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Based on observation and interview, the Facility failed to maintain doors with self-closing devices in accordance with 19.2.2.2.7 and 19.2.2.2.8.

Doors with Self-Closing Devices
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; and
* 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

FINDINGS INCLUDE:

On facility tour between 9:00 AM and 3:00 PM on 04/25/2017, observation revealed the following:
1.)The hold open magnetic device on Room- 251does not release upon activation of the fire alarm system.
2.) Room-3103 needs a self closing device installed on the door. This room is a Storage Room over 100 sq. ft.

This deficient practice was verified by the Facility Maintenance Director.

Based on documentation review and interview, the Facility failed to conduct Fire Drills in accordnance with 18.7.1.4 through 18.7.1.7, 19.7.1.4 through 19.7.1.7.

Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
18.7.1.4 through 18.7.1.7, 19.7.1.4 through 19.7.1.7.

FINDINGS INCLUDE:

On facility tour between 9:00 AM and 3:00 PM on 04/25/2017, documentation reviewed revealed that a fire drills during the past year were not conducted at unexpected times under varying conditions: The day shift conducted two drills at 11:00am, the evening shift at 3:17pm, 3:40pm, 3:30pm and the night shift at 12:20am, 12:30am and 11:30pm.


This deficient practice was verified by the Facility Maintenance Director.

Based on documentation review and interview, the Facility failed to provide a written and current Space Heater Policy.

Portable Space Heaters
Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius).
18.7.8, 19.7.8

FINDINGS INCLUDE:

On facility tour between 9:00 AM and 3:00 PM on 04/25/2017, documentation reviewed revealed that the Facility does not have a written Space Heater Policy that is specific to Rivers Edge Hospital.

This deficient practice was verified by the Facility Maintenance Director.

Based on documentation review and interview, the Facility failed to provide complete written records of Generator maintenance and testing are maintained.

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked and readily identifiable. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

FINDINGS INCLUDE:

On facility tour between 9:00 AM and 3:00 PM on 04/25/2017, documentation reviewed revealed that not all the required information is being documented during the Monthly Emergency Generator Load Test.The transfer time of how long it takes the emergency generator to assume power and the cool down time after the 30 minute monthly load test is not being recorded.

This deficient practice was verified by the Facility Maintenance Director.