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Based on observation it was determined the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code 2000, Chapter 19, 19.3.6.3.1 " Doors protecting corridor openings in other than required enclosures of vertical openings, exit, or hazardous areas shall be substantial doors, such as those constructed of 1 3/4 in. thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke...

Findings Include:

On November 19, 2014 the surveyor accompanied by the Director of Plant Operations observed the following corridor doors:

1. OB pantry door had the door closing device removed.
2. MED Surg # 12, shower room door tested three of three times, would not positively latch.

During the exit conference on November 19, 2014 the above findings were again acknowledged by the President/Chief Executive Officer and the Director of Plant Operations.

The facility failed to protect patients from heat and smoke.

Based on observation it was determined the facility failed to maintain the self closing/automatic-closing doors in the smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Sections, 19.3.7.6 "Doors in smoke barriers shall comply with 8.3.4.1*" Doors in smoke barriers shall close the opening leaving only minimum clearance necessary for proper operation and shall be without undercuts, lovers, or grills."

Findings include:

On November 19, 2014 the surveyor accompanied by the Director of Plant Operations observed the following smoke barrier door:

1. Door # 478234, rated 20 min. gap approximately 1/4 inch between the doors, not smoke tight.
2. Rated double doors by the Vice Presidents office, one of two doors will not latch when tested three of three times.

During the exit conference on November 19, 2014 the above findings were again acknowledged by the President/Chief Executive Officer and the Director of Plant Operations.

Failure to properly adjust or repair the smoke doors could cause harm to residents.
Non closing smoke doors could allow smoke to enter smoke zones not directly effected by the fire, which could cause harm to the patients.

Based on observation it was determined the facility failed to maintain the smoke resistance, of walls, ceilings or pipe chases in hazardous areas. And the facility did not maintain the integrity, smoke resistance, of doors in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 19,. Section 19.3.2.1 Requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls, doors, and ceilings must be able to resist the passage of smoke.

NFPA 80 "Fire Doors and Fire Windows" Chapter 2, Section 2-3.1.7 "The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. +/- 1/16 in for steel doors and shall not exceed 1/8 in. for wood doors.

Findings include:

On November 19, 2014 the surveyor accompanied by the Director of Plant Operations observed a hole in the Electrical room of Med. Surg, S/W corner wall, approximately 8X5 inches. In the reverse osmosis room their are three penetrations in the wall.

The following hazardous area doors:

1. Kitchen mop room does not have a door closing device, the room contains chemicals.
2. ER soiled utility room was tested three of three times and would not positively latch.
3. X-Ray, 20 minute rated door, not smoke tight.
4. Med. Surg. rated 1-1/2 hr. door will not close and latch by room 23.
5. Double rated doors to the reverse osmosis room are not smoke tight.

During the exit conference on April 2, 2014, the above findings were again acknowledged by the Administrator and the Director of Maintenance.

Failing to fill holes could allow heat and smoke to spread into walls, attics, or exit corridors which will cause harm to the patients.
Failing to prevent heat and smoke from spreading into the exit corridor will cause harm to patients.

Based on record review it was determined the facility failed to conduct the required fire drills.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.7.1.2 Fire exit drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 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."

Findings include:

On November 19, 2014 the surveyor accompanied by the Director of Plant Operations and the Security Director reviewed the Fire Drill training records. The facilities did not have Fire Drill records for First shift or second shift, third quarter of 2014. The facilities did not have records for first or second shift first, second, third or forth quarter of 2013.
Two quarters were available for review of the Fire Drill documents. The CODE RED announcement was not used in the second shift Fire Drills as written in the Fire Policy, the reason given; "the facility has a policy of no overhead announcements after 9:00 PM". The second shift second quarter Fire Drill was a table top discussion only.

During the exit conference on November 19, 2014 the above findings were again acknowledged by the President/Chief Executive Officer and the Director of Plant Operations.

Failure to train and drill the staff on fire procedures could result in harm to the patients.

Based on record review it was determined the facility did not inspect, test and maintain the automatic sprinkler system in accordance with the requirements of the Life Safety Code.
Based on observation it was determined the facility failed to maintain the sprinkler heads and assure that all parts of the sprinkler system were in accordance with the UL Listing.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.5.1. "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing , and Maintenance of Water-Based Fire Protection Systems." NFPA 25, Water Based Extinguishment Systems, requires monthly, quarterly and annual testing of automatic sprinkler systems.

NFPA 25, Section 2-2.1.1 "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign material , paint, and physical damage and shall be installed in the proper orientation..." NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, Chapter 3, Section 3-2.7.2, "Escutcheon Plates used with a recessed or flushed sprinkler shall be part of a listed sprinkler assembly."

Findings include:

On November 19, 2014 the surveyor accompanied by the Director of Plant Operations and the Security Director reviewed the records which indicated that the automatic sprinkler system quarterly test was missed for August 2014. The dates of the quarterly tests are; 12-13-13; 2-21-14; 5-30-14, and 9-5-14.
The following sprinklers are covered with lint:

1. Dish room, two of two sprinklers lint.
2. Walk in refrigerator, two of two sprinklers lint.
3. ER Nurses station, two of two sprinklers lint.
4. ER Nurses station drug area, one of two sprinklers lint.

During the exit conference on November 19, 2014 the above findings were again acknowledged by the President/Chief Executive Officer and the Director of Plant Operations.

Failure to inspect, test, and maintain the sprinkler system could result in harm to the patients through the spread of smoke and fire.
Failing to maintain sprinkler heads and keep the fusible link clean could allow a fire to burn longer before the sprinkler head will activate. Failing to maintain sprinkler heads, missing escutcheon plates, which are part of the UL Listing of the sprinkler assembly, could allow heat and smoke to effect other areas of the building. This could cause harm to the patients.

Based on observation it was determined the facility failed to clean the kitchen exhaust hood system, filters and grease drip tray.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.3.2.6 "Cooking facilities shall be protected in accordance with 9-2.3" Section 9-2.3 "Commercial cooking equipment shall be installed in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations." , Chapter 8, Section 8-3.1, " Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge".

Findings include:

On November 19, 2014 the surveyor accompanied by the Director of Plant Operations and Food Services Manager observed the kitchen exhaust system hood, filters and grease drip tray area had an excessive amount of grease buildup over the grill six of six filters and the cook top, three of six filters.

During the exit conference on November 19, 2014 the above findings were again acknowledged by the President/Chief Executive Officer and the Director of Plant Operations.

Failing to keep the entire kitchen exhaust hood system clean from grease will cause a fire, which could cause damage to the kitchen and will cause harm to the patients.

Based on observation it was determined the facility failed to maintain a clear exit access, which provides a continuous way out of the building to the public way.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. Section 7.1.10 " Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency".

Findings include:

On November 19, 2014 the surveyor accompanied by the Director of Plant Operations observed an automobile parked next to the fire lane blocking the public way from the OR South emergency exit.
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During the exit conference on November 19, 2014 the above findings were again acknowledged by the President/Chief Executive Officer and the Director of Plant Operations.

Failing to provide clear exit access will cause harm to the patients in time of a fire/emergency.

Based on observation it was determined the facilities failed to enclose the UPS equipment within a 2-hour fire rated room. The facility allowed the use of a multiple outlet adapter, power strips and did not use the wall outlet receptacles for appliances, and the facility failed to provide a guard on the light bulb located in the housekeeping closet.

NFPA 101 Life Safety Code, 2000 Chapter 19, Medical Gas Section 19.3.2.4 Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care. NFPA 99 Chapter 3 Electrical Systems, 3-4.1.1.6t Work Space Room (a) Energy converters shall be located in a separate service room dedicated to the generating equipment, separated from the remainder of the building by fire separations having a minimum 2-hour fire rating, or located in an adequate enclosure outside the building capable of preventing the entrance of snow or rain and resisting maximum wind velocity required by the building code. Rooms for such equipment shall not be shared with other equipment or electrical service equipment that is not part of the essential electrical system.

NFPA 101, Life Safety Code, 2000, Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 1999 Edition. NFPA 99, Chapter 3, Section 3-3.2.1.2, "All Patient Care Areas," Section 3-3.2.1.2 (d) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1, Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, Article 110, Section 110-27 (b) Prevent Physical Damage. " In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage.

Findings include:

On November 19, 2014 the surveyor accompanied by the Director of Plant Operations observed the instillation of a UPS battery back up system located in the corridor by OR 3. The system contains 48 batteries and produces 90 minutes of battery back up power to the OR's. The equipment is mounted in the corridor with no 2 hr. fire walls.

1. Medical records has a microwave and a refrigerator plugged into a power strip.
2. OR housekeeping closet has no cover on the light.
3. Reverse osmosis room light has no cover.

During the exit conference on November 19, 2014 the above findings were again acknowledged by the President/Chief Executive Officer and the Director of Plant Operations.

Failing to enclose the UPS behind a 2 hr. wall could expose patients to Hazardous materials.
The use of multiple outlet adapters could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.
Failure to keep light guards on the light could cause accidental damage or possibly a fire, which could cause harm to the patients.