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Based on observation and interview, the provider failed to provide egress doors as required (exit door by the CT room). Findings include:

1. Observation at 10:30 a.m. on 7/18/17 revealed the exit door in the corridor adjacent to the CT room was equipped with electrical lock hardware (magnetic lock) that prevents egress. The door did not have a manual release device located on the egress side 40 to 48 inches above the floor and within 60 inches of the secured door opening. The release needed to be labeled "push to exit" and interrupted power independent of the locking system electronics where the lock remained unlocked for a minimum of 30 seconds as required.

The maintenance manager was present when the deficiency was identified.

Failure to provide egress doors as required would increase the risk of death or injury due to fire.

The deficiency affected one of numerous corridor doors.

Ref: 2012 NFPA 101 Section 19.2.2.2.4(3), 7.2.1.6.2(3)(a)

Based on observation and interview, the provider failed to install a paved path of exit discharge to the public way at one of six ground floor exits (exit discharge adjacent to room 113 the maintenance office). Findings include:

1. Observation at 11:30 a.m. on 7/18/17 revealed the exit discharge adjacent to room 113 the maintenance office had a landing that ended approximately 65 feet from the nearest packed drive. Interview with the maintenance manager at the time of the observation confirmed that finding. He stated that condition had existed for many years.

The deficiency had the potential to affect all occupants in that smoke compartment.

Ref: 2000 NFPA 101 Section 19.2, 7.2.1.6.2

Based on observation, interview, and record review, the provider failed to install emergency lighting for exit discharge at five of five exterior exits. Findings include:

1. Observation beginning at 11:30 a.m. on 7/18/17 revealed the five exterior exit discharges were equipped with exterior lighitng. The lights were not battery pack lights. Interview with the maintenance manager revealed he did not know if the exterior lights were on the emergency circuit from the generator. Document review at 3:00 p.m. on 7/18/17 did not say whether or not the exterior lights were on the emergency circuit.

The deficiency had the potential to affect all occupants of the building.

Based on observation and interview, the provider failed to maintain emergency lighting for three of three randomly observed battery pack emergency light locations (x-ray, nursees station to the main entrance, and the generator room). Findings include:

1. Observation at 11:00 a.m. on 7/18/17 revealed the battery pack light in x-ray was not working.

2. Observation at 11:15 a.m. on 7/18/17 revealed the battery pack light from the nurses station to the main entrance was not working.

3. Observation at 11:45 a.m. on 7/18/17 revealed the battery pack light in the generator room was not working.

4. Interview with the maintenance manager at the times of the above observations confirmed those findings.

The deficiency affected one of numerous requirements for the emergency lighting system.

Based on observation and interview, the provider failed to maintain two separate hazardous areas (housekeeping storage room and linen storage) as required. Findings include:

1. Observation at 11:25 a.m. on 7/18/17 revealed the housekeeping storage room was over 100 square feet, was not equipped with automatic fire sprinkler protection, and contained combustible items. The housekeeping storage room corridor door was not equipped with a label indicating a fire-resistance of at least forty-five minutes.

2. Observation at 4:00 p.m. on 7/18/17 revealed the linen storage room was over 100 square feet and contained combustible items. The two corridor doors were equipped with closers that were disconnected and were not self-closing.

3. Interview with the maintenance manager at the times of the above observations confirmed those findings.

The deficiency affected two of numerous requirements for hazardous storage rooms.

Based on record review and interview, the provider failed to test the fire alarm system as required during the annual fire alarm inspection. Findings include:

1. Record review at 2:15 p.m. on 7/18/17 revealed the annual fire alarm report dated 8/17/16 had device test results summarized (alarm initiating, supervisory alarm initiating, and notification) for test results. An itemized list with the following information: device type, address, location, and test result as required was not documented.

The maintenance manager was present when the deficiency was identified. He stated he was unaware the fire alarm report provided did not provide the required information.

The deficiency affects all notification and detection devices of the fire alarm system.

Ref: 2012 NFPA 101 Section 19.3.4.1, 9.6.1.5; 2010 NFPA 72 Section 14.6.2.4, Figure 14.6.2.4 Section 7.12-7.14 and page 11 of 11

Based on observation and interview, the provider failed to ensure one randomly observed corridor door (old emergency room) was free from impediments to closing the door. Findings include:

1. Observation at 10:15 a.m. on 7/18/17 revealed the corridor door for the old emergency room was held open with a floor scale.

Interview with the maintenance manager at the time of the observation confirmed that finding. He stated he was unaware the door could not be held open in that manner.

The deficiency could affect 100% of the occupants of the smoke compartment.

Based on observation and interview, the provider failed to maintain the fire-resistive design of one of one randomly observed room (generator room) by installing a transfer grill in the one-hour fire-rated wall of the generator room. Findings include:

1. Observation at 11:45 a.m. on 7/18/17 revealed the one-hour fire-rated wall of the generator room was equipped with an air transfer grill above the lay-in ceiling in the corridor. The transfer grill was equipped with a fusible-link damper. Transfer grilles regardless of whether they are protected by fusible link-operated dampers shall not be used in corridor walls or doors.

Interview with the maintenance manager at the time of the above observation confirmed that finding.

The deficiency could affect 100% of the occupants of the smoke compartment for that exit corridor.

Based on observation and interview, the facility failed to conduct fire drills for the hospital as required for the previous twelve months (July 2016 through June 2017). Findings include:

1. Document review at 3:30 p.m. on 7/18/17 revealed fire drills were not conducted as required in the past twelve month period as noted below. Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills were required to be conducted at a minimum of quarterly on each shift (this was a two shift staff coverage facility). Fire drills should have been scheduled on a random basis to ensure personnel were drilled not less than once in each three month period.

Record review revealed the following:
Drills documented:
*Third quarter 2016:
-July 2016: 7/21/16 (day).
-August 2016: Not applicable.
-September 2016: 9/30/16 (night/silent).

*Fourth quarter 2016:
-October 2016: 10/10/16 (day).
-November 2016: Not applicable.
-December 2016: 12/15/16 (night).

*First quarter 2017:
-January 2017: 1/12/17 (day).
-February 2017: Not applicable.
-March 2017: 3/01/17 (night/silent).

*Second quarter 2017:
-April 2017: Not applicable.
-May 2017: (day-no alarm; night/silent).
-June 2017: Not applicable.

Fire drills that did not have documentation of the transmission of the fire alarm signal to the monitoring agency were: 9/30/16, 12/15/16, 3/01/17, 5/13/17, and 5/30/17.

The maintenance manager was present when the deficiency was identified. He stated he was unaware the alarm signal transmission needed to be conducted and verified.

Failure to conduct fire drills as required increases the risk of death or injury due to fire.

The deficiency affected five of eight required drills in the past twelve months.

Ref: 2012 NFPA 101 Section 19.7.1.6

Based on observation and interview, the provider failed to prevent the use of portable space heaters in non-employee areas (main entrance vestibule) as required. Findings include:

1. Observation at 3:15 p.m. on 7/18/17 revealed a portable space heater situated in the vestibule of the main hospital entrance. Interview with the maintenance manager at the time of the observation confirmed that finding. He stated the space heater had been placed in use during inclement winter weather as a temporary fix for keeping the vestibule warm.

The deficiency could affect 100% of the occupants of that smoke compartment.

Based on observation and interview, the provider failed to maintain electrical equipment in accordance with National Fire Protection Association (NFPA) 70 (open junction box in the oxygen room). Findings include:

1. Observation at 10:30 a.m. on 7/18/17 revealed an open electrical junction box (no cover plate) on the ceiling of the oxygen manifold room.

Interview with the maintenance manager at the time of the above observation confirmed that finding. He stated he did not know what purpose the electrical junction box and wiring served.

The deficiency affected one of numerous electrical installation/maintenance requirements.

Based on observation, testing, and interview, the provider failed to perform adequate required testing for the generator and transfer switch. Findings include:

1. Observation beginning at 3:00 p.m. on 7/18/17 revealed a single generator to provide emergency electrical service for three separate buildings (nursing home, multi-purpose building, and the hospital). The transfer switch for the nursing home was located in the nursing home boiler room; the transfer switch for the multi-purpose building was located in the generator room; and the transfer switch for the hospital was located in the hospital boiler room. The maintenance manager initiated a generator run at 3:10 p.m. using the start button on the generator (no load was on the generator). Interview with the maintenance manager at the time of the observation revealed all generator starts (weekly runs for maintenance testing) including 'load' tests were done that way. He revealed he did not utilize the transfer switches to load test the generator monthly. He would log the hour meter readings for the generator after each monthly 'load' test.

Interview with the maintenance manager at the times of the observations confirmed those findings.

The deficiency affected several requirements for maintenance and testing of the essential electrical system.

Based on observation and interview, the provider failed to secure individual compressed oxygen cylinders while in storage (two cylinders in oxygen manifold room). Findings include:

1. Observation at 10:30 a.m. on 7/18/17 revealed two unsecured compressed oxygen e cylinders standing on the concrete floor of the oxygen manifold room. There were two open slots for cylinder storage in the rack. Interview with the maintenance manager at the above time confirmed that finding. He revealed he did not know who put the cylinders in the room, and why they were not placed in the rack. He also commented there was no distinction between empty and full cylinders kept in the storage room.

The deficiency affected one of numerous requirements for oxygen cylinder storage.