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The facility failed to ensure doors to hazardous areas in fully sprinklered existing health care occupancies were equipped with self-closing/automatic latching hardware.

Observation determined:

1) The door to the Storage Room across from Elevator #2 on the ground floor did not have self-closing hardware.

2) The door to the Hospice Storage Room did not have self-closing hardware.

3) The door to the Fox Auditorium Store Room did not have self-closing hardware.

Failure to ensure doors to hazardous areas self-close and latch to the door frame increases the risk or death or injury due to fire.

The deficiency affected three (3) of numerous hazardous areas in the facility.

The facility failed to conduct fire drills as required.

Fire drill records review determined the facility failed to conduct fire drills on the Night Shift during the first quarter of 2014, and on the PM Shift during third quarter of 2014.

Failure to conduct fire drills as required increases the risk of death or injury due to fire.

The deficiency affected two (2) of twelve (12) drills in the past year.

The facility failed to ensure the fire alarm system was continuously maintained in a reliable operating condition as required by NFPA 72, National Fire Alarm Code.

Review of the 11/07/2014 annual fire alarm system test determined:

1) The fire alarm system sealed lead acid batteries failed the load voltage test and had not been replaced.

2) Three (3) audible devices failed when tested and had not been replaced.

3) Two (2) heat detectors failed when tested and had not been replaced.

Failure to test and maintain the fire alarm system in accordance with NFPA 72 increases the risk of death or injury due to fire.

This deficiency affected six (6) of numerous components of the fire alarm system in the last year. The fire alarm system serves the entire facility.

Automatic fire sprinkler systems must be installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

The facility failed to install the automatic sprinkler system in accordance with NFPA 13 to provide adequate coverage for all portions of the building.

Observation determined:

1) The Old X-Ray Storage Room and the Storage Room across from the Old X-Ray Storage Room lacked sprinkler coverage.

2) Shower curtains suspended from ceiling mounted tracks obstructed coverage of the sprinkler in the O.R. Patient Shower Room, O.R. Male Dressing Room, O.R. Female Dressing Room, and Patient Rooms 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, 114, 115, 116, 117, 118, 119, and 120.

Failure to install the automatic sprinkler system in accordance with NFPA 13 increases the risk of injury and death due to fire.

The deficiency affected twenty-four (24) of numerous areas in the facility.

The facility failed to inspect fire extinguishers in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

Observation determined portable fire extinguishers throughout the facility had not been inspected during all months of the past year.

Failure to ensure portable fire extinguishers comply with NFPA 10 increases the risk of death or injury due to fire.

The deficiency affected numerous portable fire extinguishers in the facility.

1) The facility failed to properly install grease filters in the exhaust hood in the Kitchen.

Observation determined the grease filters in the exhaust hood over the cooking equipment in the Kitchen were installed horizontally with the grease openings located at the sides of the filters instead of the vertical orientation to allow grease to drain.

Failure to properly install grease filters increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) exhaust hood in the facility.

2) Fire extinguishing systems for commercial cooking operations must meet NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. NFPA 96 requires an inspection and servicing of the fire-extinguishing system be made at least every 6 months by properly trained and qualified persons.

The facility failed to maintain the fire-extinguishing system as required by NFPA 96.

Records review determined during the 08/06/2014 cooking equipment fire extinguishing system inspection one (1) of two (2) wet chemical tanks was below pressure and had not been replaced at the time of the survey.

Failure to maintain the fire extinguishing system in accordance with NFPA 96 increases the risk of death or injury due to fire.

This deficiency affected one (1) of one (1) fire extinguishing system for commercial cooking operations in the building.

1) The facility failed to ensure smoke detectors were maintained, inspected and tested in accordance with the manufacturer's specifications.

There was no record that the weekly tests of the battery-operated smoke detectors had been conducted in accordance with the manufacturer's specifications in the past year.

Failure to maintain smoke detectors as required increases the risk of death or injury due to fire.

The deficiency affected all smoke detectors in the facility.

2) The facility failed to install and inspect fire extinguishers in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

Observation determined portable fire extinguishers throughout the facility had not been inspected during all months of the past year.

Failure to ensure portable fire extinguishers comply with NFPA 10 increases the risk of death or injury due to fire.

The deficiency affected numerous portable fire extinguishers in the facility.

3) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart. NFPA 99 4-3.5.2.1(b)27.

The facility failed to ensure medical gas cylinders were secured in accordance with the requirements of NFPA 99.

Observation determined two (2) nitrous oxide cylinders and two (2) oxygen cylinders were not secured in the Dentist Office Storage Room in the basement.

Failure to secure medical gas cylinders increases the risk of death or injury due to fire.

The deficiency affected the entire facility.

The facility failed to ensure doors to hazardous areas in fully sprinklered existing health care occupancies were equipped with self-closing/automatic latching hardware.

Observation determined:

1) The door to the Storage Room across from Elevator #2 on the ground floor did not have self-closing hardware.

2) The door to the Hospice Storage Room did not have self-closing hardware.

3) The door to the Fox Auditorium Store Room did not have self-closing hardware.

Failure to ensure doors to hazardous areas self-close and latch to the door frame increases the risk or death or injury due to fire.

The deficiency affected three (3) of numerous hazardous areas in the facility.

The facility failed to conduct fire drills as required.

Fire drill records review determined the facility failed to conduct fire drills on the Night Shift during the first quarter of 2014, and on the PM Shift during third quarter of 2014.

Failure to conduct fire drills as required increases the risk of death or injury due to fire.

The deficiency affected two (2) of twelve (12) drills in the past year.

The facility failed to ensure the fire alarm system was continuously maintained in a reliable operating condition as required by NFPA 72, National Fire Alarm Code.

Review of the 11/07/2014 annual fire alarm system test determined:

1) The fire alarm system sealed lead acid batteries failed the load voltage test and had not been replaced.

2) Three (3) audible devices failed when tested and had not been replaced.

3) Two (2) heat detectors failed when tested and had not been replaced.

Failure to test and maintain the fire alarm system in accordance with NFPA 72 increases the risk of death or injury due to fire.

This deficiency affected six (6) of numerous components of the fire alarm system in the last year. The fire alarm system serves the entire facility.

Automatic fire sprinkler systems must be installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

The facility failed to install the automatic sprinkler system in accordance with NFPA 13 to provide adequate coverage for all portions of the building.

Observation determined:

1) The Old X-Ray Storage Room and the Storage Room across from the Old X-Ray Storage Room lacked sprinkler coverage.

2) Shower curtains suspended from ceiling mounted tracks obstructed coverage of the sprinkler in the O.R. Patient Shower Room, O.R. Male Dressing Room, O.R. Female Dressing Room, and Patient Rooms 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, 114, 115, 116, 117, 118, 119, and 120.

Failure to install the automatic sprinkler system in accordance with NFPA 13 increases the risk of injury and death due to fire.

The deficiency affected twenty-four (24) of numerous areas in the facility.

The facility failed to inspect fire extinguishers in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

Observation determined portable fire extinguishers throughout the facility had not been inspected during all months of the past year.

Failure to ensure portable fire extinguishers comply with NFPA 10 increases the risk of death or injury due to fire.

The deficiency affected numerous portable fire extinguishers in the facility.

1) The facility failed to properly install grease filters in the exhaust hood in the Kitchen.

Observation determined the grease filters in the exhaust hood over the cooking equipment in the Kitchen were installed horizontally with the grease openings located at the sides of the filters instead of the vertical orientation to allow grease to drain.

Failure to properly install grease filters increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) exhaust hood in the facility.

2) Fire extinguishing systems for commercial cooking operations must meet NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. NFPA 96 requires an inspection and servicing of the fire-extinguishing system be made at least every 6 months by properly trained and qualified persons.

The facility failed to maintain the fire-extinguishing system as required by NFPA 96.

Records review determined during the 08/06/2014 cooking equipment fire extinguishing system inspection one (1) of two (2) wet chemical tanks was below pressure and had not been replaced at the time of the survey.

Failure to maintain the fire extinguishing system in accordance with NFPA 96 increases the risk of death or injury due to fire.

This deficiency affected one (1) of one (1) fire extinguishing system for commercial cooking operations in the building.

1) The facility failed to ensure smoke detectors were maintained, inspected and tested in accordance with the manufacturer's specifications.

There was no record that the weekly tests of the battery-operated smoke detectors had been conducted in accordance with the manufacturer's specifications in the past year.

Failure to maintain smoke detectors as required increases the risk of death or injury due to fire.

The deficiency affected all smoke detectors in the facility.

2) The facility failed to install and inspect fire extinguishers in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

Observation determined portable fire extinguishers throughout the facility had not been inspected during all months of the past year.

Failure to ensure portable fire extinguishers comply with NFPA 10 increases the risk of death or injury due to fire.

The deficiency affected numerous portable fire extinguishers in the facility.

3) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart. NFPA 99 4-3.5.2.1(b)27.

The facility failed to ensure medical gas cylinders were secured in accordance with the requirements of NFPA 99.

Observation determined two (2) nitrous oxide cylinders and two (2) oxygen cylinders were not secured in the Dentist Office Storage Room in the basement.

Failure to secure medical gas cylinders increases the risk of death or injury due to fire.

The deficiency affected the entire facility.