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Based on observation and interview, the facility failed to provide self-closing doors to provide separation between hazardous areas and other spaces in accordance with NFPA 101 (2012 edition), Sections 19.3.21.2, 19.3.2.1.5((7), 8.4.3.5 and 7.2.1.8. This deficient practice could affect all 6 patients as well as an undetermined number of staff and visitors.

Findings include:

On 2/5/18 at 3:25 pm, observation on the 1st floor in the soiled utility room located in smoke compartment D revealed a hazardous room with no self-closer on the corridor door.

This deficient practice was confirmed by staff D and E at the time of discovery.

Based on observation and interview, the facility failed to provide a fire alarm system in accordance with the requirements of NFPA 101 (2012 edition), 19.3.4 and 9.6 and NFPA 72 (2010 edition), 10.5.5.2.2 and 10.5.5.2.3. This deficient practice could affect all 6 patients as well as an undetermined number of staff and visitors.

Findings include:

1. On 2/5/18 at 2:30 pm, observation at the emergency electrical panel located in the boiler room, revealed an improperly identified fire alarm disconnecting means. The disconnection means was labeled FA Main Panel in-lieu-of Fire Alarm Circuit as required by the code.
2. On 2/5/18 at 2:31 pm, observation at the emergency electrical panel located in the boiler room, revealed a fire alarm disconnecting means without red marking.

These deficient practices were confirmed by staff D and E at the time of discovery.

Based on observation and interview, the facility failed to provide an automatic sprinkler system with supervisory attachments installed and monitored with integrity in accordance with NFPA 101 (2012 edition), 19.3.5 and 9.7. This deficient practice could affect all 6 patients as well as an undetermined number of staff and visitors.

Findings include:

On 2/5/18 at 2:08 pm, observation in the sprinkler riser room revealed the main water supply valve providing water to the building and sprinkler was not supervised.

This deficient practice was confirmed by staff D and E at the time of discovery.

Based on obervation, record review and interview, the facility failed to maintain its automatic sprinkler system in accordance with NFPA 101 (2012 edition), 19.3.5 and 9.7; and NFPA 25 (2011 edition), 5.2.1.1.1, 8.1.1.1 and Table 8.1.1.2. This deficient practice could affect all 6 patients as well as an undetermined number of staff and visitors.

Findings include:

1. On 2/5/18 at 11:30 am, review of the fire protection sprinkler system testing and maintenance records revealed the existence of a high capacity well serving the building and fire protection system. The single source pump was not being inspected, tested and maintained as a fire pump.
2. On 2/5/18 at 3:12 pm, observation in the nurse's lounge located in smoke compartment D revealed a pendant sprinkler head near an air diffuser with an accumulation of dust, lint and debris.

These deficient practices were confirmed by staff D and E at the time of discovery.

Based on record review and interview, the facility failed to provide inspection of portable fire extinguishers in 30-day intervals in accordance with NFPA 101 (2012 edition), 19.3.5.12 and 9.7.4.1; and NFPA 10 (2010 edition), 7.2.1.2 and 7.3.1.1.1 This deficient practice could affect all 6 patients as well as an undetermined number of staff and visitors.

Findings include:

1. On 2/5/18 at 1:19 pm, review of facility fire extinguisher inspection records revealed portable fire extinguisher 30-day inspection intervals were exceeded. The inspection dates were as follows: 1/24/17, 2/22/17, 3/27/17, 4/25/17, 5/25/17, 6/27/17, 7/25/17, 8/25/17, 9/27/17, 10/30/17, 11/21/17 and 12/21/17.
2. On 2/5/18 at 1:22 pm, review of facility fire extinguisher inspection record revealed portable fire extinguisher annual servicing interval was exceeded. The servicing dates were 11/23/16 and 12/5/17.

These deficient practices were confirmed by staff D and E at the time of discovery.

Based on observation and interview, the facility failed to provide corridor doors meeting the requirements of NFPA 101 (2012 edition), 19.3.6.3, 19.3.6.3.1, 19.3.6.3.2 and 19.3.6.3.5. This deficient practice could affect 4 patients as well as an undetermined number of staff and visitors.

Findings include:

1. On 2/5/18 at 2:05 pm, observation in B29 storage room at the double doors leading to the corridor revealed an inactive door leaf with a manual surface mounted bolt. The door did not positively self-latch.
2. On 2/5/18 at 2:46 pm, observation in the kitchen at the double doors leading to the corridor revealed an inactive door leaf with a manual surface mounted bolt. The door did not positively self-latch.

These deficient practices were confirmed by staff D and E at the time of discovery.

Based on record review and interview, the facility failed to conduct fire drills and document transmission of the fire alarm signal in accordance with the requirements of NFPA 101 (2012 edition), 19.7.1.4. This deficient practice could affect all 6 patients as well as an undetermined number of staff and visitors.

Findings included:

On 2/5/18 at 11:24 am, review of fire drill records for the last 12 months revealed 3rd shift fire drills did not include the transmission of the fire alarm signal to the monitoring company.

This deficient practice was confirmed by staff D and E at the time of discovery.

Based on record review and interview, the facility failed to provide an emergency electrical generator with transfer of electrical power within 10 seconds in accordance with the requirements of NFPA 101 (2012 edition), 19.5.1 and 9.1.3; NFPA 99 (2012 edition), 6.5.4, 6.4.3.1, and 6.4.1.1.7; and NFPA 110 (2010 edition), 6.1, 6.2 and 8.3. This deficient practice could affect all 6 patients as well as an undetermined number of staff and visitors.

Findings include:

On 2/5/18 at 1:30 pm, review of hospital generator monthly loading and transfer tests for the last 12 months revealed emergency power transfer within 10 seconds was not verified and recorded.

This deficient practice was confirmed by staff D and E at the time of discovery.