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Through observation, during the survey, June 10, 2014, it was determined that the facility failed to maintain the two hour fire resistance rating of the common wall between the Hospital and other facilities.

During the walk through of the facility, with the Maintenance Director, thetwo hour (2) separation wall between the Hospital and the Business occupancy contained one (1) unsealed pipe penetration at the staff entrance.
Per NFPA 101, Section 19.1.2.3

This deficiency effected 1 smoke compartment within the facility.

Through observation during the survey, June 10, 2014, it was determined that the facility failed to maintain the hazardous areas.

During the walk-through of the facility with the Maintenance Director;
1) The janitors closet at the west exit contained excessive storage of combustible materials, which constitutes this room as a hazardous area.
a) The room failed to contain a self closing device on the door.
b) The room failed to contain a 3/4 hour rating on the door
2) The records room door contains a "dutch door"
a) The top half of the door contained a slide lock type of lock on the door. This door opens to the corridor and all components of the door must positively latch into the frame or bottom portion of the door.
b) The door does not contain a 3/4 hour rated door, which is needed to a hazardous area.
Per NFPA 101, section 18.3.2.1 and 8.4

These deficiencies effected 2 smoke compartments.

Through observation, during the survey June 15, 2010, it was determined that the facility failed to arrange the exit access so that exits are readily accessible at all times.

During the walk through of the facility, with the Maintenance Director, the following areas contained locked doors within a means of egress that created a dead end corridor greater tahn 30' and were locked without the required clinical needs of residents.
1) One (1) set of double doors, adjacent to suite 12, contained a locking system which could only be unlocked by badge swipe. This set of doors were in a required means of egress.
2) The doors to the PACU were locked and required a badge access to egress. This door was located in a required means of egress.
Per NFPA 101, section 18.2.2.2.4

This deficiency effected 2 smoke compartments and 2 means of egress

Through observation during the survey, June 10, 2014, it was determined that the facility failed to maintain the emergency lighting of 1-1/2 hour duration.

During the walk through of the facility, with the Maintenance Director;
1) The electrical room, which housed the transfer switch for the emergency lighting system, was not equipped with a battery backup emergency light, which would not illuminate with the test button was depressed.
Per NFPA 110, Chapter 5, Section 5-3
2) The battery back up lighting testing documentation failed to indicate a monthly test on the battery back up lighting occured in February, March, and May of 2014.

This deficiency potentially effected all staff, all patients, and all visitors

Through record review during the survey, June 10, 2014, it was determined that the facility failed to conduct fire drills at least quarterly on each shift.

During the review of the facility records, with the Maintenance Director, documentation was not available to verify the facility conducted a fire drill on all shifts during the 2014 calendar year. Documentation could not be located for fire drills for;
1) Missing 1st shift during the 4th quarter of 2013
2) Missing 2nd shift during the 4th quarter of 2013

This deficiency potentially effected all staff, all patients, and all visitors.

Through a review of the records during the survey, June 10, 2014, it was determined that the facility failed to inspect and test the fire alarm per NFPA 72.

During the review of the facility records, with the Maintenance Director, documentation was not available to verify that a sensitivity test on the smoke detectors had occured within two (2) years.
Per NFPA 101 2000 Edition 19.3.4.5.1, 9.6.1, and NFPA 72 7-3 and 7-3.2.1.

This deficiency potentially effected all staff, all patients, and all visitors.

Through observation during the survey, June 10, 2014, it was determined the facility failed to test the automatic sprinkler system per NFPA 25.

During document review and a walk through of the facility, with the Maintenance Director, documentation was not available to indicate the quarterly test of the wet and dry sprinkler system has occurred in the 4th quarter of 2013 and the 2nd quarter of 2014.
Per NFPA 1999 Edition of NFPA 25, section 2-1, table 2-1.

This deficiency potentially effected all staff, all patients, and all visitors.

Through observation during the survey, June 10, 2014, it was determined that the facility failed to continuously maintain the means of egress free of all obstructions or impediments to full instant use in case of fire or other emergency.

During the walkthrough of the facility, with the Maintenance Director, items were being stored in the west corridor in the following areas at 9:30 am and again at 11:00am.
1) One (1) hand sanitizer located on a stand located outside of the mens restroom
2) One (1) linen cart
3) Three (3) Nitrogen bottles
4) Two (2) tables
Per NFPA 101 2000 Edition, Chapter 7, section 7.1.10

This deficiency effected 1 smoke compartment

Through observation during the survey, June 10, 2014, it was determined that the facility failed to maintain all oxygen storage areas and failed to secure all gas storage tanks.

During the walk through of the facility, with the Maintenance Director;
1) The facility failed to secure two (2) of four (4) of the emergency liquid oxygen tanks. The storage area, located on the exterior ground level, was equipped with a heavy duty chain and hook for securing the tanks, however the staff failed to loop the chain around the liquid oxygen tanks tanks and secure the chain at both ends.
2) The interior med gas storage room contained storage of of two (2) wooden cabinaets. Storage of combustible items -are prohibited in med gas storage rooms.
Per NFPA 99, section 4-3.1.1.2

This deficiency had the potential to effect all staff, all patients, and all visitors.

Through record review during the survey, June 10, 2014, it was determined that the facility failed to maintain the generator emergency function.

During the review of the facility record and observation, with the Maintenance Director;
1) The facility failed to provide monthly testing of the generator system for the months of February, March, April, and May 2014
2) The facility failed to show documentation that a load bank test had been conducted within one (1) year. This is due to the generator not providing 30% of the rated capacity on a monthly basis. The last documented load bank test occured April 13, 2013.
Per 1999 Edition of NFPA 101 section 21.2.9.2 and 7.9.2.3, and 1999 Edition of NFPA 110 6-4.2 and 6-4.2.2.
3) The generator system failed to contain an emergency glass break type shut off switch outside of the generator housing.
Per NFPA 110, section 3-5.5.6

This deficiency had the potential to effect all staff, all patients, and all visitors.

Through observation during the survey, June 10, 2014, it was determined the facility failed to divide the essential electrical system onto the correct branches per NFPA 99.

During the document review and observation, with the Maintenance Director, theIT room was added to the Life Safety Branch. The IT room system shall be connected to the Equipment Branch.
Per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2.

This deficiency had the potential to effect all staff, all patients, and all visitors.

Through observation during the survey, June 10, 2014, it was determined that the facility failed to install the Alcohol Based Hand Rub (ABHR) dispensers correctly.

During the walkthrough of the facility, with the Maintenance Director, four (4) alcohol based hand rub dispensers (ABHR) were located above electrical outlets in the following areas.
1) One (1) in the Main lobby waiting area
2) One (1) in the main lobby corridor
3) One (1) at the ED nurse station
4) One (1) in the ED waiting room

This deficiency potentially effected 2 smoke compartments

Through observation, during the survey, June 10, 2014, it was determined that the facility failed to maintain the two hour fire resistance rating of the common wall between the Hospital and other facilities.

During the walk through of the facility, with the Maintenance Director, thetwo hour (2) separation wall between the Hospital and the Business occupancy contained one (1) unsealed pipe penetration at the staff entrance.
Per NFPA 101, Section 19.1.2.3

This deficiency effected 1 smoke compartment within the facility.

Through observation during the survey, June 10, 2014, it was determined that the facility failed to maintain the hazardous areas.

During the walk-through of the facility with the Maintenance Director;
1) The janitors closet at the west exit contained excessive storage of combustible materials, which constitutes this room as a hazardous area.
a) The room failed to contain a self closing device on the door.
b) The room failed to contain a 3/4 hour rating on the door
2) The records room door contains a "dutch door"
a) The top half of the door contained a slide lock type of lock on the door. This door opens to the corridor and all components of the door must positively latch into the frame or bottom portion of the door.
b) The door does not contain a 3/4 hour rated door, which is needed to a hazardous area.
Per NFPA 101, section 18.3.2.1 and 8.4

These deficiencies effected 2 smoke compartments.

Through observation, during the survey June 15, 2010, it was determined that the facility failed to arrange the exit access so that exits are readily accessible at all times.

During the walk through of the facility, with the Maintenance Director, the following areas contained locked doors within a means of egress that created a dead end corridor greater tahn 30' and were locked without the required clinical needs of residents.
1) One (1) set of double doors, adjacent to suite 12, contained a locking system which could only be unlocked by badge swipe. This set of doors were in a required means of egress.
2) The doors to the PACU were locked and required a badge access to egress. This door was located in a required means of egress.
Per NFPA 101, section 18.2.2.2.4

This deficiency effected 2 smoke compartments and 2 means of egress

Through observation during the survey, June 10, 2014, it was determined that the facility failed to maintain the emergency lighting of 1-1/2 hour duration.

During the walk through of the facility, with the Maintenance Director;
1) The electrical room, which housed the transfer switch for the emergency lighting system, was not equipped with a battery backup emergency light, which would not illuminate with the test button was depressed.
Per NFPA 110, Chapter 5, Section 5-3
2) The battery back up lighting testing documentation failed to indicate a monthly test on the battery back up lighting occured in February, March, and May of 2014.

This deficiency potentially effected all staff, all patients, and all visitors

Through record review during the survey, June 10, 2014, it was determined that the facility failed to conduct fire drills at least quarterly on each shift.

During the review of the facility records, with the Maintenance Director, documentation was not available to verify the facility conducted a fire drill on all shifts during the 2014 calendar year. Documentation could not be located for fire drills for;
1) Missing 1st shift during the 4th quarter of 2013
2) Missing 2nd shift during the 4th quarter of 2013

This deficiency potentially effected all staff, all patients, and all visitors.

Through a review of the records during the survey, June 10, 2014, it was determined that the facility failed to inspect and test the fire alarm per NFPA 72.

During the review of the facility records, with the Maintenance Director, documentation was not available to verify that a sensitivity test on the smoke detectors had occured within two (2) years.
Per NFPA 101 2000 Edition 19.3.4.5.1, 9.6.1, and NFPA 72 7-3 and 7-3.2.1.

This deficiency potentially effected all staff, all patients, and all visitors.

Through observation during the survey, June 10, 2014, it was determined the facility failed to test the automatic sprinkler system per NFPA 25.

During document review and a walk through of the facility, with the Maintenance Director, documentation was not available to indicate the quarterly test of the wet and dry sprinkler system has occurred in the 4th quarter of 2013 and the 2nd quarter of 2014.
Per NFPA 1999 Edition of NFPA 25, section 2-1, table 2-1.

This deficiency potentially effected all staff, all patients, and all visitors.

Through observation during the survey, June 10, 2014, it was determined that the facility failed to continuously maintain the means of egress free of all obstructions or impediments to full instant use in case of fire or other emergency.

During the walkthrough of the facility, with the Maintenance Director, items were being stored in the west corridor in the following areas at 9:30 am and again at 11:00am.
1) One (1) hand sanitizer located on a stand located outside of the mens restroom
2) One (1) linen cart
3) Three (3) Nitrogen bottles
4) Two (2) tables
Per NFPA 101 2000 Edition, Chapter 7, section 7.1.10

This deficiency effected 1 smoke compartment

Through observation during the survey, June 10, 2014, it was determined that the facility failed to maintain all oxygen storage areas and failed to secure all gas storage tanks.

During the walk through of the facility, with the Maintenance Director;
1) The facility failed to secure two (2) of four (4) of the emergency liquid oxygen tanks. The storage area, located on the exterior ground level, was equipped with a heavy duty chain and hook for securing the tanks, however the staff failed to loop the chain around the liquid oxygen tanks tanks and secure the chain at both ends.
2) The interior med gas storage room contained storage of of two (2) wooden cabinaets. Storage of combustible items -are prohibited in med gas storage rooms.
Per NFPA 99, section 4-3.1.1.2

This deficiency had the potential to effect all staff, all patients, and all visitors.

Through record review during the survey, June 10, 2014, it was determined that the facility failed to maintain the generator emergency function.

During the review of the facility record and observation, with the Maintenance Director;
1) The facility failed to provide monthly testing of the generator system for the months of February, March, April, and May 2014
2) The facility failed to show documentation that a load bank test had been conducted within one (1) year. This is due to the generator not providing 30% of the rated capacity on a monthly basis. The last documented load bank test occured April 13, 2013.
Per 1999 Edition of NFPA 101 section 21.2.9.2 and 7.9.2.3, and 1999 Edition of NFPA 110 6-4.2 and 6-4.2.2.
3) The generator system failed to contain an emergency glass break type shut off switch outside of the generator housing.
Per NFPA 110, section 3-5.5.6

This deficiency had the potential to effect all staff, all patients, and all visitors.

Through observation during the survey, June 10, 2014, it was determined the facility failed to divide the essential electrical system onto the correct branches per NFPA 99.

During the document review and observation, with the Maintenance Director, theIT room was added to the Life Safety Branch. The IT room system shall be connected to the Equipment Branch.
Per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2.

This deficiency had the potential to effect all staff, all patients, and all visitors.