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Based on observation the facility failed to provide continuity of smoke barriers in the facility and to maintain the building's interior fire resistance rating . Failure to provide smoke barrier continuity and maintaining the interior fire resistance rating puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 1/3/2012, the surveyor noted in the closet of room 122 a penetration of the overhead that requires fire stop material.

2. On 1/5/2012, the surveyor noted that the overhead on the backside of the autoclaves had a penetration (hole) that exposes the space above.

Based on observation the facility failed to provide doors that would resist the passage of smoke. Failure on the part of the facility to provide doors that have the ability to resist the passage of smoke puts patients, staff and visitors of the facility at risk of injury in the event of a fire.

Findings include:

1. On 1/3/2012 the surveyor noted the the self closure device on the door between the small conference room and the large conference room off the lobby area had been removed.

2. On 1/3/2012, the surveyor noted that the door to the Assistant DNS's office failed to properly latch.

3. On 1/5/2012, the surveyor noted that the double doors in the cafeteria that provide access to egress exit lacked hardware that would keep the doors closed in the event of a fire or other emergency.

Based on observation the facility failed to properly mark an exit access route of travel.

Failure on the part of the facility to mark exit access routes puts patients, staff and visitors at risk should emergency exiting be required via an alternative route.

Findings include:

1. On 1/5/2012, the surveyor noted that when the double doors of the cafeteria (by small conference room door leading to corridor past the employee break room) were closed the 2nd path to egress was not apparent to cafeteria occupants as no exit sign was posted on the cafeteria side of the double doors.

Based on record review the facility failed to hold fire drills at unexpected times under varying conditions. Failure on the part of the facility to hold fire drills at unexpected times under varying conditions puts patients, staff and visitors of the facility at risk in the event of fire or other emergency.

Findings include:

1. On 1/5/2012, the surveyor noted that fire drills were being held for the various shifts at times that weren't necessarily unexpected or held under varying conditions. As an example, during the first quarter of 2011, drills were held for the day and night shifts on the same day (3/31/11) and in the same location (kitchen).

Based on record review and interview the facility failed to maintain and test smoke detection devices as is required. Failure on the part of the facility to maintain and test smoke detection devices as is required puts patients, staff and visitors of the facility at risk in the event of a smoke generating fire.

Findings include:

1. On 1/5/2012, the surveyor noted that documentation was not available to show that sensitivity testing of the smoke detection devices had been performed. Per staff interview it was determined that most but not all smoke detection devices were part of an addressable system and that documentation of the self-test for sensitivity was not available due to there not being a printer for printing out the results of the device's self testing.

2. On 1/5/2012, the surveyor was informed that documentation was not available for the monthly testing of battery powered local smoke detection devices.

Based on record review and interview the facility failed to test and maintain the automatic sprinkler system as is required. Failure to test and maintain the automatic sprinkler system as required puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 1/3/2012, the surveyor noted that sprinkler heads were being obstructed by exit signs mounted above doors at the nurses station.

2. On 1/3/2012, the surveyor noted that coaxial cable had been hung on the sprinkler piping located in the nurse's lounge.

3. On 1/5/2012, the surveyor noted that documentation was not available to show that required sprinkler system testing had been performed. More specifically, documentation was lacking for required quarterly testing of the sprinkler system (i.e. flow alarms) and it was lacking for required 5 year testing (i.e. gauges and standpipe flows).

Based on observation the facility failed to maintain its portable fire extinguishers as required. Failure on the part of the facility to maintain its portable fire extinguishers as required puts patients, staff and visitors of the facility at risk in the event of fire.

Findings include:

1. On 1/3/2012, the surveyor noted that the portable fire extinguisher mounted at the back door of the kitchen was obscured by coats hung on a coat rack placed next to the door.

Based on observation and document review the facility failed to assure the protection of its cooking facility by maintaining the kitchen hood exhaust system as required.

Failure on the part of the facility to maintain the kitchen hood exhaust system as required puts patients, staff and visitors of the facility at risk from the effects of grease accelerated fire.

Finding include:

1. On 1/3/2012, the surveyor noted that the kitchen hood system lacked a service sticker indicating when the hood and associated exhaust vent were last professionally inspected and cleaned.

2. On 1/5/2012, Fire Life Safety documentation was reviewed by the surveyor. At that time no documentation was made available showing that the hood system had been cleaned semi-annually as is required for moderate volume cooking operations.

Based on observation the facility failed to prohibit the placement of trash collection receptacles of greater than 32 gallons in the facility. Failure on the part of the facility to prohibit receptacles of greater than 32 gallons puts patients, staff and visitors of the facility at risk from the effects of fire

Findings include:

1. On 1/3/2012, the surveyor noted a trash container (shredded paper and recycling) with a combined capacity of greater than 32 gallons in the alcove across from the office of the Director of Nursing Services (DNS). Staff suggested that the container had a capacity of approximately 40 gallons.

Based on observation the facility failed provide wiring solutions in accordance with NFPA 70, National Electrical Code.

Failure on the part of the facility to provide wiring as required puts patients, staff and visitors of the facility at risk of electrical shock or fire.

Findings include:

1. On 1/3/2012, the surveyor noted that the doors to the main electrical control room were not labeled as is required.

2. On 1/3/2012, the surveyor noted that electrical panel box (G2) located in ultra sound lacked a latching/locking device.

3. On 1/3/2012, the surveyor noted in the Operating Room that a Hugger unit was plugged into a multi outlet power strip that was plugged into a wall outlet. The power strip was removed at the time of the finding.

Based on interview the facility failed to have available a policy and procedure for setting a fire watch when the automatic sprinkler system is out of service for more than 4 hours in a 24 hour period.

Failure on the part of the facility to have a policy and procedure for setting a fire watch when needed puts patients, staff and visitors of the facility a risk in the event of fire.

Findings include:

1. On 1/5/2012, the surveyor was informed by the plant services director that there wasn't a policy and procedure for setting a fire watch when the automatic sprinkler system is out of service for more than 4 hours in a 24 hour period.

Based on interview the facility failed to have available a policy and procedure for setting a fire watch when the fire alarm system is out of service for more than 4 hours in a 24 hour period.

Failure on the part of the facility to have a policy and procedure for setting a fire watch when needed puts patients, staff and visitors of the facility a risk in the event of fire.

Findings include:

1. On 1/5/2012, the surveyor was informed by the plant services director that there wasn't a policy and procedure for setting a fire watch when the fire alarm system is out of service for more than 4 hours in a 24 hour period.

Based on observation the facility failed to provide continuity of smoke barriers in the facility and to maintain the building's interior fire resistance rating . Failure to provide smoke barrier continuity and maintaining the interior fire resistance rating puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 1/3/2012, the surveyor noted in the closet of room 122 a penetration of the overhead that requires fire stop material.

2. On 1/5/2012, the surveyor noted that the overhead on the backside of the autoclaves had a penetration (hole) that exposes the space above.

Based on observation the facility failed to provide doors that would resist the passage of smoke. Failure on the part of the facility to provide doors that have the ability to resist the passage of smoke puts patients, staff and visitors of the facility at risk of injury in the event of a fire.

Findings include:

1. On 1/3/2012 the surveyor noted the the self closure device on the door between the small conference room and the large conference room off the lobby area had been removed.

2. On 1/3/2012, the surveyor noted that the door to the Assistant DNS's office failed to properly latch.

3. On 1/5/2012, the surveyor noted that the double doors in the cafeteria that provide access to egress exit lacked hardware that would keep the doors closed in the event of a fire or other emergency.

Based on observation the facility failed to properly mark an exit access route of travel.

Failure on the part of the facility to mark exit access routes puts patients, staff and visitors at risk should emergency exiting be required via an alternative route.

Findings include:

1. On 1/5/2012, the surveyor noted that when the double doors of the cafeteria (by small conference room door leading to corridor past the employee break room) were closed the 2nd path to egress was not apparent to cafeteria occupants as no exit sign was posted on the cafeteria side of the double doors.

Based on record review the facility failed to hold fire drills at unexpected times under varying conditions. Failure on the part of the facility to hold fire drills at unexpected times under varying conditions puts patients, staff and visitors of the facility at risk in the event of fire or other emergency.

Findings include:

1. On 1/5/2012, the surveyor noted that fire drills were being held for the various shifts at times that weren't necessarily unexpected or held under varying conditions. As an example, during the first quarter of 2011, drills were held for the day and night shifts on the same day (3/31/11) and in the same location (kitchen).

Based on record review and interview the facility failed to maintain and test smoke detection devices as is required. Failure on the part of the facility to maintain and test smoke detection devices as is required puts patients, staff and visitors of the facility at risk in the event of a smoke generating fire.

Findings include:

1. On 1/5/2012, the surveyor noted that documentation was not available to show that sensitivity testing of the smoke detection devices had been performed. Per staff interview it was determined that most but not all smoke detection devices were part of an addressable system and that documentation of the self-test for sensitivity was not available due to there not being a printer for printing out the results of the device's self testing.

2. On 1/5/2012, the surveyor was informed that documentation was not available for the monthly testing of battery powered local smoke detection devices.

Based on record review and interview the facility failed to test and maintain the automatic sprinkler system as is required. Failure to test and maintain the automatic sprinkler system as required puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 1/3/2012, the surveyor noted that sprinkler heads were being obstructed by exit signs mounted above doors at the nurses station.

2. On 1/3/2012, the surveyor noted that coaxial cable had been hung on the sprinkler piping located in the nurse's lounge.

3. On 1/5/2012, the surveyor noted that documentation was not available to show that required sprinkler system testing had been performed. More specifically, documentation was lacking for required quarterly testing of the sprinkler system (i.e. flow alarms) and it was lacking for required 5 year testing (i.e. gauges and standpipe flows).

Based on observation the facility failed to maintain its portable fire extinguishers as required. Failure on the part of the facility to maintain its portable fire extinguishers as required puts patients, staff and visitors of the facility at risk in the event of fire.

Findings include:

1. On 1/3/2012, the surveyor noted that the portable fire extinguisher mounted at the back door of the kitchen was obscured by coats hung on a coat rack placed next to the door.

Based on observation and document review the facility failed to assure the protection of its cooking facility by maintaining the kitchen hood exhaust system as required.

Failure on the part of the facility to maintain the kitchen hood exhaust system as required puts patients, staff and visitors of the facility at risk from the effects of grease accelerated fire.

Finding include:

1. On 1/3/2012, the surveyor noted that the kitchen hood system lacked a service sticker indicating when the hood and associated exhaust vent were last professionally inspected and cleaned.

2. On 1/5/2012, Fire Life Safety documentation was reviewed by the surveyor. At that time no documentation was made available showing that the hood system had been cleaned semi-annually as is required for moderate volume cooking operations.

Based on observation the facility failed to prohibit the placement of trash collection receptacles of greater than 32 gallons in the facility. Failure on the part of the facility to prohibit receptacles of greater than 32 gallons puts patients, staff and visitors of the facility at risk from the effects of fire

Findings include:

1. On 1/3/2012, the surveyor noted a trash container (shredded paper and recycling) with a combined capacity of greater than 32 gallons in the alcove across from the office of the Director of Nursing Services (DNS). Staff suggested that the container had a capacity of approximately 40 gallons.

Based on observation the facility failed provide wiring solutions in accordance with NFPA 70, National Electrical Code.

Failure on the part of the facility to provide wiring as required puts patients, staff and visitors of the facility at risk of electrical shock or fire.

Findings include:

1. On 1/3/2012, the surveyor noted that the doors to the main electrical control room were not labeled as is required.

2. On 1/3/2012, the surveyor noted that electrical panel box (G2) located in ultra sound lacked a latching/locking device.

3. On 1/3/2012, the surveyor noted in the Operating Room that a Hugger unit was plugged into a multi outlet power strip that was plugged into a wall outlet. The power strip was removed at the time of the finding.

Based on interview the facility failed to have available a policy and procedure for setting a fire watch when the automatic sprinkler system is out of service for more than 4 hours in a 24 hour period.

Failure on the part of the facility to have a policy and procedure for setting a fire watch when needed puts patients, staff and visitors of the facility a risk in the event of fire.

Findings include:

1. On 1/5/2012, the surveyor was informed by the plant services director that there wasn't a policy and procedure for setting a fire watch when the automatic sprinkler system is out of service for more than 4 hours in a 24 hour period.

Based on interview the facility failed to have available a policy and procedure for setting a fire watch when the fire alarm system is out of service for more than 4 hours in a 24 hour period.

Failure on the part of the facility to have a policy and procedure for setting a fire watch when needed puts patients, staff and visitors of the facility a risk in the event of fire.

Findings include:

1. On 1/5/2012, the surveyor was informed by the plant services director that there wasn't a policy and procedure for setting a fire watch when the fire alarm system is out of service for more than 4 hours in a 24 hour period.