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Based on observation and interview it was determined the facility failed to ensure the kitchen hood fire suppression system was maintained in accordance with NFPA (National Fire Protection Association) standards. The deficiency had the potential to affect all staff and other occupants of the building.

The findings include:

A Life Safety Code tour conducted on 01/22/18 at 1:25 PM with Maintenance personnel revealed the cooking range was not protected by fire extinguishing nozzles as required.

An interview with Maintenance personnel on 01/22/18 at 1:25 PM revealed the cooking range had been moved and was no longer positioned to be protected by the fire extinguishing nozzles.

The findings were revealed to the Chief Nursing Officer at exit.

Reference: NFPA 96 (2011 Edition).

12.1.2.2* Cooking appliances requiring protection shall not be moved, modified, or rearranged without prior re-evaluation of the fire-extinguishing system by the system installer or servicing agent, unless otherwise allowed by the design of the fire extinguishing system.

Based on observation and interview, it was determined the facility failed to ensure that the cross corridor fire/smoke barrier doors were maintained according to National Fire Protection Association (NFPA) standards. This deficiency had the potential to affect patients, staff, and other occupants of the building.

The findings include:

During the Life Safety Code tour on 01/22/18 at 12:20 PM with Maintenance staff, observation revealed three (3) sets of cross corridor fire/smoke barrier doors located in the Lab/Office area that had an excessive gap when closed. These doors must properly seal to help prevent fire/smoke from spreading to other parts of the building in case of a fire situation.

An interview with Maintenance staff on 01/22/18 at 12:20 PM revealed the gaps were approximately 3/8 to 5/8 inch in width.

The findings were revealed to the Chief Nursing Officer (CNO) at exit.

Reference: NFPA 101 (2012 Edition).

19.3.7.8* Doors in smoke barriers shall comply with 8.5.4 and all of the following:
(1) The doors shall be self-closing or automatic-closing in accordance with 19.2.2.2.7.
(2) Latching hardware shall not be required
(3) The doors shall not be required to swing in the direction of egress travel.

8.5.4.1* Doors in smoke barriers shall close the opening, leaving only the minimum clearance necessary for proper operation, and shall be without louvers or grilles. The clearance under the bottom of a new door shall be a maximum of 3/4 in. (19 mm).

Based on an interview and record review it was determined the facility failed to ensure there was a maintenance and testing program schedule for the Piped in Gas and Vacuum System in accordance with National Fire Protection Association (NFPA) standards. The deficiency had the potential to affect patients, staff, and other occupants of the building.

The findings include:

During the Life Safety Code survey on 01/22/18 at 2:55 PM an interview and record review with Maintenance revealed there was not a maintenance or testing schedule associated with the facility's Piped in Gas and Vacuum System. This system must be properly maintained to perform as intended.

The findings were revealed to the Chief Nursing Officer at exit.

Reference: NFPA 99 (2012 Edition).

5.1.14.2.3 Inspection and Testing Operations.
5.1.14.2.3.1 General. The elements in 5.1.14.2.2.2 through 5.1.15 shall be inspected or tested as part of the maintenance program as follows:
(1) *Medical air source, as follows:
(a) Room temperature
(b) Shaft seal condition
(c) Filter condition
(d) Presence of hydrocarbons
(e) Room ventilation
(f) Water quality, if so equipped
(g) Intake location
(h) Carbon monoxide monitor calibration
(i) Air purity
(j) Dew point
GAS AND VACUUM SYSTEMS 99-55
(2) *Medical vacuum source - exhaust location
(3) WAGD source - exhaust location
(4) *Instrument air source - filter condition
(5) *Manifold sources (including systems complying with 5.1.3.5.10, 5.1.3.5.11, 5.1.3.5.12, and 5.1.3.5.13), as follows:
(a) Ventilation
(b) Enclosure labeling
(6) Bulk cryogenic liquid source inspected in accordance with NFPA 55, Compressed Gases and Cryogenic Fluids Code
(7) Final line regulation for all positive pressure systems - delivery pressure
(8) *Valves - labeling
(9) *Alarms and warning systems-lamp and audio operation
(10) Alarms and warning systems, as follows:
(a) Master alarm signal operation
(b) Area alarm signal operation
(c) Local alarm signal operation
(11) *Station outlets/inlets, as follows:
(a) Flow
(b) Labeling
(c) Latching/delatching
(d) Leaks

Based on an interview and record review it was determined the facility failed to maintain the emergency generator standards set by the NFPA (National Fire Protection Association). This deficient practice has the potential to affect patients, staff, and other occupants of the building.

The findings include:

During the life safety code tour on 01/22/18 at 2:40 PM, an interview with Maintenance revealed the facility had three (3) outside diesel-powered generator sets that routinely received a full load test once a year. However, record review revealed the generators were last load tested on 07/15/16.

An interview with Maintenance on 01/22/18 at 2:40 PM revealed the facility lacked the funds to properly test the generators.

The findings were revealed to the Chief Nursing Officer at exit.

Reference: NFPA 110 (2010 Edition).

8.4.2* Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
(2) Under operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating

8.4.2.3 Diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours.

Based on observation and interview, it was determined the facility failed to ensure that the electrical wiring and standards met NFPA (National Fire Protection Association) requirements. This deficient practice had the potential to affect patients, staff, and other occupants of the building.

The findings include:

During the Life Safety Code tour on 01/22/18 at 11:55 AM with Maintenance, three (3) extension cords were observed to be running through the drop ceiling in the Information Technology (IT) storage area. Two (2) of the cords were observed to power a battery charger and sump pump. It could not be determined what the third extension cord may have been powering. Extension cords may not be used as a substitute for required permanent wiring.

An interview with Maintenance on 01/22/18 at 11:55 AM revealed he was not aware extension cords could not be used for permanent wiring.

The findings were revealed to the Chief Nursing Officer at exit.

Reference: NFPA 70 (2011 Edition).

400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B)
(5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
(6) Where installed in raceways, except as otherwise permitted in this Code
(7) Where subject to physical damage