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

NFPA 101 Life Safety Code, 2000, Chapter Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On September 26, 2011 the surveyor, accompanied by Maintenance Staff, observed that the following corridor doors would not tightly close when tested.

1. The door to the wash and sterile room in surgery has a roller latch.
2. The corridor door in surgery from the cleaning and staff area would not latch when tested
3 of 3 times.
3. The self-closing hardware on the anesthesia office corridor door was removed.
4. Endoscopy room the corridor self-closing hardware was removed.
5. Equipment holding room the rated door was wedged open.
6. In the Emergency Department the triage office rated corridor door has a radio cord
going through the door and plugging into the corridor receptacle. The door will not
close with the cord in the door.
7. Trauma room rated door will not latch when tested 3 of 3 time.
8. Emergency Department patient room corridor door would not latch when tested 3 of 3
times.
9. Emergency Department storage room corridor door would not latch when tested 3 of 3
times.
10. Staff locker room corridor door would not latch when tested 3 of 3 times.
11. The storage room by Social Services Office is missing self-closing hardware.
12. At Nursing Suite C the corridor door will not latch when tested.

During the exit conference on September 26, 2011, the above findings were again acknowledged by the Administrator and the Director of Maintenance.

In time of a fire failing to protect patients from heat and smoke could cause harm to the patients.

Based on observation the facility failed to fill penetrations in the smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of at least ? hour." (1 Hour New) Chapter 8, Section 8.3.6. "Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:"
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
(a) It shall be made on either side of the smoke barrier.
(b) It shall be made by an approved device that is designed for the specific purpose.

Findings include:

On September 26, 2011, the surveyor, accompanied by Maintenance Staff, observed unsealed penetrations in the smoke barriers, in the following location:

1. The smoke barrier above the 3 hour rated doors between the Hospital and Services
has an unsealed conduits.
The three hour rated doors when closed has a unsealed gap greater that 1/4 inch.

2. The smoke barrier at West corridor has unsealed penetrations.
There is an open junction box exposing electrical wiring.
The smoke barrier doors at I.T. office has a latching mechanism out of adjustment.

3. The center smoke barrier next to the Atrium has unsealed conduits.

4. In the North corridor by O.B. the smoke barrier closing device is broken.

5. The smoke barrier at the North corridor/North Atrium has unsealed penetrations.

6. The smoke barrier in the North corridor by the Doctors Conference room has unsealed
penetrations.
The doors have holes through the doors.

7. The smoke barrier North/West by Surgery has unsealed penetrations. The barrier doors
will not close or latch when tested.

During the exit conference on September 26, 2011, the above findings were again acknowledged by the Administrator and the Director of Maintenance.

Failing to fill holes in smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility, which will cause harm to patients.

Based on observation the facility failed to maintain the smoke resistance, of walls, ceilings or pipe chases 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.

Findings include:

On September 26, 2011, the surveyor, accompanied by Maintenance Staff observed unsealed penetration in the ceiling of the electrical room.

During the exit conference on September 26, 2011, the above findings were again acknowledged by the Administrator and the Director of Maintenance.

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

Based on observation the facility did not keep exits readily accessible at all times.

NFPA 101 Life Safety Code, 2000, Chapter 19 Section 19.2.1, and Section 19.2.3.3. Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 19.2.3.3 "Aisles, corridors and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft (Existing built to 8 feet must be maintained 8 feet clear) in clear and unobstructed width". Chapter 7 Section 7.5.1.1" Exits shall be so located and exit access shall be arranged so that exits are readily accessible at all times." Section 7.5.1.2 "Where exits are not immediately accessible from an open floor area, continuous passageways, aisles, or corridors leading directly to every exit and shall be maintained and shall be arranged to provide access for each occupant to not less than two exits by separate ways of travel."

Findings include:

On September 26, 2011, the surveyors, accompanied by Director of Maintenance and Maintenance Staff, observed storage in the following 8 foot exit corridors:

1. The Emergency Department exit corridor was reduced from 8 feet by storage of a gurney, weight scale,
Blood/Pressure equipment, and EKG equipment.

2. The patient room wing exit corridor was reduced from 8 feet by storage of 8 trash containers, I.V.
equipment, and two medication carts.

During the exit conference on September 26, 2011, the above findings were again acknowledged by the Administrator and the Director of Maintenance.

Failure to keep the exit corridors and exit access clear could hinder the evacuation during an emergency and will cause harm to patients.

Based on review the facility failed to complete an annual fire alarm system test and maintenance.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.4.1, "Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6." Section 9.6.1.4 "A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code...,
NFPA 72, Chapter 7 "Inspection Testing, and Maintenance" Section 7-3.2 "Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by authority having jurisdiction. Table 7-3.2 requires monthly and annual fire alarm inspections, testing and maintenance.

Findings Include:

On September 26, 2011, the surveyor, accompanied by the Director of Maintenance, reviewed the annual fire alarm maintenance inspections that were conducted on the fire alarm system. The latest record of the annual fire inspection, maintenance, and testing was May 11, 2010.

During the exit conference on September 26, 2011, the above findings were again acknowledged by the Administrator and the Director of Maintenance.

Failure to test and maintain the fire alarm system will result in harm to the patients.

Based on review the facility did not inspect, test and maintain the automatic sprinkler system in accordance with the requirements of the Life Safety Code.

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.

Findings Include:

On September 26, 2011, the surveyor, accompanied by the Director of Maintenance, reviewed the records which indicated that the automatic sprinkler system was not inspected or maintained annually since June 2, 2009.

During the exit conference on September 26, 2011, the findings were again acknowledged by the Administrator and the Director of Maintenance.

Failure to inspect, test, and maintain the sprinkler system could result in harm to the patients through the spread of smoke and fire.

Based on observation and interview the facility failed to provide a designated smoking area with noncombustible ashtrays and a self-closing metal container.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.7.4 or Chapter 19, Section 19.7.4. "Smoking regulations shall be adopted and shall include not less than the following provisions:
(3) "Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted."
(4) "Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted."

Findings Include:

On September 26, 2011, the surveyor, accompanied by Maintenance Staff , observed the ground at an exit discharge. There were cigarette butts on the ground. The Director of Maintenance stated the facility did not have a designated smoking area.

During the exit conference on September 26, 2011, the above findings were again acknowledged by the Administrator and the Director of Maintenance.

Failure to provide a designated smoking area, noncombustible ashtrays and a metal container for the disposal of cigarette butts could result in a fire which could cause harm to patients.

Based on record review and observation the kitchen hood was not cleaned or inspected in accordance with NFPA 96.

NFPA 101 Life Safety Code, 2000 Edition, Chapter 19, Section 19.3.2.6, "Cooking Facilities." "Cooking facilities shall be protected in accordance with 9.2.3." Section 9.2.3, "Commercial Cooking Equipment" "Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.... Chapter 8, Section 8-3 "Cleaning" "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. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person (s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1." Table 8-3.1, Exhaust System Inspection Schedule "Type or Volume of Cooking Frequency" "Systems serving moderate-volume cooking operations." Frequency is Semiannually"
Section 8-3.1.1 "Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified, and certified company or person (s) acceptable to the authority having jurisdiction in accordance with Section 8-3."
Section 8-3.1.2 "When a vent cleaning service is used, a certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company. It shall also indicate areas not cleaned."

Findings Include:

On September 26, 2011, the surveyor accompanied by the Director of Maintenance and Maintenance Staff, observed the kitchen hood. The hood did not have a label indicating when the hood was last cleaned and inspected. The facility was unable to provide any documented evidence that the cooking hood and vents were inspected and cleaned in accordance with NFPA 96.

In addition; The two hood filters located at the prep serving table were covered with lint and grease.

During the exit conference on September 13, 2011, the above findings were again acknowledged by the Administrator, and Director of Maintenance.

Failing to inspect and clean the kitchen hood and vents will allow a build-up of grease and provide fuel for a fire. A fire in the kitchen may cause harm to patients and staff.

The facility failed to provide a medical gas cylinder storage room free of combustible materials.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99 Standard for Health Care Facilities" NFPA 99, Chapter 8, Section 8-3.1.11 "Storage Requirements" Section 8-3.1.11.2 "Storage of nonflammable gases less than 3000 cubic. feet.." (a) "Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. (c) "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by: (c) (1) A minimum distance of 20 feet, or (c) (2) A minimum distance of 5 ft. if the entire storage location is protected by an automatic sprinkler system..."

On September 26, 2011, the surveyor, accompanied by Maintenance Staff, observed the oxygen storage area in the Surgery Suite. The storage area had combustibles stored within 20 feet of the medical gases.

Leaking oxygen will penetrate combustible material and create an extreme fire hazard, which will cause harm to the patients.

Based on interview the laboratory failed to provide a chemical spill emergency procedure plan.

NFPA 99, Health Care Facilities, 1999 Edition, Chapter 10, Section 10-2.1.3.2. "Emergency procedures shall be established for controlling chemical spills."

Findings Include:

On September 26, 2011, the surveyor accompanied by the Director of Maintenance, interviewed the Laboratory Director. The surveyor asked the Laboratory Director do you have a policy to control spills in an emergency. The Laboratory Director stated they had spill kits with-in the laboratory but did not have a written plan for review they only had the Hospital emergency plan.

During the exit conference on September 26, 2011, the above findings were again acknowledged by the Administrator and the Director of Maintenance.

Failing to have a written spill plan during a hazardous spill will cause harm to Staff and Patients.

Based on interview the laboratory did not have any written emergency procedures plan.

NFPA 99 Health Care Facilities, 1999 Edition, Chapter 10, Section 10-2.1.3.1, "Procedures for laboratory emergencies shall be developed. Such procedures shall include alarm actuation, evacuation, and equipment shutdown procedures, and provisions for control of emergencies that could occur in the laboratory, including specific detailed plans for control operations by an emergency control group within the organization or a public fire department.

Findings Include:

On September 26, 2011, the surveyor accompanied by the Director of Maintenance, interviewed the Laboratory Director. The Director was asked by the surveyor were the written emergency procedure plan was kept. The Director stated the laboratory only had the Hospital emergency procedures available. There was not a laboratory emergency procedure policy.

During the exit conference on September 26, 2011, the above findings were again acknowledged by the Administrator and the Director of Maintenance.

Failure to have a laboratory emergency procedures plan will cause harm to Staff and patients during a laboratory emergency.

Based on observation the facility failed to provide a guard on the light bulb located in the supply closet.

NFPA 101 Life Safety Code, 2000, 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 September 26, 2010, the surveyor, accompanied by Maintenance Staff, observed that the light bulbs
located in the following rooms were not protected from physical damage.

1. The Emergency Department storage room has an un-protected light bulb.

2. The Housekeeping room in the North/East wing has an un-protected light bulb.

During the exit conference on September 26, 2011, the above findings were again acknowledged by the Administrator and the Director of Maintenance.

Failure to keep light guards on the light could cause accidental damage or possibly a fire, which could cause harm to the patients.

Based on Observation the facility allowed the use of a multiple outlet adapter, power strips and did not use the wall outlet receptacles for appliances.

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.

Findings include:

On September 26, 2011 the surveyor, accompanied by Maintenance Staff, observed refrigerators and a microwave plugged into multi-outlet power strips and not directly plugged in to the wall outlet receptacles in the following rooms:

1. In the Emergency Department break room the refrigerator was plugged into a multi-outlet
power strip.

2. In the Director of Nursing office the microwave, coffee pot, and refrigerator was
plugged into a multi-outlet power strip.

During the exit conference on September 26, 2011, the above findings were again acknowledged by the Administrator and the Director of Maintenance.

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.

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

NFPA 101 Life Safety Code, 2000, Chapter Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On September 26, 2011 the surveyor, accompanied by Maintenance Staff, observed that the following corridor doors would not tightly close when tested.

1. The door to the wash and sterile room in surgery has a roller latch.
2. The corridor door in surgery from the cleaning and staff area would not latch when tested
3 of 3 times.
3. The self-closing hardware on the anesthesia office corridor door was removed.
4. Endoscopy room the corridor self-closing hardware was removed.
5. Equipment holding room the rated door was wedged open.
6. In the Emergency Department the triage office rated corridor door has a radio cord
going through the door and plugging into the corridor receptacle. The door will not
close with the cord in the door.
7. Trauma room rated door will not latch when tested 3 of 3 time.
8. Emergency Department patient room corridor door would not latch when tested 3 of 3
times.
9. Emergency Department storage room corridor door would not latch when tested 3 of 3
times.
10. Staff locker room corridor door would not latch when tested 3 of 3 times.
11. The storage room by Social Services Office is missing self-closing hardware.
12. At Nursing Suite C the corridor door will not latch when tested.

During the exit conference on September 26, 2011, the above findings were again acknowledged by the Administrator and the Director of Maintenance.

In time of a fire failing to protect patients from heat and smoke could cause harm to the patients.

Based on observation the facility failed to fill penetrations in the smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of at least ? hour." (1 Hour New) Chapter 8, Section 8.3.6. "Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:"
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
(a) It shall be made on either side of the smoke barrier.
(b) It shall be made by an approved device that is designed for the specific purpose.

Findings include:

On September 26, 2011, the surveyor, accompanied by Maintenance Staff, observed unsealed penetrations in the smoke barriers, in the following location:

1. The smoke barrier above the 3 hour rated doors between the Hospital and Services
has an unsealed conduits.
The three hour rated doors when closed has a unsealed gap greater that 1/4 inch.

2. The smoke barrier at West corridor has unsealed penetrations.
There is an open junction box exposing electrical wiring.
The smoke barrier doors at I.T. office has a latching mechanism out of adjustment.

3. The center smoke barrier next to the Atrium has unsealed conduits.

4. In the North corridor by O.B. the smoke barrier closing device is broken.

5. The smoke barrier at the North corridor/North Atrium has unsealed penetrations.

6. The smoke barrier in the North corridor by the Doctors Conference room has unsealed
penetrations.
The doors have holes through the doors.

7. The smoke barrier North/West by Surgery has unsealed penetrations. The barrier doors
will not close or latch when tested.

During the exit conference on September 26, 2011, the above findings were again acknowledged by the Administrator and the Director of Maintenance.

Failing to fill holes in smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility, which will cause harm to patients.

Based on observation the facility failed to maintain the smoke resistance, of walls, ceilings or pipe chases 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.

Findings include:

On September 26, 2011, the surveyor, accompanied by Maintenance Staff observed unsealed penetration in the ceiling of the electrical room.

During the exit conference on September 26, 2011, the above findings were again acknowledged by the Administrator and the Director of Maintenance.

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

Based on observation the facility did not keep exits readily accessible at all times.

NFPA 101 Life Safety Code, 2000, Chapter 19 Section 19.2.1, and Section 19.2.3.3. Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 19.2.3.3 "Aisles, corridors and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft (Existing built to 8 feet must be maintained 8 feet clear) in clear and unobstructed width". Chapter 7 Section 7.5.1.1" Exits shall be so located and exit access shall be arranged so that exits are readily accessible at all times." Section 7.5.1.2 "Where exits are not immediately accessible from an open floor area, continuous passageways, aisles, or corridors leading directly to every exit and shall be maintained and shall be arranged to provide access for each occupant to not less than two exits by separate ways of travel."

Findings include:

On September 26, 2011, the surveyors, accompanied by Director of Maintenance and Maintenance Staff, observed storage in the following 8 foot exit corridors:

1. The Emergency Department exit corridor was reduced from 8 feet by storage of a gurney, weight scale,
Blood/Pressure equipment, and EKG equipment.

2. The patient room wing exit corridor was reduced from 8 feet by storage of 8 trash containers, I.V.
equipment, and two medication carts.

During the exit conference on September 26, 2011, the above findings were again acknowledged by the Administrator and the Director of Maintenance.

Failure to keep the exit corridors and exit access clear could hinder the evacuation during an emergency and will cause harm to patients.

Based on review the facility failed to complete an annual fire alarm system test and maintenance.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.4.1, "Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6." Section 9.6.1.4 "A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code...,
NFPA 72, Chapter 7 "Inspection Testing, and Maintenance" Section 7-3.2 "Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by authority having jurisdiction. Table 7-3.2 requires monthly and annual fire alarm inspections, testing and maintenance.

Findings Include:

On September 26, 2011, the surveyor, accompanied by the Director of Maintenance, reviewed the annual fire alarm maintenance inspections that were conducted on the fire alarm system. The latest record of the annual fire inspection, maintenance, and testing was May 11, 2010.

During the exit conference on September 26, 2011, the above findings were again acknowledged by the Administrator and the Director of Maintenance.

Failure to test and maintain the fire alarm system will result in harm to the patients.

Based on review the facility did not inspect, test and maintain the automatic sprinkler system in accordance with the requirements of the Life Safety Code.

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.

Findings Include:

On September 26, 2011, the surveyor, accompanied by the Director of Maintenance, reviewed the records which indicated that the automatic sprinkler system was not inspected or maintained annually since June 2, 2009.

During the exit conference on September 26, 2011, the findings were again acknowledged by the Administrator and the Director of Maintenance.

Failure to inspect, test, and maintain the sprinkler system could result in harm to the patients through the spread of smoke and fire.

Based on observation and interview the facility failed to provide a designated smoking area with noncombustible ashtrays and a self-closing metal container.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.7.4 or Chapter 19, Section 19.7.4. "Smoking regulations shall be adopted and shall include not less than the following provisions:
(3) "Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted."
(4) "Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted."

Findings Include:

On September 26, 2011, the surveyor, accompanied by Maintenance Staff , observed the ground at an exit discharge. There were cigarette butts on the ground. The Director of Maintenance stated the facility did not have a designated smoking area.

During the exit conference on September 26, 2011, the above findings were again acknowledged by the Administrator and the Director of Maintenance.

Failure to provide a designated smoking area, noncombustible ashtrays and a metal container for the disposal of cigarette butts could result in a fire which could cause harm to patients.

Based on record review and observation the kitchen hood was not cleaned or inspected in accordance with NFPA 96.

NFPA 101 Life Safety Code, 2000 Edition, Chapter 19, Section 19.3.2.6, "Cooking Facilities." "Cooking facilities shall be protected in accordance with 9.2.3." Section 9.2.3, "Commercial Cooking Equipment" "Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.... Chapter 8, Section 8-3 "Cleaning" "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. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person (s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1." Table 8-3.1, Exhaust System Inspection Schedule "Type or Volume of Cooking Frequency" "Systems serving moderate-volume cooking operations." Frequency is Semiannually"
Section 8-3.1.1 "Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified, and certified company or person (s) acceptable to the authority having jurisdiction in accordance with Section 8-3."
Section 8-3.1.2 "When a vent cleaning service is used, a certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company. It shall also indicate areas not cleaned."

Findings Include:

On September 26, 2011, the surveyor accompanied by the Director of Maintenance and Maintenance Staff, observed the kitchen hood. The hood did not have a label indicating when the hood was last cleaned and inspected. The facility was unable to provide any documented evidence that the cooking hood and vents were inspected and cleaned in accordance with NFPA 96.

In addition; The two hood filters located at the prep serving table were covered with lint and grease.

During the exit conference on September 13, 2011, the above findings were again acknowledged by the Administrator, and Director of Maintenance.

Failing to inspect and clean the kitchen hood and vents will allow a build-up of grease and provide fuel for a fire. A fire in the kitchen may cause harm to patients and staff.

The facility failed to provide a medical gas cylinder storage room free of combustible materials.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99 Standard for Health Care Facilities" NFPA 99, Chapter 8, Section 8-3.1.11 "Storage Requirements" Section 8-3.1.11.2 "Storage of nonflammable gases less than 3000 cubic. feet.." (a) "Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. (c) "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by: (c) (1) A minimum distance of 20 feet, or (c) (2) A minimum distance of 5 ft. if the entire storage location is protected by an automatic sprinkler system..."

On September 26, 2011, the surveyor, accompanied by Maintenance Staff, observed the oxygen storage area in the Surgery Suite. The storage area had combustibles stored within 20 feet of the medical gases.

Leaking oxygen will penetrate combustible material and create an extreme fire hazard, which will cause harm to the patients.

Based on interview the laboratory did not have any written emergency procedures plan.

NFPA 99 Health Care Facilities, 1999 Edition, Chapter 10, Section 10-2.1.3.1, "Procedures for laboratory emergencies shall be developed. Such procedures shall include alarm actuation, evacuation, and equipment shutdown procedures, and provisions for control of emergencies that could occur in the laboratory, including specific detailed plans for control operations by an emergency control group within the organization or a public fire department.

Findings Include:

On September 26, 2011, the surveyor accompanied by the Director of Maintenance, interviewed the Laboratory Director. The Director was asked by the surveyor were the written emergency procedure plan was kept. The Director stated the laboratory only had the Hospital emergency procedures available. There was not a laboratory emergency procedure policy.

During the exit conference on September 26, 2011, the above findings were again acknowledged by the Administrator and the Director of Maintenance.

Failure to have a laboratory emergency procedures plan will cause harm to Staff and patients during a laboratory emergency.

Based on observation the facility failed to provide a guard on the light bulb located in the supply closet.

NFPA 101 Life Safety Code, 2000, 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 September 26, 2010, the surveyor, accompanied by Maintenance Staff, observed that the light bulbs
located in the following rooms were not protected from physical damage.

1. The Emergency Department storage room has an un-protected light bulb.

2. The Housekeeping room in the North/East wing has an un-protected light bulb.

During the exit conference on September 26, 2011, the above findings were again acknowledged by the Administrator and the Director of Maintenance.

Failure to keep light guards on the light could cause accidental damage or possibly a fire, which could cause harm to the patients.

Based on Observation the facility allowed the use of a multiple outlet adapter, power strips and did not use the wall outlet receptacles for appliances.

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.

Findings include:

On September 26, 2011 the surveyor, accompanied by Maintenance Staff, observed refrigerators and a microwave plugged into multi-outlet power strips and not directly plugged in to the wall outlet receptacles in the following rooms:

1. In the Emergency Department break room the refrigerator was plugged into a multi-outlet
power strip.

2. In the Director of Nursing office the microwave, coffee pot, and refrigerator was
plugged into a multi-outlet power strip.

During the exit conference on September 26, 2011, the above findings were again acknowledged by the Administrator and the Director of Maintenance.

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.