetration restricts the ability of the facility to properly confine fire and smoke products and to properly defend occupants in place, affecting approximately 12 patients in 1 of 14 smoke zones. The facility has a capacity of 25 and census of 12 at the time of the survey.

Findings include:

During the survey on Aug 28, 2018 the following observations were made:

1. 11:18 a.m. It was observed in room 265 the corridor door to the patient room will not latch closed.

2. 11:35 a.m. It was observed in room 264 the corridor door to the patient room will not latch closed.

3. 12:12 p.m. Housekeeping supply and laboratory storeroom doors in the administration corridor area are hollow doors in a non-sprinklered corridor.

4. 10:35 a.m. The corridor door from the MRI room has two locking devices installed on the door, a dead bolt and a handle lock.

Staff A and B were present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: 19.3.6.3* Corridor Doors. 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following: (1) 13/4 in. (44 mm) thick, solid-bonded core wood (2) Material that resists fire for a minimum of 20 minutes 19.3.6.3.2 The requirements of 19.3.6.3.1 shall not apply where otherwise permitted by either of the following: (1) Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials shall not be required to comply with 19.3.6.3.1. (2) In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7, the door construction materials requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke. 101-212 LIFE SAFETY CODE
2012 Edition 19.3.6.3.3 Compliance with NFPA 80, Standard for Fire Doors and Other Opening Protectives, shall not be required. 19.3.6.3.4 A clearance between the bottom of the door and the floor covering not exceeding 1 in. (25 mm) shall be permitted for corridor doors.19.3.6.3.5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction,and the following requirements also shall apply: (1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.
(2) Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic
sprinkler system in accordance with 19.3.5.7.

Review of the following NFPA Standard revealed: 19.2.2.2.6 Doors that are located in the means of egress and are permitted to be locked under other provisions of 19.2.2.2.5 shall comply with all of the following:
(1) Provisions shall be made for the rapid removal of occupants by means of one of the following:
(a) Remote control of locks
(b) Keying of all locks to keys carried by staff at all times
(c) Other such reliable means available to the staff at all times
(2) Only one locking device shall be permitted on each door.
(3) More than one lock shall be permitted on each door, subject to approval of the authority having jurisdiction.

Based upon observation and staff interview, the facility fails to assure that smoke barriers are constructed to a minimum 1/2-hour fire resistance rating. The deficient practice would not prevent the passage of smoke or fire to other areas of the building, affecting all patents, visitors and staff in 4 of 12 smoke zones. The facility has a capacity of 25 with a census of 12 at the time of this survey.

Findings include:

During the survey on August 28, 2018 the following is observed:

1. 12:33 a.m. It was observed above the ceiling on the north and south sides of the southeast smoke barrier on 3rd floor has a 2 inch penetration hole with cables passing through that is not sealed.

2. 12:45 p.m. It was observed on the 2nd floor west smoke barrier east side there is a 1 inch penetration hole through the barrier for a yellow computer cable.

3. 12:48 p.m. It was observed on the 2nd floor south west smoke barrier north and south sides there is a 1 inch penetration hole through the barrier for a yellow computer cable, and (2) holes through the sheet rock tape.

Staff A was present and acknowledged the observations:

NFPA Standard: Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)

Based upon a review of records and staff interview the facility has not documented maintenance and corrections for fire-rated door assemblies in compliance with NFPA 80. This deficient practice could prevent the ability of the facility to properly confine smoke and prevent fire from spreading to other areas of the building. This deficient practice would affect all residents, visitors, and staff in all smoke zones. The facility has a capacity of 25 with a census of 12 at the time of this survey.

Findings include:

During the record review on August 27th, 2018 the following deficiency is noted:

No documentation is available for review showing that the deficiencies listed on the fire door inspection from December 2017 have been corrected. Deficiencies are as follows:

1. (1-1/2 hr) Frame-failed. Hinges-failed. Seals-failed. Signage Failed. Gaps-failed (see deficiency report summary)

3. (1-1/2 hr) Frame-failed. Lockset-failed. Seals-failed. Gaps-failed (see deficiency report summary)

2. (3 hr) Frame-failed. Closer-failed. Seals-failed. Gaps-failed (see deficiency report summary)

9. (1-1/2 hr) Frame-failed. Gaps-failed (see deficiency report summary)

10. (1-1/2 hr) Frame-failed. Closer-failed. Seals-failed. Gaps-failed (see deficiency report summary)

23. (1-1/2 hr) Frame-failed. Hinges-failed. Signage Failed. Gaps-failed (see deficiency report summary)

21. (1-1/2 hr) Hinges-failed. Lockset-failed. Gaps-failed (see deficiency report summary)

22. (1-1/2 hr) Frame-failed. Hinges-failed. Seals-failed. Gaps-failed (see deficiency report summary)

24. (1-1/2 hr) Frame-failed. Gaps-failed (see deficiency report summary)

25. (1-1/2 hr) Frame-failed. (see deficiency report summary)

26. (3 hr) Frame-failed. Gaps-failed (see deficiency report summary)

27. (1-1/2 hr) Seals-failed. Gaps-failed (see deficiency report summary)

28. (1-1/2 hr) Frame-failed. Lockset-failed. Seals-failed. Gaps-failed (see deficiency report summary)

29. (1-1/2 hr) Frame-failed. Gaps-failed (see deficiency report summary)

30. (1-1/2 hr) Frame-failed. Closer-failed. Gaps-failed (see deficiency report summary)

31. (1-1/2 hr) Frame-failed. Lockset-failed. Gaps-failed (see deficiency report summary)

32. (1-1/2 hr) Frame-failed. Lockset-failed. Gaps-failed (see deficiency report summary)

33. (1-1/2 hr) Frame-failed. Hinges-failed. Gaps-failed (see deficiency report summary)

34. (1-1/2 hr) Frame-failed. Lockset-failed. Closer-failed. Gaps-failed (see deficiency report summary)

35. (1-1/2 hr) Frame-failed. Lockset-failed. Gaps-failed (see deficiency report summary)

36. (1-1/2 hr) Frame-failed. Lockset-failed. Gaps-failed (see deficiency report summary)

Maintenance staff A and B were present and acknowledged the findings.


NFPA Standard: NFPA 80 2010 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. 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing. 5.2.4.2 As a minimum, the following items shall be verified: (1) No open holes or breaks exist in the 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 non combustible 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 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. 3.3.95 Qualified Person. A person who, by possession of a recognized degree, certificate, professional standing, or skill, and who by knowledge, training, and experience, has demonstrated the ability to deal with the subject matter, the work, or the project.

Based upon document review and staff interview, the facility fails to properly maintain their med gas and vacuum piped systems. The deficient practice reduces the reliability of the medical gas systems, affecting all residents, visitors, and staff in 6 of 14 smoke zones. The hospital has a capacity of 25 with a census of 12 at the time of the survey.

Findings include:

During the survey on August 27, 2018 the following is observed:

1. During document review it is observed that no documentation is available for review showing that the deficiencies from the last service report provided from December of 2017 have been corrected. The deficiencies are as follows:

a. First floor OR corridor main line alarm surgery area "this area is required to have an alarm panel for all gases with sensors of all zone valve boxes in the area. No main line alarm for Vacuum."

b. First floor PACU "Does not have alarm panel with sensors down stream of zone valve box."

No documentation is available for review showing that the deficiencies have been corrected.

Staff B were present and acknowledged the finding.


NFPA Standard: Medical gas, vacuum, WAGD, or support gas systems have documented maintenance programs. The program includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets. Inspection and maintenance schedules are established through risk assessment considering manufacturer recommendations. Inspection procedures and testing methods are established through risk assessment. Persons maintaining systems are qualified as demonstrated by training and certification or credentialing to the requirements of AASE 6030 or 6040.
5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14, 5.3.13.4.2 (NFPA 99)

Based on record review and staff interview the facility failed to assure the generator is inspected and tested in accordance with NFPA 110. This deficient practice fails to ensure that the generator will not fail when needed in the event of an emergency, affecting all patients in all smoke zones. The facility has a capacity of 25 and census of 12 at the time of the survey.

Findings include:

During the survey on August 27, 2018 the following is observed:

1. It was observed during the emergency generator documentation review for for the records from 2018 and 2017 calendar years; there is no documentation available for annual load bank test on the Generac generator inspections of the generator and controls. The monthly 30 minute testing is running at approximately 210 amps every month. The generator must reach 364.29 amps every month to hit 30 percent capacity for the generator.

2. It was observed during the emergency generator documentation review for for the records from 2018 and 2017 calendar years; there is no documentation available for a complete 3 year load bank test. The 4 hour test on 12/18/15 did not reach 75% capacity for the Generac generator 777 amps for one hour is documented. 910 amps is 75% of the capacity of the Generac generator.

Staff A and B were present and acknowledged the findings.

NFPA Standard revealed: EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. 2010 NFPA 110, 8.4.1

NFPA Standard: A permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available.
The permanent record shall include the following:
(1) The date of the maintenance report
(2) Identification of the servicing personnel
(3) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(4) Testing of any repair for the time as recommended by the manufacturer. 2010 NFPA 110, 8.3.4, 8.3.4.1

NFPA Standard: Spark-ignited generator sets shall be exercised at least once a month with the available EPSS load for 30 minutes or
until the water temperature and the oil pressure have stabilized. The date and time of day for required testing shall be decided by the owner, based on facility operations. Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source. The EPS test shall be initiated by simulating a power outage using the test switch(es) on the ATSs or by opening a normal breaker. Opening a normal breaker shall not be required. Load tests of generator sets shall include complete cold starts. Time delays shall be set as follows: (1) Time delay on start: (a) 1 second minimum (b) 0.5 second minimum for gas turbine units (2) Time delay on transfer to emergency: no minimum required (3) Time delay on restoration to normal: 5 minutes minimum (4) Time delay on shutdown: 5 minutes minimum. Transfer switches shall be operated monthly. The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position. EPSS circuit breakers for Level 1 system usage, including main and feed breakers between the EPS and the transfer switch load terminals, shall be exercised annually with the EPS in the "off" position. Circuit breakers rated in excess of 600 volts for Level 1 system usage shall be exercised every 6 months and shall be tested under simulated overload conditions every 2 years. The routine maintenance and operational testing program shall be overseen by a properly instructed individual. 2010 NFPA 110, 8.4*

Where the test required in 8.4.9 is combined with the annual load bank test, the first 3 hours shall be at not less than
the minimum loading required and the remaining hour shall be at not less than 75 percent of the nameplate kW rating of the EPS.(2010) NFPA 110 8.4.9.7.

Based on observation and staff interview, the facility did not ensure that power strips, extension cords, electrical wiring and equipment is installed and maintained in accordance with NFPA 70, National Electrical Code. This deficient practice does not ensure prevention of an electrical fire or electric shock hazard, affecting all staff and visitors in 1 of 14 smoke zones. This facility has a capacity of 25 and a census of 12.

Findings include:

During the survey on August 28, 2018 the following is observed:

1) 12:40 p.m. An extension cord is plugged into a power strip in the CEO's office.

2) 12:55 p.m. The phone in the snack bar is plugged into an extension cord that is plugged into a power strip

Staff B was present and acknowledged these findings.

NFPA Standard: NFPA 70 2011, 400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following: (1) As a substitute for the fixed wiring of a structure (2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors (3) Where run through doorways, windows, or similar openings (4) Where attached to building surfaces Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B) (5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings (6) Where installed in raceways, except as otherwise permitted in this Code (7) Where subject to physical damage.