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Based on observation and interview the facility failed to ensure illumination at exit discharge was arranged in accordance with NFPA 101, 2012 Edition, Chapter 7.8 and Chapter 19.2.8 as required.

Findings:

On 06/08/17 at 1:40 pm each of the designated exit discharges from the facility were observed to have lighting fixtures on normal power. The director of maintenance was asked if the exit discharge lighting would always illuminate when the emergency generator came on and there was no normal electrical power. The director of maintenance stated the exit discharge lights are on a timer and would only come on for the given timeframes they are programmed for. The director of maintenance was asked if the installed timer would be overriden when the emergency generator came on so the electrical lighting fixtures at each exit discharge would be under emergency power and he stated no.

Based on observation and interview the facility failed to proctect hazardous area with self-closing hardware as required and failed to ensure fire wall barriers did not have penetrations and terminated at the roof deck as required per NFPA 101, 2012 Edition, Chapter 19.3.2.1.

Findings:

On 06/07/17 at 3:32 pm a hazardous room with x-ray folders and patient x-ray records was observed to not have a self-closer on the door leading into the area. The radiology manager stated he could add the self-closing hardware.

On 06/08/17 at 12:06 pm the hazardous area room housing the emergency generator was observed to have one wall which did not terminate to the roof deck. The surveyor was standing in the conferance room and could see into the hazardous area room housing the generator. The maintenance manager stated he did not know why the walls did not go to the roof deck. The surveyor explained to the maintenance manager the generator room is a hazardous area and needs its walls to terminate to the roof deck to protect the rest of the building from fire/smoke from the area. The maintenance manager stated he understood.

Based on observation and interview the facility failed to ensure alcohol based hand rub dispensers (ABHR) were not installed over ignition sources as required.

Findings:

On 06/08/17 at 10:25 am the surveyor observed two ABHR dispensers installed over a light switch in rooms #209 and #210. The director of maintenance stated he would remove the dispensers.

Based on observation, interview and record review the facility failed to maintain their sprinkler system in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems as required.

Findings:

On 06/08/17 at 3:04 pm the surveyor observed the fire sprinkler system to be yellow tagged by the P&L company on 02/17/17. The following impairments were identified in the P&L inspection report: sprinkler heads too close to each other in business office, improper coverage in medical records air handler closet, replace 30 corroded fire sprinkler heads in kitchen, dietary hall, nurse break room and emergency room area, upstairs shower, hall by administration, replace dry sidewall with wet head in generator room and emergency room entrance, replace piece of fire sprinkler pipe with clamp on it in central supply. The director of maintenance was asked if the work has been completed which was outlined on the P&L inspection report and he stated they are having a hard time getting the P&L vendor to schedule the repairs.

Based on observation and interview the facility failed to ensure corridor doors were not equipped with prohibited roller latches.

Findings:

On 06/08/17 at 10:50 am one roller latch was observed to be installed on the bathroom door located in the x-ray department. The director of maintenance stated he would remove the prohibited roller latch.

Based on observation and interview the facility failed to provide smoke barriers constructed to provide at least a one-half hour fire resistance rating as required.

Findings:

On 06/08/17 at 11:53 am the surveyor observed four penetrations of the smoke barrier wall located on the second floor north hallway. The director of maintenance stated he would get the penetrations fixed.

Based on observation, record review and interview the facility failed to provide electrical wiring and equipment which complied with the NFPA 70, National Electric Code as required.

Findings:

On 06/07/17 at 11:15 am during record review the eletrical impedance testing of patient care area eletrical receptacles was not completed.

On 06/08/17 at 11:30 am the surveyor observed four penetrations in the fire wall and open junction boxes located on the 2nd floor north hall. The director of maintenance stated he saw the four penetrations and open junction box. He stated he would get them fixed.

On 06/08/17 at 12:03 pm the surveyor observed two medication refrigerators located in the pharmacy that had out of date inspection stickers.

On 06/08/17 at 12:15 pm the surveyor observed an in use six receptacle multiplug in the laboratory.

On 06/08/17 at 4:27 pm the surveyor observed a refrigerator and microwave daisy chained into a extension cord in the business office.

On 06/08/17 at 4:40 pm a refrigerator was observed to be daisy chained into an extension cord in the medical records office.

On 06/08/17 at 4:45 pm the electrical receptacles were observed within six feet of a water source in the laboratory and they were not GFCI recptacles.

On 06/08/17 at 4:47 pm a whirpool tank was observed to be plugged into a non-GCFI eletrical receptacle located in the whirpool room.

Based on record review and interview the facilty failed to properly complete fire drills that the transmission of a trouble signal was verified with the monitoring vendor as required.

Findings:

On 06/07/17 at 11:17 am record review of facility fire drills showed there was no documentation indicating the fire drills included the transmission of a fire alarm signal as required. The director of maintenance was asked to describe the process for their fire drills. He stated they put their system into test mode by calling the monitoring company and then call the monitoring company when they are done to place their system back into active mode.

Based on observation and interview the facility failed to ensure in service portable space heater elements did not exceed 212 degrees Fahrenheit as required.

Findings:

On 06/08/17 at 4:35 pm a portable space heater was observed in the infection control manager's office. The director of maintenance was asked for the manufactures documentation indicating the heating element did not exceed 212 degrees Fahrenhiet but failed to provide it.

On 06/08/17 at 4:35 pm the director of maintenance stated the space heater from the infection control office would be removed.

Based on record review and interview the facility failed to ensure the building systems risk assessments are completed as required for their essential electrical system as required.

Findings:

On 06/07/17 at 11:00 am during record review the administrator was asked for their building systems risk assessments. She directed the surveyor to the director of maintenance for the information. The director of maintenance failed to provide the documentation for the essential electrical system risk assessment.

Based on record review and interview the facility failed to ensure completing building systems risk assessments for their medical gas system as required.

Findings:

On 06/07/17 at 11:00 am during record review the administrator was asked for their building systems risk assessment for their medical gas systems. She directed the surveyor to the director of maintenance for that information. The director of maintenance failed to provide the building systems risk assessment for their medical gas system.

Based on observation and interview the facility failed to ensure counter top electrical receptacles within 6 feet of a water source were GFCI as required.

Findings:

On 02/08/17 at 4:30 pm it was observed that the second floor medicine room had a counter top electrical receptacle was within 6 feet of a countertop operational sink and was not GFCI. The director of plant operations stated he would have the non-GFCI receptacle replaced with a GFCI receptacle.

Based on record review and interview the facility failed to ensure the facility's building system risk assessments for their essential electric system (EES) as required.

Findings:

On 02/08/17 at 4:17 pm during record review the administrator was asked for their building systems risk assessment for their essential electrical systems. The administrator directed the surveyor to speak with the director of maintenance for that information. The director of maintenance failed to provide the building systems EES risk assessment.

Based on observation and interview the facility failed to ensure a battery-powered emergency light was installed in the generator room and that the generator remote annunciator panel was installed in a location which is regularly monitored by staff as required.

Findings:

On 06/08/17 at 12:22 pm the surveyor asked the director of maintenance where the remote annunciator panel was installed and if staff monitored the panel around the clock. The director of maintenance stated a remote annunciator panel was not installed where it can be monitored by staff around the clock. The surveyor did not observe a generator annunciator panel installed within the facility.

On 06/08/17 at 12:24 pm The surveyor observed no battery powered back up lighting in the generator room. The director of maintenance stated the generator is located indoors with no battery-powered emergency light in the generator room with a flashlight for back-up.