HospitalInspections.org

Based upon observation and staff interviews, the facility failed to maintain corridor walls which will resist the passage of smoke in the event of a fire. In the event of a fire, this would allow smoke to move between the rooms and the exit access corridor and thus place patients, visitors, and staff at risk of smoke and fire.

During the facility tour on July 23, 2013 from 10:30am to 4:00pm and continued on July 24, 2013 from 11:00am and 2:00pm), the following penetrations were found in the corridor exit paths:

July 23, 2013:
1. At 10:30am inside the Operation Room corridor area behind autoclave, I observed 2 penetrations.
2. At 10:57am, I observed penetrations above ceiling tiles at fire doors from Operating Room to the exit corridor.
3. At 1:00pm, in the basement exit corridor, I observed 2 penetrations caused by cleanouts, a beam that did not get sealed after construction, and other penetrations caused by ITT wiring.
4. At 1:31pm, in the basement MDF room, I observed penetrations that need to be sealed.
5. At 2:41pm, above the ceiling tiles of the Emergency Room corridor fire doors, I observed penetrations and discovered that the fire wall did not extend to the ceiling above as required. Upon further inspecting, it was discovered that the true fire wall is not aligned with the fire doors.
6. At 3:16, I observed two small holes in the storage room by the nurses station.

July 24, 2013:
1. At 11:25, I observed that the janitor room between the two restrooms in the kitchen corridor has a very large breach in the wall that needs to be repaired and sealed.

These findings were observed and discussed with the Maintenance Director.

Based on observation and staff interview the facility failed to assure that door openings closed to resist the passage of smoke to corridors. This potentially cause the quick spread of smoke, heat and fire, and thus expose patients, visitors, and staff to the threat of fire.

The findings include, but are not limited to:

A. Upon arriving at the facility to conduct the survey on July 23, 2013, the fire doors to Radiology were observed to be in the open position. At approximately 11:00am, I observed that these doors were permanent locked in the open position for repairs. These doors are not connected to the fire alarm system and would stay open during a fire. The facility promptly disabled the doors so that they were always in the closed position. These doors are currently under repair.

B. During the facility tour on July 23, from 10:30 am to 4:30pm and continued on July 24, 2013 from 11:00am to 2:00pm I observed the following doors to not close and latch properly when tested:

1. At 3:08pm, I observed fire doors to nurses admin office did not close and latch when activated.
2. At 3:15pm, I observed that the exit door to stairs by physical therapy did not close and latch when activated.
3. At 3:25pm, I observed that the smoke doors by room 10 did not close properly.
4: At 3:26pm, I observed that the doors to rooms 13, 14, and 2 did not close and latch properly. The doors would open back up after closing. This exact same concern was brought to maintenance staff attention by way of work order. During a fire drill staff advised that the doors would open back up on 2/20/2013. No action was taken by maintenance staff and I observed the same malfunction 5 months later.
5. At 3:30pm, I observed soiled utility room door did not close and latch properly when tested.
6. On July 23, at 11:09am, I observed that the housekeeping washer room door not close and latch properly when tested.
7. At 11:20am, I observed that the dryer room and wash room self-closures were locked in the open position.

These findings were observed and discussed with the Maintenance Director.

The facility has failed to maintain exits so that the exit is readily available at all times. This could allow for patients, visitors, and staff to delay in egress out of a room or the building.

The findings include, but are not limited to:

During the facility tour on July 23, 2013 at 3:01pm, I observed that the mammography exam room was equipped with a locking latch causing the door to have two efforts to egress.

This finding was observed and discussed with the Maintenance Director.

The facility has failed to provide battery-powered emergency lighting in the Operating Room. This could allow for the OR surgeons to be in complete darkness for the 10 seconds that the generator delays to turn on. This could place patients and staff at risk of critical moments of darkness in a power outage.

The findings include, but are not limited to:

During the survey of the Operating Room on July 23, 2013 at 10:30am, I observed that there were no battery-powered emergency lights in the operating room.

This finding was observed and discussed with the Maintenance Director.

The facility has failed to provide the required number of fire drills for staff of one fire drill per quarter per shift. This could render the staff inexperience and unaware of what duties to perform in a fire emergency and thus place patients, visitors, and staff at risk of fire or smoke.

The findings include, but are not limited to:

During document review on July 23, 2013 between the hours of 9:30am and 10:30am of the facility's fire drill records from the date of survey and one year prior revealed the following deficiencies:

1. The facility was sited at the 2011 survey for only having 2 successful fire drill quarters in the year of 2010 and 2011.
2. Records revealed that the facility has 2 successful fire drill quarters in 2012.
3. To date, there have been two successful quarters of fire drills. The facility is on track for this year, however, this does make 4 consecutive years of only 2 fire drills per year per shift.

The facility was asked to conduct a fire drill at 9:00am on July 24, 2013. The results of that fire drill revealed that staff was not trained properly and the result was a failed fire drill.

1. The fire alarm pull station was activated at 9:03am. The horns/strobes notification alarms did not sound or light until a full minute later at 9:04.
2. Staff was over heard to say "what's that noise? We should call maintenance."
3. Overhead page was announced "Everybody please exit the building."
4. A patient was evacuated to the outside.
5. Another over head page was heard "Code Red in Radiology"
6. The Code Red was actually at Nurses Station. Auxiliary fire alarm panel at Nurses Station did read Nurses Station.
7. Staff member outside of the building was over heard to say "What am I suppose to do? I have never been here during a fire drill."
8. Fire doors by room 10 did not close and latch when activated by the fire alarm.

This finding was observed and discussed with the Maintenance Director.

Based on observations made during a fire drill exercise on July 23, 2013 at 9:03am, the facility has failed to maintain the proper operational condition of the fire alarm system. This has the potential of having a non-functional fire alarm system that would expose residents to a fire or smoke environment.

The findings include, but are not limited :

1. The pull station was activated at 9:03am. The horn/strobes did not sound/light until 9:04am. This exceeds the 10 second delay that is allowed by NFPA 72 Standard for Fire Alarm Systems.
2. During the general alarm of the fire drill, I observed that the roll up fire door at Radiology Reception was closed. I interviewed the receptionist and asked her if the door automatically rolled down upon the fire alarm system activation. She said, no, that it is her duty to push the button and make the door close.
3. The roll up fire door does not automatically activate into the closed position upon fire alarm as required.
4. The delay in horn/strobe activation in the old portion of the building may be an indication that the existing portion of the fire alarm is not properly interconnected withe the new as is required. This would need to be checked and verified for interconnection.

These findings were observed and discussed with the Maintenance Director.

Based on observations, the facility failed to maintain the proper operational condition of the sprinkler system. This has the potential of having a non-functional sprinkler system that would expose patients, visitors, and staff to a fire or smoke environment.

The findings include, but are not limited to:

During document review on July 23, 2013 from 9:30am to 10:30am of the facility's sprinkler system reports from the survey date to the year prior revealed the following deficiencies:

1. Quarterly inspections reports could not be produced as quarterly inspections of the sprinkler system had never been conducted. Interview with Maintenance staff revealed that the facility was not aware of the requirement to have the sprinkler system inspected quarterly.
2. Annual reports from the sprinkler company in 2011 to 2013 revealed some of the same deficiencies. No records could be produced that these items had been addressed.
3. Annual servicing reports from the sprinkler company in 2012 and 2013 were noted that the 5-year internal pipe inspection needed to be performed. No records could be produced that the 5-year internal pipe inspection had been conducted

During the survey tour on July 23, 2013 from 1:00pm to 4:00pm revealed the following sprinkler deficiencies:

1. At 1:26 the ADA restroom nearest the window walls was observed to have the escutcheon installed upside down.
2. At 1:30pm the two ADA restrooms in the basement were observed to have the orange construction protective caps still in place. The construction was completed in 2009.

These findings were observed and discussed with the Maintenance Director.

The facility has failed to maintain the kitchen hood system in proper operating conditions. This could allow for the hood to fail to extract grease laden vapors
and thus place patients, visitors, and staff at risk of fire.

The findings include, but are not limited to:

1. During the survey tour on July 24, 2013 at 11:22am, I observed the kitchen hood to be equipped with the unapproved wire mesh filters. Reports from last two servicing reports indicate that the kitchen suppression company had been advising staff that the filters needed to be changed out.

2. During document review on July 23, 2013 from 9:30am to 10:30pm, I observed that the servicing records for the kitchen suppression system were being conducted on an annual basis and not every six months as required.


These findings observed and discussed with the Maintenance Director.

The facility has failed to restrict the use of portable electric heaters to the types of heaters specified in the Life Safety Code. This could expose patients, visitors, and staff to risk of fire due to overheating of portable heaters.

The findings include, but are not limited to:

During the survey tour on July 23, 2013 at 1:46pm, I observed 3 unapproved portable heaters in the Billing and Registration offices.

This finding was observed and discussed with the Maintenance Director.

Based on observations and staff interviews, the facility failed to maintain soiled linen or trash collection receptacles to not exceed 32 gal in capacity. Exceeding the 32 gallon capacity would provide a fuel source for a fire and possibly expose residents, visitors, and staff to the threat of fire and fire spread.

The findings include, but are not limited to:

1. During the facility tour on July 23, 2013 at 1:47pm, I observed an approximately 90 gallon shred containers to be stored in the following locations:
a. One container was stored at the admin area exposed to the corridor.
b. Two containers were observed at the back exit corridor by laundry.

NOTE: All three of these shred bins were removed and relocated at the time of survey.

During the facility tour on July 24, 2013 at 11:00am, I observed a 30 gallon, a 10 gallon, and a 5 gallon trash receptacles being stored in the back exit corridor by laundry.

These findings were observed and discussed with the Maintenance Director.

The facility has failed to properly secure oxygen cylinders in an approved manner to prevent them from falling over. Failure to secure compressed gas cylinders could allow for cylinders to fall and cause missle type destruction. This would
place patients, visitors, and staff at risk of a dangerous situation and enhanced fire risk.

The findings include, but are not limited to:

During the facility tour on July 24, 2013 at 11:00am, I observed that the oxygen storage room had 6 cylinders not secured in any manner.

This violation was also cited in the 2011 survey.

This finding was observed and discussed with the Maintenance Director.

The facility has failed to provide a mechanical means of controlling humidity levels in the operating room. This could place the patient and staff at risk of fire.

The findings include, but are not limited to:


Based upon observations and staff interviews during survey of the facility Operating Room on July 23, 2013 at 10:30am, the facility does not have a mechanical means of controlling humidity levels at equal to or greater than 20%.

When staff was interviewed as to what actions are taking when the humidity levels have to be adjusted, staff indicated that they adjust the temperature of the room and turn on fans.

The operating room staff has been diligent in the maintaining of the humidity level logs.

This finding was observed and discussed with the Maintenance Director.

Based on observations and staff interviews, the facility failed to maintain the proper inspection and testing of the generator. This could potentially allow for the generator to become inoperable and staff not aware and thus expose residents, visitors, and staff to the threat of no life safety systems and emergency power during a power outage.

The findings include, but are not limited to:

Document review on July 23, 2013 between the hours of 9:00am and 10:30am of the facility's generator inspection and testing records from the date of survey and the year prior revealed that the facility has failed to conduct weekly inspections and monthly 30 minute full load tests of the generator. Interview with maintenance staff revealed that the newly hired Maintenance Director recently became aware the lack of monthly 30 minute full load test and conducted a test in July. This was memorialized in an email to the CEO. However, no log was created. This was also cited as a violation in the 2011 survey. Since the 2011 survey the only 30 minute full load test conducted was in July 2013.

This finding was observed and discussed with the Maintenance Director.

The facility has failed to maintain premises free of electrical hazards. This could provide for electrical fire and expose staff and patients to threat of fire.

The findings include, but are not limited to:

During the facility survey on July 23, 2013 from 11:00am to 4:00pm, electrical hazards were observed in the following location(s):

1. At 1:40pm, I observed Payroll Office to have power strip plugged into another power strip.
2. At 2:05pm, I observed IT room by reception/admitting to have an unapproved adaptor.
3. At 2:56pm, I observed the Digitizer in memo prep room to be have an extension cord as its permanent source of power.
4. At 3:42pm, I observed the General Surgeon office to have a power strip plugged into a power strip.
5. At 3:43pm, I observed Pharmacy to have a beige extension cord extended through a doorway into another room. An orange extension cord for the fan plugged into a power strip. And a black power strip plugged into another power strip. I observed all these items were corrected at time of the survey.
6. At 3:45pm, I observed the back room to pharmacy to have a power strip that is dangling and adding stress to the cords.

These findings were observed and discussed with the Maintenance Director.

Based on observations made during document review conducted on July 23, 2013 from 9:30am to 10:30am, the facility failed to provide a written plan for actions to implement a fire watch in the event of the automatic fire sprinkler system were to be out of service for more than 4 hours in a 24 hour period. Failure to provide an action plan to implement a fire watch could possibly expose staff and patients to be unprotected by a life safety system as required.

The findings include, but are not limited to:

1. Documentation review of the facility's disaster plan did not have a policy in place for a fire watch in the event of the automatic fire sprinkler system were to be out of service for greater than 4 hours in a 24 hour period.

This finding was observed and discussed with Maintenance Director.

Based on observations made during document review conducted on July 23, 2013 from 9:30am to 10:30am, the facility failed to provide a written plan for actions to implement a fire watch in the event of the fire alarm system were to be out of service for more than 4 hours in a 24 hour period. Failure to provide an action plan to implement a fire watch could possibly expose staff and patients to be unprotected by a life safety system as required.

The findings include, but are not limited to:

1. Documentation review of the facility's disaster plan did not have a policy in place for a fire watch in the event of the fire alarm system were to be out of service for greater than 4 hours in a 24 hour period.

This finding was observed and discussed with Maintenance Director.

The facility failed to maintain the proper distance for alcohol based hand sanitizers (ABHS) from an electrical source. This potentially allows a fire ignition source that exposes patients, visitors, and staff to the threat of fire.

The findings include, but are not limited to:

During the facility survey on July 23, 2013 from 11:00am to 4:00pm and continued on July 24, 2013 from 11:00am to 2:00pm, improper mounting of alcohol based hand rub was observed in the following location(s):

1. At 3:00pm I observed the mammography room to have the ABHS to close to an electrical outlet.
2. At 3:01pm, I observed the tech work/sleep station room to have the ABHS to close to an electrical outlet.
3. At 3:03pm, I observed the Radiologist Reading room to have the ABHS to close to a power switch.
4. At 3:07pm, I observed the Nurses Admin Office to have the ABHS to close to a power switch.
5. At 3:38pm, I observed the ICU room 1 and room 2 to have ABHS to close to an electrical unit and one ABHS has drip line at the emergency floor light.
6. At 3:55pm, I observed Optometry exam room to have ABHS to close to an electrical switch.
7. On July 24, at 1:18pm, I observed the the Emergency Room entrance has ABHS drip line to be at the floor electrical unit.

Alcohol Based Hand Sanitizers were also cited in the 2011 survey.

These findings were observed and discussed with the Maintenance Director.

Based upon observation and staff interviews, the facility failed to maintain corridor walls which will resist the passage of smoke in the event of a fire. In the event of a fire, this would allow smoke to move between the rooms and the exit access corridor and thus place patients, visitors, and staff at risk of smoke and fire.

During the facility tour on July 23, 2013 from 10:30am to 4:00pm and continued on July 24, 2013 from 11:00am and 2:00pm), the following penetrations were found in the corridor exit paths:

July 23, 2013:
1. At 10:30am inside the Operation Room corridor area behind autoclave, I observed 2 penetrations.
2. At 10:57am, I observed penetrations above ceiling tiles at fire doors from Operating Room to the exit corridor.
3. At 1:00pm, in the basement exit corridor, I observed 2 penetrations caused by cleanouts, a beam that did not get sealed after construction, and other penetrations caused by ITT wiring.
4. At 1:31pm, in the basement MDF room, I observed penetrations that need to be sealed.
5. At 2:41pm, above the ceiling tiles of the Emergency Room corridor fire doors, I observed penetrations and discovered that the fire wall did not extend to the ceiling above as required. Upon further inspecting, it was discovered that the true fire wall is not aligned with the fire doors.
6. At 3:16, I observed two small holes in the storage room by the nurses station.

July 24, 2013:
1. At 11:25, I observed that the janitor room between the two restrooms in the kitchen corridor has a very large breach in the wall that needs to be repaired and sealed.

These findings were observed and discussed with the Maintenance Director.

Based on observation and staff interview the facility failed to assure that door openings closed to resist the passage of smoke to corridors. This potentially cause the quick spread of smoke, heat and fire, and thus expose patients, visitors, and staff to the threat of fire.

The findings include, but are not limited to:

A. Upon arriving at the facility to conduct the survey on July 23, 2013, the fire doors to Radiology were observed to be in the open position. At approximately 11:00am, I observed that these doors were permanent locked in the open position for repairs. These doors are not connected to the fire alarm system and would stay open during a fire. The facility promptly disabled the doors so that they were always in the closed position. These doors are currently under repair.

B. During the facility tour on July 23, from 10:30 am to 4:30pm and continued on July 24, 2013 from 11:00am to 2:00pm I observed the following doors to not close and latch properly when tested:

1. At 3:08pm, I observed fire doors to nurses admin office did not close and latch when activated.
2. At 3:15pm, I observed that the exit door to stairs by physical therapy did not close and latch when activated.
3. At 3:25pm, I observed that the smoke doors by room 10 did not close properly.
4: At 3:26pm, I observed that the doors to rooms 13, 14, and 2 did not close and latch properly. The doors would open back up after closing. This exact same concern was brought to maintenance staff attention by way of work order. During a fire drill staff advised that the doors would open back up on 2/20/2013. No action was taken by maintenance staff and I observed the same malfunction 5 months later.
5. At 3:30pm, I observed soiled utility room door did not close and latch properly when tested.
6. On July 23, at 11:09am, I observed that the housekeeping washer room door not close and latch properly when tested.
7. At 11:20am, I observed that the dryer room and wash room self-closures were locked in the open position.

These findings were observed and discussed with the Maintenance Director.

The facility has failed to maintain exits so that the exit is readily available at all times. This could allow for patients, visitors, and staff to delay in egress out of a room or the building.

The findings include, but are not limited to:

During the facility tour on July 23, 2013 at 3:01pm, I observed that the mammography exam room was equipped with a locking latch causing the door to have two efforts to egress.

This finding was observed and discussed with the Maintenance Director.

The facility has failed to provide battery-powered emergency lighting in the Operating Room. This could allow for the OR surgeons to be in complete darkness for the 10 seconds that the generator delays to turn on. This could place patients and staff at risk of critical moments of darkness in a power outage.

The findings include, but are not limited to:

During the survey of the Operating Room on July 23, 2013 at 10:30am, I observed that there were no battery-powered emergency lights in the operating room.

This finding was observed and discussed with the Maintenance Director.

The facility has failed to provide the required number of fire drills for staff of one fire drill per quarter per shift. This could render the staff inexperience and unaware of what duties to perform in a fire emergency and thus place patients, visitors, and staff at risk of fire or smoke.

The findings include, but are not limited to:

During document review on July 23, 2013 between the hours of 9:30am and 10:30am of the facility's fire drill records from the date of survey and one year prior revealed the following deficiencies:

1. The facility was sited at the 2011 survey for only having 2 successful fire drill quarters in the year of 2010 and 2011.
2. Records revealed that the facility has 2 successful fire drill quarters in 2012.
3. To date, there have been two successful quarters of fire drills. The facility is on track for this year, however, this does make 4 consecutive years of only 2 fire drills per year per shift.

The facility was asked to conduct a fire drill at 9:00am on July 24, 2013. The results of that fire drill revealed that staff was not trained properly and the result was a failed fire drill.

1. The fire alarm pull station was activated at 9:03am. The horns/strobes notification alarms did not sound or light until a full minute later at 9:04.
2. Staff was over heard to say "what's that noise? We should call maintenance."
3. Overhead page was announced "Everybody please exit the building."
4. A patient was evacuated to the outside.
5. Another over head page was heard "Code Red in Radiology"
6. The Code Red was actually at Nurses Station. Auxiliary fire alarm panel at Nurses Station did read Nurses Station.
7. Staff member outside of the building was over heard to say "What am I suppose to do? I have never been here during a fire drill."
8. Fire doors by room 10 did not close and latch when activated by the fire alarm.

This finding was observed and discussed with the Maintenance Director.

Based on observations made during a fire drill exercise on July 23, 2013 at 9:03am, the facility has failed to maintain the proper operational condition of the fire alarm system. This has the potential of having a non-functional fire alarm system that would expose residents to a fire or smoke environment.

The findings include, but are not limited :

1. The pull station was activated at 9:03am. The horn/strobes did not sound/light until 9:04am. This exceeds the 10 second delay that is allowed by NFPA 72 Standard for Fire Alarm Systems.
2. During the general alarm of the fire drill, I observed that the roll up fire door at Radiology Reception was closed. I interviewed the receptionist and asked her if the door automatically rolled down upon the fire alarm system activation. She said, no, that it is her duty to push the button and make the door close.
3. The roll up fire door does not automatically activate into the closed position upon fire alarm as required.
4. The delay in horn/strobe activation in the old portion of the building may be an indication that the existing portion of the fire alarm is not properly interconnected withe the new as is required. This would need to be checked and verified for interconnection.

These findings were observed and discussed with the Maintenance Director.

Based on observations, the facility failed to maintain the proper operational condition of the sprinkler system. This has the potential of having a non-functional sprinkler system that would expose patients, visitors, and staff to a fire or smoke environment.

The findings include, but are not limited to:

During document review on July 23, 2013 from 9:30am to 10:30am of the facility's sprinkler system reports from the survey date to the year prior revealed the following deficiencies:

1. Quarterly inspections reports could not be produced as quarterly inspections of the sprinkler system had never been conducted. Interview with Maintenance staff revealed that the facility was not aware of the requirement to have the sprinkler system inspected quarterly.
2. Annual reports from the sprinkler company in 2011 to 2013 revealed some of the same deficiencies. No records could be produced that these items had been addressed.
3. Annual servicing reports from the sprinkler company in 2012 and 2013 were noted that the 5-year internal pipe inspection needed to be performed. No records could be produced that the 5-year internal pipe inspection had been conducted

During the survey tour on July 23, 2013 from 1:00pm to 4:00pm revealed the following sprinkler deficiencies:

1. At 1:26 the ADA restroom nearest the window walls was observed to have the escutcheon installed upside down.
2. At 1:30pm the two ADA restrooms in the basement were observed to have the orange construction protective caps still in place. The construction was completed in 2009.

These findings were observed and discussed with the Maintenance Director.

The facility has failed to maintain the kitchen hood system in proper operating conditions. This could allow for the hood to fail to extract grease laden vapors
and thus place patients, visitors, and staff at risk of fire.

The findings include, but are not limited to:

1. During the survey tour on July 24, 2013 at 11:22am, I observed the kitchen hood to be equipped with the unapproved wire mesh filters. Reports from last two servicing reports indicate that the kitchen suppression company had been advising staff that the filters needed to be changed out.

2. During document review on July 23, 2013 from 9:30am to 10:30pm, I observed that the servicing records for the kitchen suppression system were being conducted on an annual basis and not every six months as required.


These findings observed and discussed with the Maintenance Director.

The facility has failed to restrict the use of portable electric heaters to the types of heaters specified in the Life Safety Code. This could expose patients, visitors, and staff to risk of fire due to overheating of portable heaters.

The findings include, but are not limited to:

During the survey tour on July 23, 2013 at 1:46pm, I observed 3 unapproved portable heaters in the Billing and Registration offices.

This finding was observed and discussed with the Maintenance Director.

Based on observations and staff interviews, the facility failed to maintain soiled linen or trash collection receptacles to not exceed 32 gal in capacity. Exceeding the 32 gallon capacity would provide a fuel source for a fire and possibly expose residents, visitors, and staff to the threat of fire and fire spread.

The findings include, but are not limited to:

1. During the facility tour on July 23, 2013 at 1:47pm, I observed an approximately 90 gallon shred containers to be stored in the following locations:
a. One container was stored at the admin area exposed to the corridor.
b. Two containers were observed at the back exit corridor by laundry.

NOTE: All three of these shred bins were removed and relocated at the time of survey.

During the facility tour on July 24, 2013 at 11:00am, I observed a 30 gallon, a 10 gallon, and a 5 gallon trash receptacles being stored in the back exit corridor by laundry.

These findings were observed and discussed with the Maintenance Director.

The facility has failed to properly secure oxygen cylinders in an approved manner to prevent them from falling over. Failure to secure compressed gas cylinders could allow for cylinders to fall and cause missle type destruction. This would
place patients, visitors, and staff at risk of a dangerous situation and enhanced fire risk.

The findings include, but are not limited to:

During the facility tour on July 24, 2013 at 11:00am, I observed that the oxygen storage room had 6 cylinders not secured in any manner.

This violation was also cited in the 2011 survey.

This finding was observed and discussed with the Maintenance Director.

The facility has failed to provide a mechanical means of controlling humidity levels in the operating room. This could place the patient and staff at risk of fire.

The findings include, but are not limited to:


Based upon observations and staff interviews during survey of the facility Operating Room on July 23, 2013 at 10:30am, the facility does not have a mechanical means of controlling humidity levels at equal to or greater than 20%.

When staff was interviewed as to what actions are taking when the humidity levels have to be adjusted, staff indicated that they adjust the temperature of the room and turn on fans.

The operating room staff has been diligent in the maintaining of the humidity level logs.

This finding was observed and discussed with the Maintenance Director.

Based on observations and staff interviews, the facility failed to maintain the proper inspection and testing of the generator. This could potentially allow for the generator to become inoperable and staff not aware and thus expose residents, visitors, and staff to the threat of no life safety systems and emergency power during a power outage.

The findings include, but are not limited to:

Document review on July 23, 2013 between the hours of 9:00am and 10:30am of the facility's generator inspection and testing records from the date of survey and the year prior revealed that the facility has failed to conduct weekly inspections and monthly 30 minute full load tests of the generator. Interview with maintenance staff revealed that the newly hired Maintenance Director recently became aware the lack of monthly 30 minute full load test and conducted a test in July. This was memorialized in an email to the CEO. However, no log was created. This was also cited as a violation in the 2011 survey. Since the 2011 survey the only 30 minute full load test conducted was in July 2013.

This finding was observed and discussed with the Maintenance Director.

The facility has failed to maintain premises free of electrical hazards. This could provide for electrical fire and expose staff and patients to threat of fire.

The findings include, but are not limited to:

During the facility survey on July 23, 2013 from 11:00am to 4:00pm, electrical hazards were observed in the following location(s):

1. At 1:40pm, I observed Payroll Office to have power strip plugged into another power strip.
2. At 2:05pm, I observed IT room by reception/admitting to have an unapproved adaptor.
3. At 2:56pm, I observed the Digitizer in memo prep room to be have an extension cord as its permanent source of power.
4. At 3:42pm, I observed the General Surgeon office to have a power strip plugged into a power strip.
5. At 3:43pm, I observed Pharmacy to have a beige extension cord extended through a doorway into another room. An orange extension cord for the fan plugged into a power strip. And a black power strip plugged into another power strip. I observed all these items were corrected at time of the survey.
6. At 3:45pm, I observed the back room to pharmacy to have a power strip that is dangling and adding stress to the cords.

These findings were observed and discussed with the Maintenance Director.

Based on observations made during document review conducted on July 23, 2013 from 9:30am to 10:30am, the facility failed to provide a written plan for actions to implement a fire watch in the event of the automatic fire sprinkler system were to be out of service for more than 4 hours in a 24 hour period. Failure to provide an action plan to implement a fire watch could possibly expose staff and patients to be unprotected by a life safety system as required.

The findings include, but are not limited to:

1. Documentation review of the facility's disaster plan did not have a policy in place for a fire watch in the event of the automatic fire sprinkler system were to be out of service for greater than 4 hours in a 24 hour period.

This finding was observed and discussed with Maintenance Director.

Based on observations made during document review conducted on July 23, 2013 from 9:30am to 10:30am, the facility failed to provide a written plan for actions to implement a fire watch in the event of the fire alarm system were to be out of service for more than 4 hours in a 24 hour period. Failure to provide an action plan to implement a fire watch could possibly expose staff and patients to be unprotected by a life safety system as required.

The findings include, but are not limited to:

1. Documentation review of the facility's disaster plan did not have a policy in place for a fire watch in the event of the fire alarm system were to be out of service for greater than 4 hours in a 24 hour period.

This finding was observed and discussed with Maintenance Director.