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Based on observation and staff interview, the facility failed to provide illumination of the means of egress that was continuously in operation, or automatic operation. This condition would leave an exit stairwell in darkness.

Findings are:
Observation on 8/22/18, at 1:33 pm revealed the lights at the top landing of the East Stairwell were not illuminated.

In an interview on 8/22/18, at 1:33 pm Maintenance A acknowledged a portion of the lights in the stairwell were not lit.

Based on record review and staff interview, the facility failed to conduct a monthly visual inspection for components of the range hood fire-extinguishing system. This condition did not ensure that all system components were in position and intact, that the system was not obstructed or damaged, and increased the potential that the fire-extinguishing system would not operate as designed during a cooking fire.

Findings are:
Record review on 8/22/18, at 11:34 am revealed documentation was not provided to verify that monthly visual range hood fire-extinguishing system inspections were conducted.

In an interview on 8/22/18, at 11:34 am, Maintenance A confirmed the inspection was not implemented.

Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.

NFPA 96, 2011, 10.2.6 Automatic fire-extinguishing systems shall be installed in
accordance with the terms of their listing, the manufacturer's
instructions, and the following standards where applicable:
(1) NFPA 12
(2) NFPA 13
(3) NFPA 17
(4) NFPA 17A

NFPA 17A, 2009, 7.2 Owner ' s Inspection.
7.2.1 On a monthly basis, inspection shall be conducted in
accordance with the manufacturer ' s listed installation and
maintenance manual or the owner ' s manual.
7.2.2 At a minimum, this " quick check " or inspection shall
include verification of the following:
(1) The extinguishing system is in its proper location.
(2) The manual actuators are unobstructed.
(3) The tamper indicators and seals are intact.
(4) The maintenance tag or certificate is in place.
(5) No obvious physical damage or condition exists that
might prevent operation.
(6) The pressure gauge(s), if provided, shall be inspected
physically or electronically to ensure it is in the operable
range.
(7) The nozzle blowoff caps, where provided, are intact and
undamaged.
(8) Neither the protected equipment nor the hazard has not
been replaced, modified, or relocated.

Based on observation and staff interview, the facility failed to provide corridor doors that would resist the passage of smoke. This practice would allow smoke to migrate into the exit corridors.

Findings are:
Observation on 8/22/18, from 12:58 pm to 1:20 pm revealed:
1. The ER Door did not positively latch when auto-closed.
2. The Dictation Room 249 Door did not positively latch when self-closed.

In an interview on 8/22/18, from 12:58 pm to 1:20 pm, Maintenance A confirmed the doors did not positively latch.

Based on record review and staff interview, the facility failed to conduct fire drills under varying conditions. This deficient practice did not provide simulated training for staff to respond to a fire emergency during various activities and staffing levels.

Findings are:

Record review on 8/22/18, at 11:25 am revealed fire drills were conducted less than one hour apart between each quarter for the following shift:
2nd Shift: 5/29/18 at 3:57 pm, 2/27/18 at 3:30 pm, 11/21/17 at 3:28 pm and 8/24/17 at 3:43 pm

In an interview on 8/22/18, at 11:25 am, Maintenance A acknowledged that the times fire drills were conducted were not varied.

NFPA 101, 2012, 19.7.1.4* Fire drills in health care occupancies shall include
the transmission of a fire alarm signal and simulation of emergency
fire conditions.
19.7.1.5 Infirm or bedridden patients shall not be required
to be moved during drills to safe areas or to the exterior of the
building.
19.7.1.6 Drills shall be conducted quarterly on each shift to
familiarize facility personnel (nurses, interns, maintenance
engineers, and administrative staff) with the signals and emergency
action required under varied conditions.
19.7.1.7 When drills are conducted between 9:00 p.m. and
6:00 a.m. (2100 hours and 0600 hours), a coded announcement
shall be permitted to be used instead of audible alarms.

Based on record review and staff interview, the facility failed to test electrical receptacles in patient sleeping rooms annually throughout the facility. This practice increased the risk of fire from a failed outlet.

Findings are:
Record review on 8/22/18, at 11:30 am revealed documentation of annual patient care room receptacle testing was not provided for review.

In an interview on 8/22/18, at 11:30 am, Maintenance A confirmed the testing was not conducted, and was not aware of the requirement.

NFPA 99, 2012, 6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.
6.3.3.2 Receptacle Testing in Patient Care Rooms.
6.3.3.2.1 The physical integrity of each receptacle shall be
confirmed by visual inspection.
6.3.3.2.2 The continuity of the grounding circuit in each
electrical receptacle shall be verified.
6.3.3.2.3 Correct polarity of the hot and neutral connections
in each electrical receptacle shall be confirmed.
6.3.3.2.4 The retention force of the grounding blade of each
electrical receptacle (except locking-type receptacles) shall be
not less than 115 g (4 oz).

Based on record review and staff interview, the facility failed to have the diesel fuel serving the emergency generator tested annually for quality. This practice increased the potential that emergency power would not be supplied to the facility.

Findings are:
Record review on 8/22/18, at 11:26 am revealed documentation was not provided to verify the diesel fuel for the generator tank was tested annually for quality.

In an interview on 8/22/18, at 11:26 am, Maintenance A confirmed the testing was not conducted.

NFPA 99, 2012, 8.3.8 A fuel quality test shall be performed at least annually
using tests approved by ASTM standards.

Based on observation and staff interview, the facility failed to use electrical equipment in a way that would not create a fire hazard. This condition had the potential to cause a fire.

Findings are:
Observation on 8/22/18, at 2:02 pm revealed a microwave and toaster were plugged into a power strip in the OR Doctor Lounge.

In an interview on 8/22/18, at 2:02 pm, Maintenance A acknowledged the findings, and plugged the appliances directly into a hardwired outlet at the time of observation.

NFPA 70, 2011, 210.23 Permissible Loads. In no case shall the load exceed
the branch-circuit ampere rating. An individual branch
circuit shall be permitted to supply any load for which it is
rated. A branch circuit supplying two or more outlets or
receptacles shall supply only the loads specified according
to its size specified in 210.23(A) through (D) and as summarized
in 210.24 and table 210.24.