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Based on observation, policy review and interview, the facility failed to ensure that a pair of smoke/fire doors added during a post-2003 expansion of the emergency department were equipped with rabbets, bevels or astragals (a smoke resistant groove, bevel or strip along the meeting edges of on one or both doors that overlaps and prevents the spread of smoke or fire into unaffected areas) in areas of new construction in accordance with NFPA 2000, chapter 18.3.7.8, New Health Care Occupancies.

The Centers for Medicare and Medicaid Services has determined that after March 13, 2003, any expansion or major modification in an existing facility involving 50 percent or more that 4,500 square feet of the involved smoke compartment must be surveyed under the 2000 New Life Safety Code. (Appendix I)

18.3.7.8 Rabbets, bevels or astragals shall be required at the meeting edges, and stops shall be required at the head and sides of the door frames in smoke barriers. Positive latching hardware shall not be required. Center mullions shall be prohibited. NFPA 2000 (new).

This deficient practice potentially exposes all staff and patients and fails to protect them from the spread of smoke throughout the structure into unaffected areas. The facility census was 14.

Findings included:

1. Observation on 08/25/15 at 10:00 AM showed emergency department located on the north side of the building was of new construction and separated from the existing 1972 constructed hospital with a two hour wall. The self-closing fire doors separating the hospital and the post-2003 constructed emergency department were not equipped with an astragal to cover the gap between meeting edges.

2. During an interview on 08/25/15 at 10:00 PM, Staff R, Director of Facilities acknowledged the finding and stated that the doors were part of the emergency department expansion that had been completed less than five years ago. He stated that he checks all smoke and fire doors during monthly PM rounds but does not have a specific policy or procedure.

Based on observation, record review and interview, the facility failed to complete an annual load bank test on their diesel powered generator in accordance with the CMS approved 1999 edition of NFPA 110, Chapter 6-4.2.2. Hospitals are required to have an Emergency Power Supply (EPS) installed when failure of the equipment to perform could result in the loss of human life or serious injuries. The facility census was one.

The 1999 edition of NFPA 110, Chapter 6-4.2.2 states: Diesel-powered EPS installations that use less than 30 percent of the nameplate Kilowatt (kW) rating should be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

Findings included:

1. Record review on 08/25/15 of the facility's generator maintenance log showed that tests of the generator using the facility load had been conducted monthly, and that the annual load test had been performed on 05/18/15.

2. Record review of the service invoice dated 05/18/15 showed the service mechanic recorded that he performed a building load test on the 125 kilowatt generator. He also indicated he performed routine maintenance and identified some leaks and deficient parts. The data indicated that he ran the generator and recorded engine temperature, oil temperature, oil pressure, and voltage output. However, the run data was incomplete and did not indicate the duration of the test run, amperages generated under a full load, or that the generator had been tested using the combined maximum facility load and a supplemental load bank to assure the maximum performance capability of the generator.

3. During an interview on 08/25/26 at 10:00 AM, Staff R Director of Facilities stated that the service mechanic visited on 05/18/15 and ran a load test, but he did not remember any more details. He stated that he was not exactly sure how long the service mechanic was on site, but it seemed to be only about1½ hours.