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Based on observation, the facility failed to maintain the integrity of their building construction, as evidenced by unsealed penetrations in two walls. This affected 1 of 2 smoke compartments and could result in the spread of smoke or fire to other locations in the facility.

Findings:

During a tour of the facility with the Plant Operations Manager, Administrator, and Maintenance Staff, on May 2, 2012, the building construction was observed.

At 1:38 p.m., there was an approximately 1 inch unsealed opening around a 3 inch pipe in the wall in the Information Technology Room, south wall. The Plant Operations Manager, Maintenance Staff, and Administrator confirmed there was a penetration around the pipe.

At 4:12 p.m., there was an approximately 3 inch by 3 inch penetration below the clock in the business office south wall. The Maintenance Staff confirmed the finding.

Based on observation, the facility failed to display exits signs in all exit pathways, as evidenced by no sign displayed in 2 of 4 areas. This could delay evacuation from 1 of 2 smoke compartments and cause potential harm to patients and staff in the event of a fire emergency.

Findings:

During a tour of the facility with the Plant Operations Supervisor and Maintenance Staff, on May 2, 2012, the exit paths and exit signs were observed.

At 12:51 p.m., there was no exit sign to indicate the exit direction in the North corridor near Room 4. The Plant Operations Manager and Maintenance Staff acknowledged that this was an exit path with no exit sign.

At 3:45 p.m., there was no exit sign to indicate the exit direction above the smoke barrier doors near the activity office. The Plant Operations Manager and Maintenance Staff acknowledged that this was an exit path with no exit sign.

Based on observation, the facility failed to maintain the integrity of its smoke barrier walls in accordance with 8.3.6.1. This was evidenced by penetrations in one smoke barrier wall. This could result in a reduction in the ability to protect in place and increase the risk of injury to patients due to smoke and fire. This affected 2 of 2 smoke compartments.

Findings:

During a tour of the facility with the Plant Operations Manager on May 3, 2012, the smoke barrier walls were observed.

At 8:45 a.m., there were two unsealed penetrations in the smoke barrier wall near the Jacuzzi Room. There was an approximately 3 inch round pipe sleeve around a 1 inch conduit on the right side of the wall. The pipe was unsealed. This revealed an approximately 2 inch unsealed opening inside of 6 inch pipe sleeve.
There was an approximately 2 inch penetration inside a 4 inch pipe on the left. The Plant Operations Manager observed and confirmed the penetrations.

Based on observation, the facility failed to ensure that the smoke barrier doors could protect against fire for a minimum of 20 minutes, as evidenced by a penetration in one door frame. This affected 1 of 2 smoke compartments and could change the fire rating of the door.

Findings:

The smoke barrier doors and frames were observed during a tour of the facility, with the Plant Operations Manager and Maintenance Staff, on May 2, 2012.

At 3:43 p.m., there was an approximately 2 inch penetration in the top portion of the smoke barrier door frame, near the Activity Office. The Plant Operations Manager and Maintenance Staff acknowledged the finding.

Based on observation and interview, the facility failed to protect its hazardous area enclosures. This was evidenced by one hazardous area with no self closing door. This affected 1 of 2 smoke compartments within the facility, and could result in the spread of smoke and fire.

Findings:

During a tour of the facility with the Plant Operations Manager, Maintenance Staff, and Administrator, on May 2, 2012, the hazardous area enclosures were observed. Hazardous areas are areas used for combustible storage greater than 50 square feet in size.

At 1:32 p.m., the corridor door to Medical Records failed to have a self-closing mechanism on it. The room was over 50 square feet and contained over 100 paper medical record files and several cardboard boxes. The Plant Operations Manager, Maintenance Staff, and Administrator acknowledged the room contained quantities of combustibles.

Based on observation and interview, the facility failed to maintain their exit signs. This was evidenced by an exit that failed to fully illuminate. This affected 1 of 2 smoke compartments and could result in a delay in evacuation.

Findings:

During a facility tour with the Plant Operations Manager and Maintenance Staff, on May 2, 2012, the facility exit signs were observed.

At 12:42 p.m., the exit sign near the DON office was not fully illuminated. The light bulb on the left side of the sign was not working. The Plant Operations Manager and Maintenance Staff confirmed the light bulb was burnt out in the exit sign.

Based on document review and interview, the facility failed to maintain complete records for 3 of 12 fire drills. This was evidenced by fire drill records with incomplete drill information. This affected 2 of 2 smoke compartments, and could result in a delay in staff response in the event of a fire.

Findings:

During document review with the Plant Operations Manager on May 2, 2012, the fire drill records were reviewed.

At 1:43 p.m., three fire drill records failed to provide information for the time of the drill, a list of participants, location of the fire, and indication of activity under sections 1, 2, and 3. There was no verification confirming activation of the fire alarm during the drill. The three drills were dated January 9, 2012, September 7, 2011 and September 8, 2011.

At 1:47 p.m., the Plant Operation Manager was interviewed. When asked for details for the fire drills, he stated "we did the fire drill but failed to complete the paperwork."

Based on observation, the facility failed to maintain their sprinkler system in accordance with NFPA 13. This was evidenced by a sprinkler that was obstructed by a light fixture. This could result in a delay in the development of the spray pattern and a delay in extinguishing a fire. This affected 1 of 2 smoke compartments.

NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition
5-5.5.3* Obstructions that Prevent Sprinkler Discharge from Reaching the Hazard. Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. (457 mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 5-5.5.3.

Findings:

During a tour of the facility with the Plant Operations Manager, Maintenance Staff, and Administrator, on May 2, 2012, the sprinkler system was examined.

At 1:10 p.m., there was a light fixture mounted approximately 1 inch away from a sprinkler in Medication Room 1. The fixture was protruding in front of the the sprinkler approximately 4 inches.

The Plant Operations Manager confirmed the sprinkler was obstructed.

Based on document review, and interview, the facility failed to maintain and test the fire sprinkler system in accordance with NFPA 25. This was evidenced by incomplete records for quarterly sprinkler testing for three of four quarters in 2011. This could result in a failure of the sprinkler system and cause potential harm to patients and staff in the event of a fire. This affected 2 of 2 smoke compartments.

NFPA 25 Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (1998 Edition)
1-8 Records. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.

2-1 General. This chapter provides the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems. Table 2-1 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.

Exception: Valves and fire department connections shall be inspected, tested, and maintained in accordance with Chapter 9.

2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.

9-5.1.1 All valves shall be inspected quarterly. The inspection shall verify that the valves are in the following condition:
(a) In the open position
(b) Not leaking
(c) Maintaining downstream pressures in accordance with the design criteria
(d) In good condition, with handwheels installed and unbroken


Findings:

During document review with the Plant Operations Manager on May 2, 2012, the facility sprinkler system inspection reports were reviewed and a staff member was interviewed.

At 2:10 p.m., the facility provided a test log for the sprinkler system. The record for 2011 documented a test was performed on October 28, 2011, by ABC Fire. There were no other records for quarterly testing provided by the facility.

At 2:12 p.m., the Plant Operations Manager was interviewed and stated "we check the sprinkler system quarterly but haven't logged it." The Plant Operations Manager acknowledged the finding. He stated the vendor completes the annual inspection and test.

Based on observation and interview, the facility failed to maintain the portable fire extinguishers in accordance with NFPA 10. This was evidenced by an unsecured fire extinguisher and by a fire extinguisher that was not inspected. This affected 1 of 2 smoke compartments and had the potential to result in the failure of the extinguisher, or harm to patients if the extinguisher tipped over.

NFPA 10 Standard for Portable Fire Extinguishers (1998 Edition),
1.5.7 Portable fire extinguishers other than wheeled extinguisher shall be installed securely on the hanger, or in the bracket supplied by the extinguisher manufacturer, or in a listed bracket approved for such purpose, or placed in cabinets or wall recesses. Wheeled fire extinguishers shall be located in a designated location.
1.5.8 Fire extinguishers installed under conditions where they are subject to dislodgement shall be installed in manufacturer's strap-type brackets specifically designed to cope with this problem.
1.5.9 Fire extinguishers installed under conditions where they are subject to physical damage, (e.g., from impact, vibration, the environment ) shall be adequately protected.

4-3.1 Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire Extinguishers shall be inspected at more frequent intervals when circumstances require.
4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.
4-3.4.3 Records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or in an electronic system (e.g., bar coding) that provides a permanent record.

Findings:

During the facility tour with the Plant Operations Manager, Maintenance Staff, and Administrator on May 2, 2012, the fire extinguishers were observed.

At 1:18 p.m., the fire extinguisher in the Boiler Room was unsecured and sitting on the floor.

At 1:34 p.m., the label, attached to the fire extinguisher in the Business Office, was not signed for the month of April 2012. The Plant Operations Manager and Administrator observed the tag was not signed for the month of April 2012.

Based on observation, the facility failed to maintain their oxygen storage area, as evidenced by no precautionary sign on the door to the storage area. This affected 2 of 2 smoke compartments and had the potential to increase the risk of fire.

NFPA 99 Standard for Health Care Facilities (1999 Edition)
8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:
CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

Findings:

During the facility tour with the Administrator on May 3, 2012, the facility oxygen storage areas were observed.

At 8:04 a.m., there was no sign posted with the minimum required wording, on the door to the oxygen storage area that was identified as Dirty Utility. The room contained 18 e-type cylinders. The Administrator confirmed the oxygen was stored in the room and that there was no sign on the door.

Based on record review and interview, the facility failed to maintain their emergency generator, as evidenced by incomplete records for inspecting the generator on a weekly basis, and exercising their emergency generator for the minimum 30 minutes for eight of 12 months. This affected all patients and could result in a malfunction of the emergency generator during a power outage.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition
6-3.4 A written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises. The written record shall include the following:
(a) The date of the maintenance report
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer
6-4.1 Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
6-4.2 Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

Findings:

During record review on May 2, 2012, with the Plant Operations Manager, the emergency generator test records were reviewed and a staff member was interviewed.

At 2:17 p.m., the weekly inspection log listed the dates the generator was inspected. According to the logs the generator was inspected monthly until April 2012. The generator was inspected on the following dates: 10/31/11, 11/24/11, 12/21/11, 1/23/12, 2/13/12, 3/20/12, 4/16/12, 4/23/12, and 4/30/12. No other records were provided to indicate the facility conducted weekly inspections.

At 2:53 p.m., the monthly full load test log book listed the dates for generator 30 minute testing. The last completed "Generator Test Log" date was on August 16, 2011. There were no other records for monthly testing under load.

During an interview at 2:53 p.m., the Plant Operations Manager stated "we have conducted the tests but we did not log it."

Based on document review, interview and observation, the facility failed to maintain the electrical equipment and utilities. This was evidenced by incomplete records for receptacle tension and polarity testing, by an unlabeled circuit in an electrical panel, and by an uncovered electrical outlet. This affected 1 of 2 smoke compartments, and could result in an electrical fire.

NFPA 70 National Electrical Code, (1999 Edition)
384-13. General. All panelboards shall have a rating not less than the minimum feeder capacity required for the load computed in accordance with Article 220. Panelboards shall be durably marked by the manufacturer with the voltage and the current rating and the number of phases for which they are designed and with the manufacturer's name or trademark in such a manner so as to be visible after installation, without disturbing the interior parts or wiring. All panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or board.

370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

NFPA 99 Health Care Facilities Code, 1999 edition
3-3.3.3 Receptacle Testing in Patient Care Areas.
(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).
3-3.4.2.3(a) Testing Interval for Receptacles in Patient Care Areas.
1. Testing shall be performed after initial installation, replacement, or servicing of the device.
2. Additional testing shall be performed at intervals defined by documented performance data.
Exception: Receptacles not listed as hospital-grade shall be tested at intervals not exceeding 12 months.
3-3.4.3.1 A record shall be maintained of the tests required by this chapter and associated repairs or modification. At a minimum, this record shall contain the date, the rooms or areas tested, and an indication of which items have met or have failed to meet the performance requirements of this chapter.

Findings:

During document review and a facility tour with the Plant Operations Manager, Maintenance Staff, and Administrator on May 2, 2012, the electrical equipment and wiring were observed.

At 1:02 p.m., in electrical Panel "A," near the Drug Room, 3 of 40 circuits were unlabeled and in the on position. Circuits 26, 27, and 28, were unidentified. The Plant Operations Manager stated during a concurrent interview, "I don't know what those circuits are connected to."

At 1:12 p.m., an electrical outlet was missing a cover plate in the Employee Health Office. The Plant Operations Manager and Administrator confirmed the finding.

At 3:01 p.m., the facility provided a log book titled Receptacle Testing. There were approximately 50 pages of receptacle testing logs that were unmarked and left blank. The Plant Operations Manger stated during a concurrent interview "we have done the testing but did not log it in the book".