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K-0321: Based upon observations made in the presence of the plant manager on 08-02-2017, it was determined that the facility did not maintain hazardous areas to be fire and smoke separated from other sections of the facility in accordance with NFPA 101 19.3.2.1, 19.3.2.1.1 through 19.3.2.1.5

This deficiency affected 1 of 3 smoke compartments

Findings include:

1-During the facility tour it was observed that in the basement conference room the storage room door did not have a door closure. The door is required to be self-closing or automatic closing to the latch position in accordance with NFPA 101 19.3.2.1.

2- During the facility tour it was observed that the fire rated roll down fire rated door at the basement kitchen serving area and Administrative area have been disable and will not close. They are also not being tested annually in accordance with NFPA 80 5.2.5. , 5.2.14 this finding was verified by the facility director who stated that they had been disabled.

K-345: Based upon record review made in the presence of the administrator on 08/02/2017, it was determined that the facility did not maintain the fire alarm system in accordance with NFPA 101 19.3.4.4 & 9.6.3.1.; and NFPA 72. Table 14.4.5 (6) (3), 14.6.2

This deficiency affected smoke 3 of 3 compartments


Findings include:

1-During the record review the facility failed to provide documentation that the fire alarm control panel batteries had been tested under load two times in the last year, there was only one documented test. Batteries need to be tested semiannually in accordance with NFPA. 101 19.3.4.4. & 9.6.1.3.; and NFPA 72. Table 14.4.5 (6) (3)

2- During the record review the fire alarm annual inspection report failed to give the locations, address and test results to each device as required by NFPA 72.

K-0363 Based upon observations made in the presence of the plant manager on 08-02-2017, it was determined that the facility did not maintain corridor doors to be positively latching and to resist the passage of smoke in accordance with NFPA 101 19.3.6.3.2., 19.3.6.3.5.

This deficiency affected 1 of 3 smoke compartments

Findings include:

During the facility tour the corridor door entering into the medical records department did not close and positively latch during the testing of the fire alarm in accordance with NFPA 101 19.3.6.3.2.

K-0511 Based upon observations made in the presence of the plant manager on 08-02-2017, it was determined that the facility did not maintain electrical equipment in accordance with NFPA 101 19.5.1 and 9.1.2.

This deficiency affected 2 of 3 smoke compartments

Findings include:

1. During the facility tour it was observed that the power cord for the ice machine in the birthing room was running thru a hole cut into the wall and then into the break room where it was plugged in to furnish power.
2-During the facility tour it was observed that the electrical service panels in the basement service corridor were unlocked allowing unauthorized access to unqualified persons not in accordance with NFPA 70,110-31
3-During the facility tour it was observed that the electrical outlets in several areas were within 6 ft. of the sinks in the public restrooms, basement kitchen area, lab area, male and female locker rooms, nursery, soiled utility room by resident room 115 and the medication storage room the decision was made that all areas would be checked by the facility director and upgraded as necessary.

K-0902 Based on record review the facility it was determined that the facility did not maintain the medical gas system in accordance with NFPA 99.

This deficiency affected all oxygen outlets.

Findings include:

During the facility tour it was observed that the hospital had no emergency oxygen connection. The bulk oxygen system has underground piping, therefore requires an emergency oxygen supply outlet. The facility director stated that the attached nursing home that was not owned by the hospital had an emergency oxygen supply outlet that may be able to be used by the hospital. However during a interview with the hospital management no one was aware of any policy or procedure for supplying emergency oxygen to the hospital. Per NFPA 99 5.1.3.5.13., 12.5.3.3.6.5

K-920 Based upon observations made in the presence of the plant manager on 08-02-2017, it was determined that the facility did not use power and extension cords in accordance with NFPA 101, 99 and 70.

This deficiency affected 2 of 3smoke compartments.

Findings include:

1-During the facility tour it was observed that a power strip was plugged into another power strip in the administrative area, emergency room bed #3 and at the nurse's station in front of resident room #105. The power strips were removed at the time of the tour. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling in accordance with NFPA 70 110-3b

2- During the facility tour it was observed that power strips in the nurse's lounge and equipment room were affixed to the structure and used in place of permanent wiring. Flexible cords and cables cannot be used as a substitute for permanent wiring in accordance with NFPA 101 19.5.1, 9.1.2, and NFPA 70 400.8.

K-923 Based upon observations made in the presence of the plant manager on 03/29/2017, it was determined that the facility did not maintain medical gas storage in accordance with NFPA 101 19.3.2.4.

This deficiency affected 1 of 3 smoke compartments

Findings include:

1-During the facility tour it was observed that 2 cylinders were stored in the basement dietary area were not secured.
2- During the facility tour it was observed that there was an H cylinder in the medical gas manifold room that was not secured per NFPA 101 19.3.2.4 and NFPA 99 4-3.1.1.2.