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Based upon observations made in the presence of the plant manager on 11/15/12, it was determined that the facility did not maintain 2 of approximately 200 corridor doors to be positively latching and to resist the passage of smoke in accordance with NFPA 101 18.3.6.3.2.

Findings include:

The doors to procedure rooms 1 & 2 were observed to be held open by the use of a wedge between the door and floor keeping the door in a position that would not allow it to close and latch in case of an emergency.

Based upon observations made in the presence of the plant manager on 11/15/12, it was determined that the facility did not maintain hazardous areas to be fire and smoke separated from other sections of the facility in accordance with NFPA 101 18.3.2.1.

Findings include:

The kitchen store room that is over 100 square feet in size was observed to have no fire rating. This room was storing a large quantity of combustible material and needs to maintain one-hour fire resistance rated walls with a 45-minute fire resistant rated self closing door in accordance with NFPA 101 18.3.2.1.

Based upon staff interview and observations made in the presence of the plant manager on 11/15/12, it was determined that the facility did not provide doors in a required means of egress that were not equipped with a lock that required the use of a tool or key from the egress side at all times in accordance with NFPA 101 18.2.2.2.4.

Findings include:

The east and west egress doors to the stairwell from the second floor medical/surgical rooms were observed to have a magnetic lock on the door that required the use of a card to release the locking device for egress. There is no clinical need for patients to be restricted access to the exits.

Based upon observations made in the presence of the plant manager and administrator on 11/15/12, it was determined that the facility did not provide an emergency lighting system in accordance with NFPA 101 18.2.1.9 & 7.9.3.

Findings Include:

The facility was observed to be lacking an emergency light that has battery back up capabilities on the third floor in the mechanical room for the transfer switch.

Based upon observations made in the presence of the plant manager on 11/15/12, it was determined that the facility did not maintain the fire sprinkler system in accordance with NFPA 25 and NFPA 101 9.7.5.

Findings include:

The ceiling of the store room in surgery was observed to have a 3 ' x 4 ' opening in the suspended ceiling that would allow heat and smoke to rise above the sprinkler heads possibly delaying the sprinkler response time.

Based upon observations made in the presence of the plant manager on 11/15/12, it was determined that the facility did not maintain electrical equipment in accordance with NFPA 101 18.5.1 and 9.1.2.

Findings include:

1. The quality control office was observed to have a power strip plugged into another power strip creating a fire hazard.
2. Several areas in the facility were observed to be using power strips inappropriately to supply power to small appliances. This includes the dock, employee health, and soiled utility room in the labor and delivery area.
3. The facility was observed to be using extension cords on a permanent basis to supply power to equipment in the kitchen soup area, OR 1 and procedure room 2.

Based upon observations made in the presence of the plant manager on 11/15/12, it was determined that the facility did not maintain 2 of approximately 200 corridor doors to be positively latching and to resist the passage of smoke in accordance with NFPA 101 18.3.6.3.2.

Findings include:

The doors to procedure rooms 1 & 2 were observed to be held open by the use of a wedge between the door and floor keeping the door in a position that would not allow it to close and latch in case of an emergency.

Based upon observations made in the presence of the plant manager on 11/15/12, it was determined that the facility did not maintain hazardous areas to be fire and smoke separated from other sections of the facility in accordance with NFPA 101 18.3.2.1.

Findings include:

The kitchen store room that is over 100 square feet in size was observed to have no fire rating. This room was storing a large quantity of combustible material and needs to maintain one-hour fire resistance rated walls with a 45-minute fire resistant rated self closing door in accordance with NFPA 101 18.3.2.1.

Based upon staff interview and observations made in the presence of the plant manager on 11/15/12, it was determined that the facility did not provide doors in a required means of egress that were not equipped with a lock that required the use of a tool or key from the egress side at all times in accordance with NFPA 101 18.2.2.2.4.

Findings include:

The east and west egress doors to the stairwell from the second floor medical/surgical rooms were observed to have a magnetic lock on the door that required the use of a card to release the locking device for egress. There is no clinical need for patients to be restricted access to the exits.

Based upon observations made in the presence of the plant manager and administrator on 11/15/12, it was determined that the facility did not provide an emergency lighting system in accordance with NFPA 101 18.2.1.9 & 7.9.3.

Findings Include:

The facility was observed to be lacking an emergency light that has battery back up capabilities on the third floor in the mechanical room for the transfer switch.

Based upon observations made in the presence of the plant manager on 11/15/12, it was determined that the facility did not maintain the fire sprinkler system in accordance with NFPA 25 and NFPA 101 9.7.5.

Findings include:

The ceiling of the store room in surgery was observed to have a 3 ' x 4 ' opening in the suspended ceiling that would allow heat and smoke to rise above the sprinkler heads possibly delaying the sprinkler response time.

Based upon observations made in the presence of the plant manager on 11/15/12, it was determined that the facility did not maintain electrical equipment in accordance with NFPA 101 18.5.1 and 9.1.2.

Findings include:

1. The quality control office was observed to have a power strip plugged into another power strip creating a fire hazard.
2. Several areas in the facility were observed to be using power strips inappropriately to supply power to small appliances. This includes the dock, employee health, and soiled utility room in the labor and delivery area.
3. The facility was observed to be using extension cords on a permanent basis to supply power to equipment in the kitchen soup area, OR 1 and procedure room 2.