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Based on record review and interview, the facility (prior to COVID) failed to provide documentation for circuit breaker testing and the facility failed to conduct weekly inspections of the emergency generator. These deficient practices increase the probability that the generator would fail to run during an emergency loss of power and the emergency systems in the facility.

Findings are:
Record review conducted on 7-26-22 at 12:33 pm of the facility's generator inspection reports revealed:
1. Facility failed the inspection of the main and feeder circuit breakers were inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements.
2. Facility failed to conduct weekly generator inspections; last inspection dated 12/14/21.
3. The facility failed to provide current fuel test.

During an interview on 7-26-22 at 12:33 pm, Maintenance Staff A confirmed that the generator testing documentation failed to be complete.

NFPA Standard:
NFPA 99, 2012, 6.4.4.1.2.1
Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer's recommendations.

Based on observation and interview, the facility failed to assure the self-closing door separating construction to the occupied area would close and latch within the doorframe. This deficient practice would allow fire, gases and smoke to migrate between the areas.

Findings are:
Observations on 7-26-22 at 11:34 am revealed, the southwest door separating the construction from the occupied hospital failed to close and latch within the doorframe.

During an interview on 7-26-22 at 11:34 am, Maintenance Staff A confirmed the door failed to close and latch.

Based on observation and interview, the facility failed to assure an exit sign for a required exit was visible. This deficient practice has the potential delay or cause confusion during an emergency as occupants would not be aware of the exit.

Findings are:
Observations on 7-26-22 at 10:45 am and 11:35 am revealed:
1. The exit sign above the ED doors at the nurse's station failed to provide left orientation directional indicators for exiting, as the ED doors were magnetically locked and not an exit path.
2. The exit sign above the OR doors failed provide left and right orientation directional indicators.
3. Standing in the ED hall next to the CT control room looking west, no exit sign was provided.
4. The exit sign above the smoke doors next to the construction wall was not provided and located on the other side of the construction wall.

During an interview on 7-26-22 at 10:45 am and 11:35 am, Maintenance Staff A confirmed the exit signs failed to be visible.

NFPA Standard:
NFPA 101, 2012, 7.10.2.1*
A sign complying with 7.10.3, with a directional indicator showing the direction of travel, shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.

Based on observation and interview, the facility failed to provide smoke resistant enclosures for hazardous areas to separate them from the rest of the facility. This deficient practice would allow fire, smoke, and gases to migrate into the exit corridors. .

Findings are:
Observation on 7-26-22 between 10:32 am and 11:42 am revealed:
1. The latching device to the electrical room door near the nurse's station was taped, and the door failed to latch within the doorframe.
2. Patient room 100 was used as a storage room, and a self-closing device was not provided for the door.
3. Missing ceiling tiles in the IT room.
4. Door to the contractor's office, equipped with a self-closing device failed to latch within the doorframe.
5. The north door to clean utility room in therapy failed to close and latch within the doorframe.

During an interview on 7-26-22 between 10:32 am and 11:42 am, Maintenance Staff A confirmed the findings.

Based on observation and interview, the facility failed to provide audio/visual devices tied to the fire alarm system in staff sleeping rooms. This deficient practice would not notify occupants in the areas of an emergency.

Findings are:
Observation on 7-26-22 at 10:55 am and 11:38 am revealed:
1. Patient room 106 was used as doctor's sleeping room and failed to provide an audio/visual device connected to the fire alarm system.
2. The audio/visual device in the EMT sleeping room, inside eye clinic was obstructed by the television.

During an interview on 7-26-22 at 10:55 am and 11:38 am, Maintenance Staff A confirmed the lack of an audio/visual device and the obstructed device.

Based on observation and interview, the facility failed to assure the smoke compartments doors would latch and be smoke tight which would allow smoke, fire, and gases to migrate to other smoke compartments.

Findings are:
Observation on 7-26-22 at 10:32 am and 11:36 am revealed,
1. The smoke doors near Pharmacy failed to close and latch within the doorframe.
2. The smoke doors at the construction wall was not smoke tight, only one door was provided which created an approximate 24 inch gap between the door and the wall.

During an interview on at 10:32 am and 11:36 am, 7-26-22, Maintenance Staff A confirmed the failure to latch and excessive gap.

Based on observation and interview, failed to provide an electrical panel directory. This deficient practice would delay when turning off the power during an electrical emergency.

Findings are:
Observations on 7-26-22 at 11:24 am revealed:
1. The electrical panel box identified as AHA1 in the contractor's office failed to provide a directory.
2. The electrical panel box identified as AHACE in the contractor's office failed to provide a directory.

During an interview on 7-26-22 at 11:24 am, Maintenance Staff A confirmed the lack of directories in the panel boxes.

Based on record review and interview, the facility (prior to COVID) failed to provide documentation for circuit breaker testing and the facility failed to conduct weekly inspections of the emergency generator. These deficient practices increase the probability that the generator would fail to run during an emergency loss of power and the emergency systems in the facility.

Findings are:
Record review conducted on 7-26-22 at 12:33 pm of the facility's generator inspection reports revealed:
1. Facility failed the inspection of the main and feeder circuit breakers were inspected annually, and a program for periodically
exercising the components is established according to manufacturer requirements.
2. Facility failed to conduct weekly generator inspections; last inspection dated 12/14/21.
3. The facility failed to provide current fuel test.

During an interview on 7-26-22 at 12:33 pm, Maintenance Staff A confirmed that the generator testing documentation failed to be complete.

NFPA Standard:
NFPA 99, 2012, 6.4.4.1.2.1
Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer's recommendations.

Based on observation and interview, the facility failed to prohibit the use of extension cords, power strips and electrical adaptors as a substitute for adequate wiring. This deficient practice would create an increased fire hazard.

Findings are:
Observation on 7-26-22 between 10:30 am and 11:26 am revealed:
1. Microwave and refrigerator plugged into a power-strip in the temporary changing room.
2. Two refrigerators plugged into a power-strip in the report/changing room.
3. An extension cord ran above the ceiling tiles in the contractor's office for a television on the other side of the room.
4. 6-plex electrical adaptor in the EMT sleeping room.

During an interview on 7-26-22 between 10:30 am and 11:26 am, Maintenance Staff A confirmed the findings.

Based on record review and interview, the facility failed to conduct power-strip assessments. This deficient practice would create electrical injury and fire hazards. The facility has the capacity for 24 beds with a census of 4 on the day of survey.

Findings are:
Record review on 7-26-22 at 4:29 pm revealed:
1. Facility failed to provide documentation for power strip assessments.

During an interview on 7-26-22 at 4:29 pm, Maintenance Staff A confirmed the lack of testing of power strips throughout the facility.

NFPA Standard:
NFPA 99, 2012,
10.3.1* Physical Integrity. The physical integrity of the power cord assembly composed of the power cord, attachment plug, and cord-strain relief shall be confirmed by visual inspection.
10.3.2* Resistance.