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Based on observation and interview, the facility failed to ensure closure of a door separating a large combustible storage room from the mail room and corridor, in accordance with 19.2.2.2.6. This deficient practice affects the staff, visitors and patient census of eight with five swing beds.

Findings included:

1. Observation on 11/12/13 at 1:40 PM showed the single door to a large storage room in the basement known as "Clean Storage" was propped open with a flip-down door stop. The door was equipped with a pneumatic door closing device to ensure separation from the storage room, the intervening mail room and the corridor. The unoccupied clean storage room was filled with large metal racks and wood pallets of office and clinical supplies in stored in numerous configurations of unfinished plywood, cardboard, paper and plastic wrapping. The facility has a complete automatic sprinkler system.

During an interview on 11/12/13 at 1:40 PM, Staff Z, Director of Maintenance, stated that the Clean Storage room was always left with the door open, door stop down and no staff assigned to be in attendance. He stated that there was no written facility policy he was aware of that addressed keeping the room occupied or doors closed when no staff are in attendance.

Based on observation and interview, the facility failed to maintain the integrity of a one hour enclosure to a basement boiler room in accordance with 19.3.2.1. This deficient practice affects staff, visitors, and the patient census of eight with five swing beds.

Findings included:

1. Observations on 11/12/13 at 1:50 PM showed numerous annular spaces and unsealed holes in three of the four walls that enclosed the boiler room and separated it from lesser hazards as follows:
-Seven unsealed annular spaces around large water pipes that traversed across the ceiling of the mechanical room where the boilers were located, and two unsealed four-inch holes penetrated completely through the north wall of the boiler room into the heat exchanger room. The largest annular space was one inch wide by four inches long.
-Ten holes, four inches in diameter and a large 12 inch wide by six inch high opening into the southwest wall and the adjacent Heat Exchanger room.
-A large opening, 10 by 10 inches, in the northeast wall of the boiler room penetrated into the open space above the east-west corridor of the basement. This corridor is the main protected path of egress to designated exits at ground level.
-Five, one inch wide annular spaces around water pipes that penetrated a northeast wall, into the adjacent electrical room where the automatic transfer switches for the generator were located.

During an interview on 11/13/13 at 2:10 PM, Staff Z, Director of Maintenance, acknowledged the holes and stated that no inspectors had voiced concerns about them in the past. He stated that he makes Preventive Maintenance rounds every morning and reviews work orders. He stated that there was no policy to ensure penetrations of smoke and fire walls were repaired to maintain the integrity of the walls separating hazardous areas.

Based on observation and interview, the facility failed to provide secure storage of medical and other compressed gases in accordance with NFPA 99, 4.3.1.1.2 and 4.3.5.2.1 with racks, chains or other fastenings to individually secure all cylinders to prevent them from falling or inadvertently being tipped over during change-outs, potentially affecting staff, visitors and the facility census of eight with five swing beds.
Findings included:
1. Observation on 11/13/13 at 1:40 PM showed three unsecured and uncapped "H" size cylinders of compressed gases in a vented storage room. Without protective caps, the unsecured cylinders could accidentally be knocked over during change outs and turn into unguided projectiles with enough force to penetrate a brick or concrete wall and cause injury or death.
During an interview on 11/13/13 at 1:50 PM, Staff Z stated that he didn't think cylinders that were empty posed much of a hazard.

Based on observation and interview, the facility failed to ensure safe storage of flammable products in a room where Automatic Transfer Switches (ATS-automatically activated electrical switches that shift facility power requirements to an alternative emergency power source.) are co-located with limited non-flammable storage. This deficient practice affects staff, visitors, and the patient census of eight with five swing beds.

Findings included:

1. Observation on 11/12/14 at 1:50 PM showed two gallons of flammable Zone Marking paint product and a partially filled one gallon container of paint thinner on some shelves where latex paint and adhesive products were stored. The three containers all carried the warning "Flammable liquid or vapor, keep away from heat, sparks or flame." The one gallon paint containers also carried a NFPA 704 identification code of a flame with the digit 3 on a red diamond, which means the product "ignites at ambient temperatures." (NFPA, National Fire Protection Association-standards and codes formally adopted by the Centers for Medicare & Medicaid Services.)

During an interview on 11/12/13 at 1:55 PM, Staff Z, Director of Maintenance stated that he would remove the flammables and either store them in an approved cabinet or outside in the heated maintenance garage. He stated that he did not have a formal policy that addressed storing flammables.

Based on record review and interview, the facility failed to provide a plan for the institution of a fire watch in accordance with paragraph 9.7.6.1 of NFPA 101, to protect the patients, staff and visitors during the unlikely eventual failure of the automatic sprinkler system. This deficient practice affects staff, visitors, and the patient census of eight with five swing beds.

Findings included:

NFPA 9.7.6.1 Where a required automatic sprinkler system is out of service for more than four hours in a 24 hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.
Appendix 9.7.6.1.8 A fire watch should at least involve some special action beyond normal staffing, such as assigning an additional security guard(s) to walk the areas affected. These individuals should be specifically trained in fire prevention and in occupant and fire department notification techniques, and they should understand the particular fire safety situation for public education purposes.
1. Record review of maintenance policies and the facility's board approved disaster plan dated 5/19/11 showed no procedure, or provision of designated personnel to assume Fire Watch duties in the event that the automatic sprinkler system is temporarily out of service for more than four hours.
2. During an interview on 11/13/13 at 1:00 P.M. the Director of Plant Operations (DPO) said the facility does not have a formal written plan for a fire watch and has not identified or trained specific personnel to perform this duty.

Based on record review and interview, the facility failed to provide a plan for the institution of a fire watch in accordance with paragraph 9.6.1.8 of NFPA 101, to protect the patients, staff and visitors during the unlikely eventual failure of the fire alarm system. This deficient practice affects staff, visitors, and the patient census of eight with five swing beds.

Findings included:

NFPA 9.6.1.8 Where a required fire alarm system is out of service for more than four hours in a 24 hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.
Appendix 9.7.6.1.8 A fire watch should at least involve some special action beyond normal staffing, such as assigning an additional security guard(s) to walk the areas affected. These individuals should be specifically trained in fire prevention and in occupant and fire department notification techniques, and they should understand the particular fire safety situation for public education purposes.
1. Record review of maintenance policies and the facility's board approved disaster plan dated 5/19/11 showed no procedure, or provision of designated personnel to assume Fire Watch duties in the event that the Fire Alarm system is temporarily out of service for more than four hours.
2. During an interview on 11/13/13 at 1:00 P.M. the Director of Plant Operations (DPO) said the facility does not have a formal written plan for a fire watch and has not identified or trained specific personnel to perform this duty.

Based on observation and interview, the facility failed to ensure closure of a door separating a large combustible storage room from the mail room and corridor, in accordance with 19.2.2.2.6. This deficient practice affects the staff, visitors and patient census of eight with five swing beds.

Findings included:

1. Observation on 11/12/13 at 1:40 PM showed the single door to a large storage room in the basement known as "Clean Storage" was propped open with a flip-down door stop. The door was equipped with a pneumatic door closing device to ensure separation from the storage room, the intervening mail room and the corridor. The unoccupied clean storage room was filled with large metal racks and wood pallets of office and clinical supplies in stored in numerous configurations of unfinished plywood, cardboard, paper and plastic wrapping. The facility has a complete automatic sprinkler system.

During an interview on 11/12/13 at 1:40 PM, Staff Z, Director of Maintenance, stated that the Clean Storage room was always left with the door open, door stop down and no staff assigned to be in attendance. He stated that there was no written facility policy he was aware of that addressed keeping the room occupied or doors closed when no staff are in attendance.

Based on observation and interview, the facility failed to maintain the integrity of a one hour enclosure to a basement boiler room in accordance with 19.3.2.1. This deficient practice affects staff, visitors, and the patient census of eight with five swing beds.

Findings included:

1. Observations on 11/12/13 at 1:50 PM showed numerous annular spaces and unsealed holes in three of the four walls that enclosed the boiler room and separated it from lesser hazards as follows:
-Seven unsealed annular spaces around large water pipes that traversed across the ceiling of the mechanical room where the boilers were located, and two unsealed four-inch holes penetrated completely through the north wall of the boiler room into the heat exchanger room. The largest annular space was one inch wide by four inches long.
-Ten holes, four inches in diameter and a large 12 inch wide by six inch high opening into the southwest wall and the adjacent Heat Exchanger room.
-A large opening, 10 by 10 inches, in the northeast wall of the boiler room penetrated into the open space above the east-west corridor of the basement. This corridor is the main protected path of egress to designated exits at ground level.
-Five, one inch wide annular spaces around water pipes that penetrated a northeast wall, into the adjacent electrical room where the automatic transfer switches for the generator were located.

During an interview on 11/13/13 at 2:10 PM, Staff Z, Director of Maintenance, acknowledged the holes and stated that no inspectors had voiced concerns about them in the past. He stated that he makes Preventive Maintenance rounds every morning and reviews work orders. He stated that there was no policy to ensure penetrations of smoke and fire walls were repaired to maintain the integrity of the walls separating hazardous areas.

Based on observation and interview, the facility failed to provide secure storage of medical and other compressed gases in accordance with NFPA 99, 4.3.1.1.2 and 4.3.5.2.1 with racks, chains or other fastenings to individually secure all cylinders to prevent them from falling or inadvertently being tipped over during change-outs, potentially affecting staff, visitors and the facility census of eight with five swing beds.
Findings included:
1. Observation on 11/13/13 at 1:40 PM showed three unsecured and uncapped "H" size cylinders of compressed gases in a vented storage room. Without protective caps, the unsecured cylinders could accidentally be knocked over during change outs and turn into unguided projectiles with enough force to penetrate a brick or concrete wall and cause injury or death.
During an interview on 11/13/13 at 1:50 PM, Staff Z stated that he didn't think cylinders that were empty posed much of a hazard.

Based on observation and interview, the facility failed to ensure safe storage of flammable products in a room where Automatic Transfer Switches (ATS-automatically activated electrical switches that shift facility power requirements to an alternative emergency power source.) are co-located with limited non-flammable storage. This deficient practice affects staff, visitors, and the patient census of eight with five swing beds.

Findings included:

1. Observation on 11/12/14 at 1:50 PM showed two gallons of flammable Zone Marking paint product and a partially filled one gallon container of paint thinner on some shelves where latex paint and adhesive products were stored. The three containers all carried the warning "Flammable liquid or vapor, keep away from heat, sparks or flame." The one gallon paint containers also carried a NFPA 704 identification code of a flame with the digit 3 on a red diamond, which means the product "ignites at ambient temperatures." (NFPA, National Fire Protection Association-standards and codes formally adopted by the Centers for Medicare & Medicaid Services.)

During an interview on 11/12/13 at 1:55 PM, Staff Z, Director of Maintenance stated that he would remove the flammables and either store them in an approved cabinet or outside in the heated maintenance garage. He stated that he did not have a formal policy that addressed storing flammables.

Based on record review and interview, the facility failed to provide a plan for the institution of a fire watch in accordance with paragraph 9.7.6.1 of NFPA 101, to protect the patients, staff and visitors during the unlikely eventual failure of the automatic sprinkler system. This deficient practice affects staff, visitors, and the patient census of eight with five swing beds.

Findings included:

NFPA 9.7.6.1 Where a required automatic sprinkler system is out of service for more than four hours in a 24 hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.
Appendix 9.7.6.1.8 A fire watch should at least involve some special action beyond normal staffing, such as assigning an additional security guard(s) to walk the areas affected. These individuals should be specifically trained in fire prevention and in occupant and fire department notification techniques, and they should understand the particular fire safety situation for public education purposes.
1. Record review of maintenance policies and the facility's board approved disaster plan dated 5/19/11 showed no procedure, or provision of designated personnel to assume Fire Watch duties in the event that the automatic sprinkler system is temporarily out of service for more than four hours.
2. During an interview on 11/13/13 at 1:00 P.M. the Director of Plant Operations (DPO) said the facility does not have a formal written plan for a fire watch and has not identified or trained specific personnel to perform this duty.

Based on record review and interview, the facility failed to provide a plan for the institution of a fire watch in accordance with paragraph 9.6.1.8 of NFPA 101, to protect the patients, staff and visitors during the unlikely eventual failure of the fire alarm system. This deficient practice affects staff, visitors, and the patient census of eight with five swing beds.

Findings included:

NFPA 9.6.1.8 Where a required fire alarm system is out of service for more than four hours in a 24 hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.
Appendix 9.7.6.1.8 A fire watch should at least involve some special action beyond normal staffing, such as assigning an additional security guard(s) to walk the areas affected. These individuals should be specifically trained in fire prevention and in occupant and fire department notification techniques, and they should understand the particular fire safety situation for public education purposes.
1. Record review of maintenance policies and the facility's board approved disaster plan dated 5/19/11 showed no procedure, or provision of designated personnel to assume Fire Watch duties in the event that the Fire Alarm system is temporarily out of service for more than four hours.
2. During an interview on 11/13/13 at 1:00 P.M. the Director of Plant Operations (DPO) said the facility does not have a formal written plan for a fire watch and has not identified or trained specific personnel to perform this duty.