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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 18, Section 18.3.6.3.1, 18.3.6.3.2, 18.3.6.3.3. "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 18. 18.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 18. 18.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On September 1, 2011, the surveyor, accompanied by the Director of Plant Operations,and the Executive Assistant observed the following doors would not positively latch when tested three of three times.

1. Room 114
2 Visitors lounge

During the exit conference on September 1, 2011, the above findings were again acknowledged by the Chief Executive Officer, Executive Assistant, and the Director of Plant Operations.

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 18, Section 18.3.7.3 "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 6, 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 1, 2011, the surveyor, accompanied by the Director of Plant Operations,and the Executive Assistant observed unsealed penetrations in the smoke barrier/s, located at In Patient Nurses station and the In Patient lounge smoke barriers.

During the exit conference on September 1, 2011, the above findings were again acknowledged by the Chief Executive Officer, Executive Assistant, and the Director of Plant Operations.

Smoke from a fire will involve other wings or possibly the whole facility if the smoke barriers provided are penetrated which could cause harm to residents/patients.

Based on observation the facility did not maintain the integrity, smoke resistance, of walls in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 18, Section 18.3.2.1 Requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls and doors must be able to resist the passage of smoke.

Findings include:

On September 1, 2011, the surveyor, accompanied by the Director of Plant Operations,and the Executive Assistant observed unsealed pipe chase holes, holes in walls or ceilings in the following rooms:

1. Mechanical room in the conference room, two pipe penetrations need to be sealed, to include re-install latch to door handle mechanism
2. Surgery sterile process room, three conduit penetrations
3. Main electrical room, penetrations in the wall
4. In Patient corridor wall from the North exit to the South Exit, numerous penetrations

During the exit conference on September 1, 2011, the above findings were again acknowledged by the Chief Executive Officer, Executive Assistant, and the Director of Plant Operations.

The pipe chases or holes could allow heat and smoke to spread into walls, attics, or exit corridors which could cause harm to residents/patients.

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

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.2.1 and Section 18.2.3.3 Section 18.2.1 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 18.2.3.3 "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 1, 2011, the surveyor, accompanied by the Director of Plant Operations,and the Executive Assistant observed storage of, a Bronchial cart with radio, trash can, two food carts(stored over thirty one minutes), two beds, a weight scale, and two life monitor machines, within the exit corridor. The storage was blocking the exit access located in the complete In Patient corridor from the North Exit to the South Exit

During the exit conference on September 1, 2011, the above findings were again acknowledged by the Chief Executive Officer, Executive Assistant, and the Director of Plant Operations.

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

Based on observation the facility failed to provide sprinkler protection through out the facility.

NFPA 101 Life Safety Code,2000,Chapter 18,Section 18.3.5.1, " Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7."NFPA 13 Section, 5-13.11 electrical Equipment."Sprinkler protection shall be required in electrical equipment rooms. Hoods or shields installed to protect important electrical equipment from sprinkler discharge shall be noncombustible.'
Exception: Sprinkler shall not be required where all of the following conditions are met:
(a) The room is dedicated to electrical equipment only.
(b) Only dry-type electrical equipment is used.
(c) Equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations.
(d) No combustible storage is permitted to be stored in the room.

Findings include:

On September 1, 2011, the surveyor, accompanied by the Director of Plant Operations and the Executive Assistant observed the ATS automatic switch electrical room had no sprinkler protection, the sprinkler was removed.

During the exit conference on September 1, 2011, the above findings were again
acknowledged by the Chief Executive Officer, Executive Assistant, and the Director of Plant Operations.

A fire starting in a non sprinkled area could grow rapidly and cause more sprinkler heads to fuse than necessary. Smoke produced by a fire in a non sprinkled area will cause harm to the residents/patients.

Based on record 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 18 Section 18.3.5.1, "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 1, 2011, the surveyor, and the Director of Plant Operations reviewed the records which indicated that the automatic sprinkler system was not inspected, or tested quarterly. The missing documentation of testing for the First quarter, January, February,March of 2011 and the Second quarter, February,March,April of 2011 does not exist.

During the exit conference on September 1, 2011, the above findings were again
acknowledged by the Chief Executive Officer, Executive Assistant, and the Director of Plant Operations.

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

Based on observation the facility failed to provide a medical gas cylinder storage room free of combustible materials.

NFPA 101 Life Safety Code 2000, Chapter 18, Section 18.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99 Standard for Health Care Facilities" NFPA 99, "Health Care Facilities", Chapter 4, Section 4-5.1.1.2 "Storage Requirements (Location, Construction, Arrangement.) Section 4-5.1.1.2 (b) 5 "Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials." Section 4-5.1.1.2 (b) 7 "Combustible materials, such as paper, cardboard, plastics, and fabrics shall not be stored or kept near supply system cylinders or manifolds containing oxygen..."

Findings include:

On September 1, 2011, the surveyor, accompanied by the Director of Plant Operations and the Executive Assistant observed one E type O2 cylinder stored in the storage room. The location was a storage room in the south west side of the In Patient corridor, The room had storage of plastics and cardboard boxes.

During the exit conference on September 1, 2011, the above findings were again
acknowledged by the Chief Executive Officer, Executive Assistant, and the Director of Plant Operations.

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

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 1, 2011 the surveyor, accompanied by the Director of Plant Operations and the executive Assistant, observed refrigerators and microwaves plugged into multi-outlet power strips and not directly plugged in to the wall outlet receptacles in the following rooms:

1. Clean supply Blood freezer
2. Cat scan/MRI control room, refrigerator and microwave
3. Director of Information Technology, refrigerator
4. ER Charting room two power strips, refrigerator and microwave

During the exit conference on September 1, 2011, the above findings were again
acknowledged by the Chief Executive Officer, Executive Assistant, and the Director of Plant Operations.

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.