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Based on surveyor observation and staff interview, the facility failed to provide proper heating, ventilating and air conditioning systems (HVAC) throughout the hospital.

Findings:

a) Pre air filter racks on roof top unit (RTU) 5 were not being used or maintained. Filters were out of the racks allowing dirt and other items to clog up the cooling and heating coils.

b) Thirteen exhaust fans were installed on the roof; twelve fans were not functioning. The motors were burnt out and the fan belts were broken.

c) HVAC units in the mechanical rooms serving patient rooms were located over the patient wings on both sides of the facility. The HEPA filters installed was dated 06 /14 2001, these filters had not been replaced since original construction. On the afternoon of 04/21/2015, Staff Y indicated that he did not know if the filters had ever been replaced.

d) RTU #5's cooling coil was frozen at 2:30 p.m. on 04/21/2015. Staff Y was unaware of the problem.

e) Rooms 101 A, 101 C, 102 A, 102 C, 103, the common areas of 100 and 103, half of room 103 A and 103 C, had air supply diffusers that had been closed off. On the afternoon of 04/21/2015, Staff Y was asked why they were shut, however no answer was given. With these air grills shut and exhaust fans not working, there was no air exchange provided to the patient rooms.

d) Test and Balance Report assure that air exchanges in patient areas met minimum standards was not available or had been completed.

f) The construction Type of the building is Type V (111) meaning that the building requires the sheet rock to protect the unprotected steel frame, however wood construction was also found. Dampers are required and installed to protect every opening. There was no documentation the dampers had been tested and exercised.

g) The annual fire alarm report did not contain documentation the combination Fire and Smoke Dampers had been tested.

Based on observation and interview with staff, the facility failed to have a preventive maintenance program for all equipment in accordance with NFPA 99 1999 edition chapter 7-6.2.2.2.

Findings:

a) Scheduled preventive maintenance was not conducted on the 13 exhaust fans located on the roof. Exhaust fans motor were burnt out & fan belts were broken and were observed not connected to the motor and fan.

b) Roof top unit (RTU) #5 coil was observed frozen, filters located up stream were not protecting the coil. The filters were old and full of mildew.

c) HEPA filters were not changed since the building was built. Filters installed had the original date of when the building was completed.

d) Fire dampers installed in the Room Air Grills were closed throughout the building. No damper testing documentation was available for review. On the afternoon of 04/21/2015, Staff member Y stated that he had not had them tested or knew that this was required.

e) Bio Medical Equipment testing was not complete. Comprehensive review of equipment testing was not done or assigned. Staff A indicated since she had taken over as administrator, the preventive maintenance had not been completed.

f) Heating, ventilation and air conditioning (HVAC) Roof Top Equipment serving the 30 bed unused portion of the building, located on the east end of the building, was used as replacement parts for the occupied portion of the west end of the building. Fan motor from a condenser was removed, wiring and other parts of equipment was observed removed. This was verified by Staff Y.

Based on observation and review of hospital documents, the facility failed to provide electrical wiring and equipment that is in accordance with NFPA 70, National Electrical Code & NFPA 99 1999 edition. Findings include:

Findings:

1. Facility failed to establish policy & protocols for the type and testing intervals for each appliance. Physio Defibrillator located in emergency room (ER) and in the patient care corridor outside room 103 was last tested in December 2012; GOMCO suction pump located in the ER was last tested December 201; MAC-1200 electrocardiogram (EKG) was last tested June 2013; and the Dina Map Blood Pressure Pulse machine was last tested October 10, 2012.

2. Receptacle testing in accordance with 3-3.3.5 that requires integrity, continuity of ground, correct polarity, and rentention of force was not conducted and records were not kept.

3. Testing of patient care areas for impedance measurements required by 3-3.3.2.5 were not conducted.