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Based on observation and interview, it was determined that the facility failed to protect the automatic sprinkler from freezing.

The findings include:

Observation and interview with the interim maintenance director and the Director of Nursing (DON) on January 21, 2015 at 9:30 a.m. revealed a sprinkler head in the surgery suite froze and busted affecting the following areas:
1. 2 of 2 surgery suites flooded causing damage to the floor, walls and ceilings.
2. The facility's Lab department located below the flooded area was affected by water damage. The lath and plaster ceiling above the drop ceiling separating the floors is water damaged and is having to be torn out.
3. Dietary was flooded and the lath and plaster ceiling has been torn out in areas that had extensive water damage. Due to the clean-up process and construction to repair the dietary departments ceiling, dietary is closed for an extended period of time.

These findings were verified by the interim maintenance director on January 21, 2015 and acknowledged by the administrator on in the exit interview on February 5, 2015.

Actually NFPA Standard:
2-2.5 Buildings.
Annually, prior to the onset of freezing weather, buildings with wet pipe systems shall be inspected to verify that windows, skylights, doors, ventilators, other openings and closures, blind spaces, unused attics, stair towers, roof houses, and low spaces under buildings do not expose water-filled sprinkler piping to freezing and to verify that adequate heat [minimum 40°F (4.4°C)] is available.

Based on observation, it was determined that the facility failed to have the means of egress free from obstructions.

The findings include:

Observation on January 21, 2015 at 8:45 a.m. revealed the means of egress from the Lab department is obstructed by debris and equipment from demoing out the ceiling in the corridor from the water damage due to the frozen sprinkler head in the surgery suite. When exiting out of the Lab.

This finding was verified by the interim maintenance director on January 21, 2015 and acknowledged by the administrator on February 5, 2015.

Actual NFPA standard:
7.1.10.2.1
No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.

Based on observation, record review and interview, the facility failed to provide a permanently installed emergency generator to supply back up power for the emergency power supply system (EPSS) and failed to maintain the emergency power supply system (EPSS) with a remote system alarm at a work site that is readily observable by personnel.

The findings include:

1. Observation on January 21, 2015 at 10:30 a.m. revealed the facility is using temporary generator located outside on the ground floor of the building.

Interview and record review revealed the original permanent generator quit functioning September 5, 2015. No generator has been purchased yet and at this times only bids for a new generator is all that has occurred.

2. Interview with the interim maintenance director on February 5, 2015 at 1:00 p.m. revealed the facility's emergency power supply (EPS) consisted of a temporary generator located outside on the ground floor of the building. The temporary generator is not provide or connected to a remote annunciator panel that is at a location that is readily observable by the staff.

These findings were verified by the interim maintenance director and acknowledged by the administrator during on February 5, 2015.


2-2.4.1*
Level 1 defines the most stringent equipment performance requirements for applications where failure of the equipment to perform could result in loss of human life or serious injuries. All Level 1 equipment shall be permanently installed.

2-2.4.2*
Level 2 defines equipment performance requirements for applications where failure of the EPSS to perform is less critical to human life and safety and where it is expected that the authority having jurisdiction will exercise its option to allow a higher degree of flexibility than provided by Level 1. All Level 2 equipment shall be permanently installed.