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Based on observation and interview, the facility failed to ensure each emergency exit discharge area was provided with emergency powered lighting.

Findings:

On 03/28/17 at 2:04 pm, the surveyor observed each of the exit discharges of the faclity to include the exit discharge area located at the main entrance and exit discharge area located near the cafeteria to have lighting fixtures on normal power.

On 03/28/17 at 2:04 pm, the director of plant operations stated he did not know what existing light fixtures located at each exit discharge were wired to and powered by the emergency generator.

Based on observation and interview, the facility failed to ensure exit signage was in compliance for letter/word size and proper wording as required.


Findings:


On 03/28/17 at 1:42 pm, the surveyor observed a closed-in meditation courtyard with two doors that had stenciled lettering reading, "Not a fire exit". The facility had an occupancy of over 30 people and if there was an emergency there would be potential to cause confusion if this was an approved exit.


On 03/28/17 at 1:42 pm, the director of plant operations stated he did not know there was specific working or sizing of the letters for exit signs.

Based on observation and interview, the facility failed to ensure hazardous areas were protected as required.


Findings:


On 03/28/17 at 1:19 pm, ten "E" sized oxygen cylinders were observed to be stored in the decontamination room with other combustible materials including a large plastic waste container.


On 03/28/17 at 1:19 pm, the director of plant operations stated he thought the oxygen cylinders could be stored in the decontamination area.

Based on record review, observation, and interview, the facility failed to ensure heating, cooling, and ventilation were in accordance with ASHRAE 170.

Findings:

On 03/28/17 at 1:56 pm, a decontamination bronchoscope processing room was observed to have Cidex OPA and the surveyor could not determine if the room was negatively mechanically ventilated as required. One test & balance report was provided and reviewed. This one report only indicated air exchanges and air velocity, it did not indicate what areas tested were negatively or positively ventilated per ASHRAE 170 requirements.

On 03/28/17 at 1:56 pm, the director of plant operations stated he saw the test and balance report indicate minimum air exchanges per hour but saw it did not include if the areas were negatively or positively mechanically ventilated.

On 03/28/17 at 1:57 pm, the test & balance reports for 2015 and 2016 were requested and not provided. Rooms requiring verification of negative/positive airflow, air exchanges per hour and pressure testing was not completed per ASHRAE 170 requirements.

Based on observation, the facility failed to ensure alcohol based hand rub dispensers (ABHR) were not installed over ignition sources.


Findings:


On 03/28/17 at 10:25 am, while on tour near the nurses station, with the director of plant operations, the surveyor observed a ABHR dispenser to be installed over a light switch near the nurses station.

Based on record review, observation, and interview, it was determined the facility failed to ensure fire alarm system components were inspected and maintained as required.


Findings:


On 03/29/17 at 11:12 am, during record review, the facility failed to provide the smoke dectector sensitivity testing inspection reports.


On 03/29/17 at 11:12 am, the director of plant operations stated the facility had not completed smoke detector sensitivity testing.

Based on record review and interview, the facility failed to ensure their sprinkler system was inspected and maintained as required.


Findings:


On 03/29/17 at 11:15 am, based on record review, the facility failed to provide the five year internal inspection of the facility sprinkler system.


On 03/29/17 at 11:15 am, the director of plant operations stated the facility did not have the five year internal sprinkler system inspection reports.

Based on observation and interview, the facility failed to ensure multiplugs were not used.


Findings:


On 03/28/17 at 12:02 pm, while on tour of the pharmacy with the director of plant operations, the surveyor observed a refrigerator and microwave to be plugged into a power tap.


On 03/28/17 at 12:03 pm, the surveyor also observed two refrigerators which held medications located in the pharmacy to not have current inspection stickers.


On 03/28/17 at 12:15 pm, while on tour of the ICU, with the director of plant operations, the surveyor observed a multiplug to be in use and it had three non-patient care related devices plugged into it.


On 03/28/17 at 12:16 pm, while on tour, with the director of plant operations, the surveyor observed the soiled linen room door would not positively latch and was unlocked. A clean equipment storage area door was observed to not positively latch.


On 03/28/17 at 2:01 pm, two penetrations in the fire wall were observed near the physical therapy door. There was an open junction box observed in the plenum space.


On 03/28/17 at 2:01 pm, the director of plant operations stated he saw the penetrations and open junction box. He stated he will have to start following the electricians and fire system inspectors when they are in the ceiling space.

Based on record review and interview, the facility failed to ensure fire drills were conducted as required.

Findings:

On 03/21/17 at 11:03 am, record review of facility fire drills showed there was no documentation indicating the fire drills included the transmission of a fire alarm signal as required.

On 03/21/17 at 11:03 am, the director of plant operations reviewed the fire drills and stated they did not include in their documentation the verifying of the fire alarm signal transmission during each of the faclity's fire drills.

Based on record review, observation, and interview, the facility failed to ensure space heaters electrical element did not exceed 212 degrees Fahrenheit.


Findings:


On 03/28/17 at 12:34 pm, a space heater was observed in the cafeteria manager's office.


During record review the facility failed to produce the manufacturers documentation indicating the heating element did not exceed 212 degrees Fahrenheit.


On 03/28/17 at 12:34 pm, the director of plant operations stated they would look for the documention or remove the space heater from the cafeteria managers' office.

Based on observation, record review, and interview, the facility failed to ensure testing and maintenance of facility oxygen cylinders in accordance with NFPA 99, 2012 Edition.


Findings:


On 03/28/17 at 2:27 pm, during record review the faclity failed to provide the hydrostatic testing and maintenance records of the oxygen cylinders used at the facility.


On 03/28/17 at 2:27 pm, the director of plant operations stated he understood the need to have testing and maintenance records for the cylinders in use at their facility. He stated he thought it was the responsibility of the company they are renting the equipment from to do the testing and maintenance.

Based on observation, record review, and interview, the facility failed to ensure generator fuel quality testing was completed annually per ASTM test standards and the facility failed to ensure the emergency generator was capable of supplying service within 10 seconds as required in NFPA 110, 2010 Edition.


Findings:


On 03/28/17 at 10:43 am, record review of facility monthly emergency generator logs for 2015, 2016 and 2017 showed several test times of 12 seconds for the automatic transfer switch to transfer electrical emergency power.


On 03/28/17 at 10:43 am, the director of plant operations stated the 12 second times recorded in their facilitys' monthly generator logs just occurred a few times. He stated he corrected the time by counting the time differently.


On 03/28/17 at 2:27 pm, during record review the facility failed to provide the annual generator fuel quality testing for 2014, 2015, and 2016.


On 03/28/17 at 2:27 pm, the director of plant operations stated he obtained a company to do their diesel fuel testing and sent them a sample earlier in the week and it had not been done previously.


Reference:

NFPA 110, 2010 Edition, Section 8.3.8