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Based on document review and interview, the facility failed to conduct semi-annual disaster drills to ensure staff were trained and familiar with the policy and procedures for disasters. This was evidenced by no documentation for 1 of 2 semi-annual disaster drills. This failure could result in staff not trained and familiar with the disaster response procedures in the event of an emergency. This affected 5 of 5 smoke compartments and could result in potential harm to patients, staff and visitors.

NFPA 99, 1999 Edition
Chapter 11 Health Care Emergency Preparedness

11-5.3.8 Staff Education.
Each health care facility shall implement an educational program. This program shall include an overview of the components of the emergency preparedness plan and concepts of the Incident Command System. Education concerning the staff's specific duties and responsibilities shall be conducted upon reporting to their assigned departments or position.
General overview education of the Emergency Preparedness Plan and Incident command System shall be conducted at the time of hire. Department/staff specific education shall be conducted upon reporting to their assignments or position and annually thereafter.

11-5.3.9 Drills
Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both.

Findings:

During document review and interview with the Maintenance Supervisor on 9/16/13 and 9/17/13, the documentation for disaster drills were requested.

On 9/16/13 at 3:54 p.m., the facility provided documentation for one disaster drill rehearsing mass casualty, that was held on 5/15/13. During interview, the Maintenance Supervisor stated there were no additional records and stated there were no disaster drills held in 2012.

Based on document review and interview, the facility failed to conduct quarterly fire drills, as evidenced by failing conduct drills at unexpected times, by failing to provide documentation for 1 of 4 NOC shift fire drills and for 1 of 4 AM shift fire drills. This failure had the potential for staff not being prepared to respond to a fire drill according to the facilities fire protection plan and affected 5 of 5 smoke compartments.

NFPA 101, Life Safety Code (2000 Edition)
19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m., (2100 hours) and 6:00 a.m., (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Findings:

During document review and interview with the Maintenance Supervisor on 9/16/13 through 9/18/13, the fire drill reports were requested.

1. At 3:15 a.m., on 9/16/13, the facility failed to provide documentation for the first quarter AM shift fire drill (7 am to 7 pm) and for the frist quarter NOC shift fire drill (7 pm to 7 am.) During an interview, the maintenance supervisor stated there were no fire drills held during the first quarter (January, February, March 2013) and stated there was no additional records for review.

2. The AM shift fire drills held on the second quarter and third quarter were held between 11:05 a.m., and 11:18 a.m., and not at varied times.

3. The NOC shift fire drills held on the second and fourth quarter were both held at 6:00 a.m., and not at varied times.

Based on document review and interview, the facility failed to maintain the fire alarm system in accordance with NFPA 72, 1999 edition. This was evidenced by incomplete documentation for the testing of the fire alarm system signal with the central monitoring station on a monthly basis. This could result in the fire alarm system not functioning as designed and had the potential for fire alarm transmission failure. This affected patients, staff and visitors in 5 of 5 smoke compartments.

NFPA 72, National Fire Alarm Code (1999 Edition)
Table 7-3.2, Testing Frequencies, Item 23 - requires the system be tested monthly with Monitoring/Supervising Station.

Findings:

During document review and interview with the maintenance supervisor on 9/16/13 through 9/18/13, the documentation for monthly testing of the fire alarm signal with the central station was requested.

At 3:03 p.m., on 9/17/13, during document review, the facility failed to provide documentation for the monthly testing of the fire alarm system confirming the monitoring station received signals during the month of January, March, May, July of 2013 and for October and November of 2012. During interview, the Maintenance Supervisor stated he did not check the fire alarm system signal with the central station every month and stated he would check if the signal was received by the monitoring station during fire drills.

Based on observation, the facility failed to ensure the automatic sprinkler system was maintained and inspected periodically, as evidenced by sprinklers heads that were contaminated with dust or paint. This failure could result in the sprinkler not functioning as designed in the event of a fire and affected patients, staff and visitors in 2 of 5 smoke compartments.

NFPA 25, 1998 Edition
Standard for the Inspection, Testing, and Maintenance of the Water-Based Fire Protection Systems
2-2 Inspection. 2-2.1 Sprinklers.
2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

Findings:

During a tour of the facility with the Maintenance Supervisor and staff on 9/16/13 through 9/18/13, the sprinkler system was observed.

1. At 9:40 a.m., on 9/17/13, the sprinkler in the med surge social services dept. office had paint on the sprinkler deflector.

2. At 9:49 a.m., on 9/17/13, the sprinkler in the bathroom of patient room 111, had paint on the sprinkler deflector.

3. At 10:03 a.m., on 9/17/13, the sprinkler in the bathroom of patient room 115, had green paint on the sprinkler deflector.

4. At 10:04 a.m., on 9/17/13, the sprinkler in the bathroom of patient room 114, had green paint on the sprinkler deflector.

5. At 1:29 p.m., on 9/17/13, the sprinkler in patient room 203, had signs of a leak on the sprinkler. The room is located in the rehabilitation dept.

Based on observation and interview, the facility failed to provide ashtrays of noncombustible material or a metal container with a self-closing cover devices for the disposal of cigarette butts and ashes. This was evidenced by no containers for the disposal of cigarette material in 2 of 2 designated smoking areas.

Findings:

During a tour of the facility with the Maintenance Supervisor and staff on 9/17/13, the designated smoking area for employees and patients were observed.

1. At 9:27 a.m., the designated smoking area for employees did not have a container for the disposal of cigarette butts and ashes. The container that was used for the disposal of the cigarette butts and ashes was also use for the disposal of trash. There was no metal container or ashtray of safe design in the smoking area.

2. At 9:34 a.m. the designated smoking area for patients did not have a metal container or ashtray of safe design for the disposal of cigarette butts and ashes. During interview, the maintenance supervisor stated he did not know what happen to the metal container that was supposed to be in the smoking area.

Based on observation, document review and interview, the facility failed to maintain the kitchen hood exhaust in accordance with NFPA 96, as evidenced by grease and dirt inside the kitchen hood exhaust and by no documentation for the cleaning of the kitchen hood by a certified company. This could result in the increase risk of a grease fire and affected patients, staff and visitors in 1 of 5 smoke compartments.

NFPA 96, 1998 Edition
Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations8-3 Cleaning.
8-3.1 Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or
person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1
Table 8-3.1 Exhaust System Inspection Schedule
Type or Volume of Cooking Frequency Frequency
Systems serving solid fuel cooking operations Monthly
Systems serving high-volume cooking operations such as Quarterly
24 hour cooking, charbroiling or wok cooking
Systems serving moderate-volume cooking operations Semiannually
Systems serving low-volume cooking operations, such as Annually
churches, day camps, seasonal businesses, or senior centers

Findings:

During document review, interview and a tour of the facility with the Maintenance Supervisor and staff on 9/16/13 and 9/17/13, the records for the cleaning of the kitchen hood was requested.

1. At 4:03 p.m., on 9/16/13, the facility failed to provide documentation for the cleaning of the kitchen hood. During an interview, maintenance stated the hood is cleaned by dietary staff and stated the hood is not cleaned by a licensed vendor.

2. At 10:48 a.m., on 9/17/13, during a tour of the facility kitchen the hood above the cooking area was observed to have grease and dirt in the hood. A small portion at the bottom of the hood was clean. During an interview, the Dietary supervisor stated dietary staff tries to clean as best possible, but can only reach so far up in the hood.

Based on observation, the facility failed to maintain the electrical safety, as evidenced by electrical panels that were missing blank covers. This failure could result in the potential spread of an electrical fire and affected patients, staff and visitors in 2 of 5 smoke compartments.

NFPA 70, National Electrical Code (1999 Edition), article 373-4. Unused Openings. Unused openings in enclosures within the scope of this article shall be effectively closed to afford protection substantially equivalent to that of the enclosures within the scope of this article. Where metal plugs or plates are used with nonmetallic cabinets or cutout boxes, they shall be recessed at least ? in. (6.35 mm) from the outer surface.

Findings:

During a tour of the facility with the maintenance supervisor and staff on 9/16/13 through 9/18/13, the electrical wiring and equipment was observed.

1. At 10:01 a.m., on 9/17/13, electrical panel "AA" located in Med Surge was missing blank covers for space 39 and 41.

2. At 10:09 a.m., on 9/17/13, electrical panel "CD" located in the OB department was missing a blank cover for space 23.

Based on document review and interview, the facility failed to conduct semi-annual disaster drills to ensure staff were trained and familiar with the policy and procedures for disasters. This was evidenced by no documentation for 1 of 2 semi-annual disaster drills. This failure could result in staff not trained and familiar with the disaster response procedures in the event of an emergency. This affected 5 of 5 smoke compartments and could result in potential harm to patients, staff and visitors.

NFPA 99, 1999 Edition
Chapter 11 Health Care Emergency Preparedness

11-5.3.8 Staff Education.
Each health care facility shall implement an educational program. This program shall include an overview of the components of the emergency preparedness plan and concepts of the Incident Command System. Education concerning the staff's specific duties and responsibilities shall be conducted upon reporting to their assigned departments or position.
General overview education of the Emergency Preparedness Plan and Incident command System shall be conducted at the time of hire. Department/staff specific education shall be conducted upon reporting to their assignments or position and annually thereafter.

11-5.3.9 Drills
Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both.

Findings:

During document review and interview with the Maintenance Supervisor on 9/16/13 and 9/17/13, the documentation for disaster drills were requested.

On 9/16/13 at 3:54 p.m., the facility provided documentation for one disaster drill rehearsing mass casualty, that was held on 5/15/13. During interview, the Maintenance Supervisor stated there were no additional records and stated there were no disaster drills held in 2012.

Based on document review and interview, the facility failed to conduct quarterly fire drills, as evidenced by failing conduct drills at unexpected times, by failing to provide documentation for 1 of 4 NOC shift fire drills and for 1 of 4 AM shift fire drills. This failure had the potential for staff not being prepared to respond to a fire drill according to the facilities fire protection plan and affected 5 of 5 smoke compartments.

NFPA 101, Life Safety Code (2000 Edition)
19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m., (2100 hours) and 6:00 a.m., (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Findings:

During document review and interview with the Maintenance Supervisor on 9/16/13 through 9/18/13, the fire drill reports were requested.

1. At 3:15 a.m., on 9/16/13, the facility failed to provide documentation for the first quarter AM shift fire drill (7 am to 7 pm) and for the frist quarter NOC shift fire drill (7 pm to 7 am.) During an interview, the maintenance supervisor stated there were no fire drills held during the first quarter (January, February, March 2013) and stated there was no additional records for review.

2. The AM shift fire drills held on the second quarter and third quarter were held between 11:05 a.m., and 11:18 a.m., and not at varied times.

3. The NOC shift fire drills held on the second and fourth quarter were both held at 6:00 a.m., and not at varied times.

Based on document review and interview, the facility failed to maintain the fire alarm system in accordance with NFPA 72, 1999 edition. This was evidenced by incomplete documentation for the testing of the fire alarm system signal with the central monitoring station on a monthly basis. This could result in the fire alarm system not functioning as designed and had the potential for fire alarm transmission failure. This affected patients, staff and visitors in 5 of 5 smoke compartments.

NFPA 72, National Fire Alarm Code (1999 Edition)
Table 7-3.2, Testing Frequencies, Item 23 - requires the system be tested monthly with Monitoring/Supervising Station.

Findings:

During document review and interview with the maintenance supervisor on 9/16/13 through 9/18/13, the documentation for monthly testing of the fire alarm signal with the central station was requested.

At 3:03 p.m., on 9/17/13, during document review, the facility failed to provide documentation for the monthly testing of the fire alarm system confirming the monitoring station received signals during the month of January, March, May, July of 2013 and for October and November of 2012. During interview, the Maintenance Supervisor stated he did not check the fire alarm system signal with the central station every month and stated he would check if the signal was received by the monitoring station during fire drills.

Based on observation, the facility failed to ensure the automatic sprinkler system was maintained and inspected periodically, as evidenced by sprinklers heads that were contaminated with dust or paint. This failure could result in the sprinkler not functioning as designed in the event of a fire and affected patients, staff and visitors in 2 of 5 smoke compartments.

NFPA 25, 1998 Edition
Standard for the Inspection, Testing, and Maintenance of the Water-Based Fire Protection Systems
2-2 Inspection. 2-2.1 Sprinklers.
2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

Findings:

During a tour of the facility with the Maintenance Supervisor and staff on 9/16/13 through 9/18/13, the sprinkler system was observed.

1. At 9:40 a.m., on 9/17/13, the sprinkler in the med surge social services dept. office had paint on the sprinkler deflector.

2. At 9:49 a.m., on 9/17/13, the sprinkler in the bathroom of patient room 111, had paint on the sprinkler deflector.

3. At 10:03 a.m., on 9/17/13, the sprinkler in the bathroom of patient room 115, had green paint on the sprinkler deflector.

4. At 10:04 a.m., on 9/17/13, the sprinkler in the bathroom of patient room 114, had green paint on the sprinkler deflector.

5. At 1:29 p.m., on 9/17/13, the sprinkler in patient room 203, had signs of a leak on the sprinkler. The room is located in the rehabilitation dept.

Based on observation and interview, the facility failed to provide ashtrays of noncombustible material or a metal container with a self-closing cover devices for the disposal of cigarette butts and ashes. This was evidenced by no containers for the disposal of cigarette material in 2 of 2 designated smoking areas.

Findings:

During a tour of the facility with the Maintenance Supervisor and staff on 9/17/13, the designated smoking area for employees and patients were observed.

1. At 9:27 a.m., the designated smoking area for employees did not have a container for the disposal of cigarette butts and ashes. The container that was used for the disposal of the cigarette butts and ashes was also use for the disposal of trash. There was no metal container or ashtray of safe design in the smoking area.

2. At 9:34 a.m. the designated smoking area for patients did not have a metal container or ashtray of safe design for the disposal of cigarette butts and ashes. During interview, the maintenance supervisor stated he did not know what happen to the metal container that was supposed to be in the smoking area.

Based on observation, document review and interview, the facility failed to maintain the kitchen hood exhaust in accordance with NFPA 96, as evidenced by grease and dirt inside the kitchen hood exhaust and by no documentation for the cleaning of the kitchen hood by a certified company. This could result in the increase risk of a grease fire and affected patients, staff and visitors in 1 of 5 smoke compartments.

NFPA 96, 1998 Edition
Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations8-3 Cleaning.
8-3.1 Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or
person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1
Table 8-3.1 Exhaust System Inspection Schedule
Type or Volume of Cooking Frequency Frequency
Systems serving solid fuel cooking operations Monthly
Systems serving high-volume cooking operations such as Quarterly
24 hour cooking, charbroiling or wok cooking
Systems serving moderate-volume cooking operations Semiannually
Systems serving low-volume cooking operations, such as Annually
churches, day camps, seasonal businesses, or senior centers

Findings:

During document review, interview and a tour of the facility with the Maintenance Supervisor and staff on 9/16/13 and 9/17/13, the records for the cleaning of the kitchen hood was requested.

1. At 4:03 p.m., on 9/16/13, the facility failed to provide documentation for the cleaning of the kitchen hood. During an interview, maintenance stated the hood is cleaned by dietary staff and stated the hood is not cleaned by a licensed vendor.

2. At 10:48 a.m., on 9/17/13, during a tour of the facility kitchen the hood above the cooking area was observed to have grease and dirt in the hood. A small portion at the bottom of the hood was clean. During an interview, the Dietary supervisor stated dietary staff tries to clean as best possible, but can only reach so far up in the hood.

Based on observation, the facility failed to maintain the electrical safety, as evidenced by electrical panels that were missing blank covers. This failure could result in the potential spread of an electrical fire and affected patients, staff and visitors in 2 of 5 smoke compartments.

NFPA 70, National Electrical Code (1999 Edition), article 373-4. Unused Openings. Unused openings in enclosures within the scope of this article shall be effectively closed to afford protection substantially equivalent to that of the enclosures within the scope of this article. Where metal plugs or plates are used with nonmetallic cabinets or cutout boxes, they shall be recessed at least ? in. (6.35 mm) from the outer surface.

Findings:

During a tour of the facility with the maintenance supervisor and staff on 9/16/13 through 9/18/13, the electrical wiring and equipment was observed.

1. At 10:01 a.m., on 9/17/13, electrical panel "AA" located in Med Surge was missing blank covers for space 39 and 41.

2. At 10:09 a.m., on 9/17/13, electrical panel "CD" located in the OB department was missing a blank cover for space 23.