HospitalInspections.org

Based on observations and interview it was determined that the facility failed to separate sections of health care facilities from non-healthcare facilities. This resulted in the potential for the spread of fire & smoke into other sections of the health care facility (LSC 19.1.2.3, 19.1.1.4). Findings include, but are not limited to:

1. On June 27, 2011 at 2:30 p.m., there were unsealed penetrations in the 2-hour separation wall between the business offices and the hospital above the drop-ceiling tiles.

Based on observations and interview it was determined that the facility failed to separate sections of health care facilities from non-healthcare facilities. This resulted in the potential for the spread of fire & smoke into other sections of the health care facility (LSC 19.1.2.3, 19.1.1.4). Findings include, but are not limited to:

1. On June 27, 2011 at 2:32 p.m., the 2-hour separation wall between the business offices and the hospital had non-fire-rated spray foam sealing penetrations above the drop-ceiling tiles.

2. On June 27, 2011 at 2:57 p.m., two roll-down fire windows separating the Kitchen from the Dining Room were past due for annual service and inspection (last dated 1999).

Based on observations and interviews it was determined that the facility failed to meet or maintain the construction type requirements. This resulted in the potential for fire/smoke to spread to other areas of the facility, causing the exposure of patients & staff to hazardous products of fire (LSC 19.3.6.1, .2, .5). Findings include, but are not limited to:

1. On June 27, 2011 at 3:45 p.m., unsealed penetrations were found in the smoke barrier wall by Room 125.

Based on observations and interviews it was determined that the facility failed to maintain integrity of smoke separations. This resulted in the potential for smoke to spread to other areas of the facility, causing the exposure of residents & staff to hazardous products of fire (LSC 19.3.6.1, .2, .5). Findings include, but are not limited to:

1. On June 27, 2011 at 3:38 p.m., the doors leading to the Emergency Room were not smoke rated and did not close automatically.

Based on observations, record review and interviews it was determined that the facility failed to maintain exit corridor doors to resist the passage of smoke in accordance with NFPA 80. This resulted in the potential for passage of smoke into the means of egress in the event of a hostile fire event (LSC 19.2.3.5, 19.3.2.1, 19.3.6.3, 4.6.12.1). Findings include, but are not limited to:

1. On June 27, 2011 at 1:11 p.m., the Maintenance Assistant indicated that the facility did not have access to the adopted standard NFPA 80, 1999 Edition, for maintaining, testing, & inspecting smoke and fire doors; therefore facility was not documenting maintenance, testing, & inspections in accordance with this standard..

2. On June 27, 2011 at 2:46 p.m., the 90-minute rated doors separating the Business Offices from the Hospital were not latching.

3. On June 27, 2011 at 3:07 p.m., a kick-down door prop was found at the Radiology Department, the door to the Medical Imaging area, the Housekeeping closet door in the lobby, the Housekeeping closet in the Med/Surg hallway, and the Lab entrance door.

4. On June 27, 2011 at 3:15 p.m., the smoke barrier doors between the Medical/Surgery area and the Lobby did not close, due to improper air flow.

Based on observations, record review and interviews it was determined that the facility failed to maintain exit corridor doors to resist the passage of smoke in accordance with NFPA 80. This resulted in the potential for passage of smoke into the means of egress in the event of a hostile fire event (LSC 19.2.3.5, 19.3.6.3, 4.6.12.1). Findings include, but are not limited to:

1. On June 27, 2011 at 2:54 p.m., kick down door props were found on the exterior doors near Materials Management.

Based on observations and interview it was determined that the facility failed to provide opening protection, which separates exit corridors from hazardous areas with a sprinkler and smoke partition in existing facilities. This resulted in the potential for the spread of fire/smoke into other portions of the facility including the means of egress during a hostile fire event (LSC 19.3.2.6, 8.2.3.2, 7.2.1.8, 19.3.2.1). Findings include, but are not limited to:

1. On June 27, 2011 at 2:36 p.m., combustible curtains made of plastic and a cabinet made of wood were found in the Mechanical Room.

Based on observations, interviews and record review it was determined that the facility failed to maintain emergency action plan current & readily available. This resulted in the potential for limited staff effectiveness during emergency conditions (LSC 19.7.1.1). Findings include, but are not limited to:

1. On June 27, 2011 at 1:30 p.m., the facility's disaster manual was found to be deficient in the following items: The fire plan did not indicate to call 9-1-1 if a fire is discovered; evacuation of the smoke compartment was not planned for unless the Charge Nurse decided it was necessary; the plan did not include a "defend in place" strategy for evacuating the involved smoke compartment to another smoke compartment in the event of a fire and directed staff to not pass through the fire doors; there was no plan for marking rooms that had been evacuated; there were no instructions for manually starting the generator if it failed to start automatically; there was no map included in the plan that indicated where the main utility shut-offs were located; the plan for a bomb threat did not use "code brown" for a bomb threat; the staffing plan did not include a plan for accommodating staff in temporary and long-term emergency situations; there was no documentation of an annual review of the disaster manual by the safety committee; and there was no transfer or transportation agreements with equivalent facilities if the building had to be evacuated.

Based on record reviews and interviews it was determined that the facility failed to provide fire drills for all staff. This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing patients to smoke and fire in the facility (LSC 19.7.1.2, A.19.7.1.2). Findings include, but are not limited to:

1. On June 27, 2011 at 1:11 p.m., a review of the fire drill records for the past three years indicated that the forms were found to be incomplete, false alarms were counted as drills and that fire drills were not conducted at staggered times throughout the shift.

Based on observations, record review and interviews it was determined that the facility failed to test and maintain fire alarm in accordance with NFPA 72. This resulted in the potential for system and device failure during fire emergencies (LSC 4.6.12.1, 9.6.1.4, NFPA 70, NFPA 72). Findings include, but are not limited to:

1. On June 27, 2011 at 1:11 p.m., the Maintenance Assistant indicated that the facility did not have access to the adopted standard NFPA 72, 1999 Edition, for maintaining, testing, & inspecting fire alarm systems; therefore facility was not documenting maintenance, testing, & inspections in accordance with this standard.

2. On June 27, 2011 at 3:32 p.m., fire alarm notification appliances were found in the Operating Room, patient rooms, Therapy room, and bathrooms. According to staff, this condition was throughout the facility.

Based on observations, record review and interviews it was determined that the facility failed to test and maintain smoke detectors in accordance with NFPA 72. This resulted in the potential for system and device failure during fire emergencies (LSC 4.6.12.1, 9.6.1.3, NFPA 70, NFPA 72). Findings include, but are not limited to:

1. On June 27, 2011 at 2:40 p.m., a smoke detector was mounted in a "dead-air" space above the fire alarm panel.

Based on observations, record review and interviews it was determined that the facility failed to ensure that sprinkler system is continuously maintained & in reliable operating condition. This resulted in the potential for system failure during fire emergencies (LSC 4.6.12.1, NFPA 13 3-2.91, .2, .3, NFPA 25 9.6.2.1, .2 & 8.17.4.6). Findings include, but are not limited to:

1. On June 27, 2011 at 1:11 p.m., the Maintenance Assistant indicated that the facility did not have access to the adopted standard NFPA 25, 1998 Edition, for maintaining, testing, & inspecting sprinkler systems; therefore facility was not documenting maintenance, testing, & inspections in accordance with this standard.

2. On June 27, 2011 at 1:11 p.m., the facility did not have documentation for a current annual forward flow test and five-year, III-C test of the fire sprinkler system.

3. On June 27, 2011 at 2:38 p.m., the air compressor serving the dry fire sprinkler system was not listed for use with a fire sprinkler system per UL 2125.

4. On June 27, 2011 at 2:42 p.m., there was no fire sprinkler protection under the air duct that measured over 4-feet in width in the Mezzanine.

5. On June 27, 2011 at 3:25 p.m., a dirty fire sprinkler head was found in the Lab bathroom.

6. On June 27, 2011 at 3:50 p.m., there were no fire sprinklers found protecting the exterior overhang by Room 130 (Med/Surg Hallway).

7. On June 27, 2011 at 3:57 p.m., there were no fire sprinklers found protecting the Oxygen Storage Room.

8. On June 27, 2011 at 4:00 p.m., the upper exterior overhang above the Main Entrance of the facility had no fire sprinkler protection.

Based on observations, record review and interviews it was determined that the facility failed to ensure that sprinkler system is continuously maintained & in reliable operating condition. This resulted in the potential for system failure during fire emergencies (LSC 4.6.12.1, NFPA 13 3-2.91, .2, .3, NFPA 25 9.6.2.1, .2 & 8.17.4.6). Findings include, but are not limited to:

1. On June 27, 2011 at 2:32 p.m., a wrench was missing in the spare fire sprinkler head box.

2. On June 27, 2011 at 2:33 p.m., a dirty fire sprinkler head was found in the Maintenance Office.

3. On June 27, 2011 at 2:53 p.m., the overhang outside of Materials Management was not protected by fire sprinklers.

4. On June 27, 2011 at 3:02 p.m., there was a corroded fire sprinkler head above the dishwasher sink.

Based on observations and interview it was determined that the facility failed to maintain fire extinguishers. This resulted in the potential for fires to progress beyond incipient stage (LSC 19.3.5.6, 4.6.12.1, 9.7.4.1, NFPA 10). Findings include, but are not limited to:

1. On June 27, 2011 at 1:11 p.m., the Maintenance Assistant indicated that the facility did not have access to the adopted standard NFPA 10, 1998 Edition, for maintaining, testing, & inspecting fire extinguishers; therefore facility was not documenting maintenance, testing, & inspections in accordance with this standard.

2. On June 27, 2011 at 1:30 p.m., the fire extinguisher tags were missing documentation of being checked monthly, per the adopted standards.

Based on observations and interview it was determined that the facility failed to maintain fire extinguishers. This resulted in the potential for fires to progress beyond incipient stage (LSC 19.3.5.6, 4.6.12.1, 9.7.4.1, NFPA 10). Findings include, but are not limited to:

1. On June 27, 2011 at 2:54 p.m., the K-class fire extinguisher in the Kitchen was overcharged and installed over 60-inches from the floor.

2. On June 27, 2011 at 2:58 p.m., a fire extinguisher by the sink in the Kitchen was found to be mounted over 60-inches from the floor.

Based on observations and interview it was determined that the facility failed to install an approved ventilation hood and duct system. This resulted in the potential for fire spread due to inappropriate and/or inadequate fire protection (LSC 4.6.12.1, 9.2.3, 19.3.2.6, NFPA 96 A.1.1.4, UL300). Findings include, but are not limited to:

1. On June 27, 2011 at 3:00 p.m., the kitchen hood suppression pull station was found to be 8-feet from protected appliances and mounted 53-inches above the floor.

Based on observations, record review and interviews it was determined that the facility failed to ensure that exit egress remained clear & unobstructed to the constructed clear width with no projections exceeding 6" up to 80" above the floor. This resulted in the potential for impeding full instant use of the exit system in case of fire or other emergency (LSC 7.1.10, S&C). Findings include, but are not limited to:

1. On June 27, 2011 at 3:17 p.m., the corridor through the Lobby was found to be reduced to 5'8" in width between the Gift Shop counter and furnishings placed along the wall.

2. On June 27, 2011 at 3:27 p.m., a scale, carts and blood pressure machines (plugged in and charging) were found unattended in the corridor.

3. On June 27, 2011 at 3:51 p.m., the rear exit from the Operating Room corridor was found to be obstructed by a gurney and a lift.

Based on observations, record review and interviews it was determined that the facility failed to provide safe storage for compressed gas. This resulted in the potential for damage to electrical switches and receptacles during the movement of oxygen tanks (LSC 19.3.2.4, 4.3.1.1.2). Findings include, but are not limited to:

1. On June 27, 2011 at 3:57 p.m., compressed gas cylinders in the Oxygen Storage Room were secured with only a single chain.

Based on observations, record review and interviews it was determined that the facility failed to ensure that piped-in medical gas systems comply with NFPA 99. This resulted in the potential for injury to patients during medical procedures. Findings include, but are not limited to:

1. On June 27, 2011 at 1:30 p.m., the facility was not able to provide current documentation from a third-party contractor indicating that the medical gas system for the facility passed annual certification testing.

Based on observations, record review and interviews it was determined that the facility failed to ensure anesthetizing locations were protected in accordance with NFPA 99. This resulted in the potential for injury to the patients during medical procedures. Findings include, but are not limited to:

1. On June 27, 2011 at 1:30 p.m., a review of the records dated February 21, 2011 through May 12, 2011, indicated that the humidity levels of the Operating Room were under the minimum limit of 35% (facility's policy indicates 30 % to 60%) on the following dates: 2/21- 28.24%, 2/22- 32.94%, 2/23- 33.34%, 2/24- 26.67%, 2/28- 23.92%, 3/17- 32.94%, 3/18- 32.55%, 3/22- 28.24%, 4/12- 25.1%, 4/18- 34.12%, 4/19- 27.06%, 4/21- 34.51%, 4/22- 26.28%, 5/10- 34.12%, 5/12- 30.2%. The facility's policy did not include steps for shutting down the Operating Room when the humidity level was not acceptable.

Based on observations, record review and interviews it was determined that the facility failed to properly maintain the generator. This resulted in the potential for the lack of emergency electrical power (LSC 4.6.12.1, NFPA 110, NFPA 99, 3.4.4.1, 6.4.2) Findings include, but are not limited to:

1. On June 27, 2011 at 1:11 p.m., the Maintenance Assistant indicated that the facility did not have access to the adopted standard NFPA 110, 1999 Edition, for maintaining, testing, & inspecting generators; therefore facility was not documenting maintenance, testing, & inspections in accordance with this standard.

2. On June 27, 2011 at 1:11 p.m., the facility did not have documentation of the three-year, four-hour load bank test of the generator.

3. On June 27, 2011 at 1:30 p.m., a review of the facility's records of fuel levels for the generator indicated that from January to March of 2011 the fuel levels were below 80 percent.

4. On June 27, 2011 at 2:39 p.m., there was no battery-powered emergency light found at the generator transfer switch.

5. On June 27, 2011 at 4:06 p.m., the emergency shut off switch for the generator was not located outside of the cabinet.

6. On June 27, 2011 at 4:07 p.m., there was no battery-powered emergency light found at the generator.

7. On June 27, 2011 at 4:08 p.m., maintenance-free batteries were found to be installed at the generator.

Based on observations, record review and interviews it was determined that the facility failed to ensure that electrical wiring & equipment was used/maintained and in accordance with NFPA 70. This resulted in the potential for injury to residents & staff (NFPA 70 550.13 (B), 9.1.2, NEC 110-3.8) (for light switch in oxygen storage room/ref. NFPA 99, A-4-3.1.1.2(a)2 #4). Findings include, but are not limited to:

1. On June 27, 2011 at 2:38 p.m., the air compressor serving the dry fire sprinkler system was found to be plugged into an extension cord in the Mezzanine.

2. On June 27, 2011 at 2:40 p.m., an extension cord was found connected to a relocatable power tap serving the STAEFA Control System.

3. On June 27, 2011 at 2:42 p.m., a relocatable power tap was found serving the Emergency Broadcast System and the phone system.

4. On June 27, 2011 at 2:44 p.m., a transformer serving the PA Amplifier was found to be rated at an improper amperage.

5. On June 27, 2011 at 3:07 p.m., three relocatable power taps were found in the Admitting area, one was found in the Reading room of Radiology, one in the Dark room in Radiology, one in the Director of Imaging office, one in the Pharmacy office, two in the Respiratory Treatment room, one in the Operating room break room, and multiple relocatable power taps at the Nurse's station.

6. On June 27, 2011 at 3:23 p.m., the electrical outlets near the Lab sink were found to not have GFCI protection.

7. On June 27, 2011 at 3:24 p.m., a broken wire mould with exposed electrical wiring was found in the Lab near the microscopes.

8. On June 27, 2011 at 3:24 p.m., a household-use microwave was found in the Lab.

9. On June 27, 2011 at 3:33 p.m., a relocatable power tap was found on the floor of the Operating Room and was not rated for patient areas.

10. On June 27, 2011 at 3:36 p.m., a household-use microwave was found in the Nursing break room.

17. On June 27, 2011 at 3:53 p.m., a household-use microwave and coffee maker were found in the Operating Room break room.

20. On June 27, 2011 at 3:59 p.m., an electrical outlet in the Oxygen Storage Room was found to be less than 60-inches from the floor.

Based on observations, record review and interviews it was determined that the facility failed to ensure that electrical wiring & equipment was used/maintained and in accordance with NFPA 70. This resulted in the potential for injury to residents & staff (NFPA 70 550.13 (B), 9.1.2, NEC 110-3.8). Findings include, but are not limited to:

1. On June 27, 2011 at 2:48 p.m., a relocatable power tap was found in the Environmental Services Office.

2. On June 27, 2011 at 2:50 p.m., two relocatable power taps were found serving a radio and a computer in Materials Management.

3. On June 27, 2011 at 2:58 p.m., a household-use microwave was found in the Kitchen.

4. On June 27, 2011 at 3:03 p.m., a relocatable power tap was found serving the computer in Dietary.

5. On June 27, 2011 at 3:03 p.m., a household-use microwave was found in the Dining Room.

6. On June 27, 2011 at 3:04 p.m., a relocatable power tap was found in the IS Department.

7. On June 27, 2011 at 3:05 p.m., an extension cord was connected to a relocatable power tap at the Administration Reception desk and a relocatable power tap was found at the copier.

Based on observations and interviews it was determined that the facility failed to install alcohol gel hand sanitizing dispensing stations away from sources of ignition and a minimum of 4' spacing between dispensers. This resulted in the potential for injury to residents and staff (LSC 18.3.2.7, CFR 403.744, 418.100, 460.72, 482.41, 483.70, 486.623, 485.623). Findings include, but are not limited to:

1. On June 27, 2011 at 3:20 p.m., an alcohol hand gel dispenser was found mounted over a light switch in the Laboratory.

Based on observations and interview it was determined that the facility failed to separate sections of health care facilities from non-healthcare facilities. This resulted in the potential for the spread of fire & smoke into other sections of the health care facility (LSC 19.1.2.3, 19.1.1.4). Findings include, but are not limited to:

1. On June 27, 2011 at 2:30 p.m., there were unsealed penetrations in the 2-hour separation wall between the business offices and the hospital above the drop-ceiling tiles.

Based on observations and interview it was determined that the facility failed to separate sections of health care facilities from non-healthcare facilities. This resulted in the potential for the spread of fire & smoke into other sections of the health care facility (LSC 19.1.2.3, 19.1.1.4). Findings include, but are not limited to:

1. On June 27, 2011 at 2:32 p.m., the 2-hour separation wall between the business offices and the hospital had non-fire-rated spray foam sealing penetrations above the drop-ceiling tiles.

2. On June 27, 2011 at 2:57 p.m., two roll-down fire windows separating the Kitchen from the Dining Room were past due for annual service and inspection (last dated 1999).

Based on observations and interviews it was determined that the facility failed to meet or maintain the construction type requirements. This resulted in the potential for fire/smoke to spread to other areas of the facility, causing the exposure of patients & staff to hazardous products of fire (LSC 19.3.6.1, .2, .5). Findings include, but are not limited to:

1. On June 27, 2011 at 3:45 p.m., unsealed penetrations were found in the smoke barrier wall by Room 125.

Based on observations and interviews it was determined that the facility failed to maintain integrity of smoke separations. This resulted in the potential for smoke to spread to other areas of the facility, causing the exposure of residents & staff to hazardous products of fire (LSC 19.3.6.1, .2, .5). Findings include, but are not limited to:

1. On June 27, 2011 at 3:38 p.m., the doors leading to the Emergency Room were not smoke rated and did not close automatically.

Based on observations, record review and interviews it was determined that the facility failed to maintain exit corridor doors to resist the passage of smoke in accordance with NFPA 80. This resulted in the potential for passage of smoke into the means of egress in the event of a hostile fire event (LSC 19.2.3.5, 19.3.2.1, 19.3.6.3, 4.6.12.1). Findings include, but are not limited to:

1. On June 27, 2011 at 1:11 p.m., the Maintenance Assistant indicated that the facility did not have access to the adopted standard NFPA 80, 1999 Edition, for maintaining, testing, & inspecting smoke and fire doors; therefore facility was not documenting maintenance, testing, & inspections in accordance with this standard..

2. On June 27, 2011 at 2:46 p.m., the 90-minute rated doors separating the Business Offices from the Hospital were not latching.

3. On June 27, 2011 at 3:07 p.m., a kick-down door prop was found at the Radiology Department, the door to the Medical Imaging area, the Housekeeping closet door in the lobby, the Housekeeping closet in the Med/Surg hallway, and the Lab entrance door.

4. On June 27, 2011 at 3:15 p.m., the smoke barrier doors between the Medical/Surgery area and the Lobby did not close, due to improper air flow.

Based on observations, record review and interviews it was determined that the facility failed to maintain exit corridor doors to resist the passage of smoke in accordance with NFPA 80. This resulted in the potential for passage of smoke into the means of egress in the event of a hostile fire event (LSC 19.2.3.5, 19.3.6.3, 4.6.12.1). Findings include, but are not limited to:

1. On June 27, 2011 at 2:54 p.m., kick down door props were found on the exterior doors near Materials Management.

Based on observations and interview it was determined that the facility failed to provide opening protection, which separates exit corridors from hazardous areas with a sprinkler and smoke partition in existing facilities. This resulted in the potential for the spread of fire/smoke into other portions of the facility including the means of egress during a hostile fire event (LSC 19.3.2.6, 8.2.3.2, 7.2.1.8, 19.3.2.1). Findings include, but are not limited to:

1. On June 27, 2011 at 2:36 p.m., combustible curtains made of plastic and a cabinet made of wood were found in the Mechanical Room.

Based on observations, interviews and record review it was determined that the facility failed to maintain emergency action plan current & readily available. This resulted in the potential for limited staff effectiveness during emergency conditions (LSC 19.7.1.1). Findings include, but are not limited to:

1. On June 27, 2011 at 1:30 p.m., the facility's disaster manual was found to be deficient in the following items: The fire plan did not indicate to call 9-1-1 if a fire is discovered; evacuation of the smoke compartment was not planned for unless the Charge Nurse decided it was necessary; the plan did not include a "defend in place" strategy for evacuating the involved smoke compartment to another smoke compartment in the event of a fire and directed staff to not pass through the fire doors; there was no plan for marking rooms that had been evacuated; there were no instructions for manually starting the generator if it failed to start automatically; there was no map included in the plan that indicated where the main utility shut-offs were located; the plan for a bomb threat did not use "code brown" for a bomb threat; the staffing plan did not include a plan for accommodating staff in temporary and long-term emergency situations; there was no documentation of an annual review of the disaster manual by the safety committee; and there was no transfer or transportation agreements with equivalent facilities if the building had to be evacuated.

Based on record reviews and interviews it was determined that the facility failed to provide fire drills for all staff. This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing patients to smoke and fire in the facility (LSC 19.7.1.2, A.19.7.1.2). Findings include, but are not limited to:

1. On June 27, 2011 at 1:11 p.m., a review of the fire drill records for the past three years indicated that the forms were found to be incomplete, false alarms were counted as drills and that fire drills were not conducted at staggered times throughout the shift.

Based on observations, record review and interviews it was determined that the facility failed to test and maintain fire alarm in accordance with NFPA 72. This resulted in the potential for system and device failure during fire emergencies (LSC 4.6.12.1, 9.6.1.4, NFPA 70, NFPA 72). Findings include, but are not limited to:

1. On June 27, 2011 at 1:11 p.m., the Maintenance Assistant indicated that the facility did not have access to the adopted standard NFPA 72, 1999 Edition, for maintaining, testing, & inspecting fire alarm systems; therefore facility was not documenting maintenance, testing, & inspections in accordance with this standard.

2. On June 27, 2011 at 3:32 p.m., fire alarm notification appliances were found in the Operating Room, patient rooms, Therapy room, and bathrooms. According to staff, this condition was throughout the facility.

Based on observations, record review and interviews it was determined that the facility failed to test and maintain smoke detectors in accordance with NFPA 72. This resulted in the potential for system and device failure during fire emergencies (LSC 4.6.12.1, 9.6.1.3, NFPA 70, NFPA 72). Findings include, but are not limited to:

1. On June 27, 2011 at 2:40 p.m., a smoke detector was mounted in a "dead-air" space above the fire alarm panel.

Based on observations, record review and interviews it was determined that the facility failed to ensure that sprinkler system is continuously maintained & in reliable operating condition. This resulted in the potential for system failure during fire emergencies (LSC 4.6.12.1, NFPA 13 3-2.91, .2, .3, NFPA 25 9.6.2.1, .2 & 8.17.4.6). Findings include, but are not limited to:

1. On June 27, 2011 at 1:11 p.m., the Maintenance Assistant indicated that the facility did not have access to the adopted standard NFPA 25, 1998 Edition, for maintaining, testing, & inspecting sprinkler systems; therefore facility was not documenting maintenance, testing, & inspections in accordance with this standard.

2. On June 27, 2011 at 1:11 p.m., the facility did not have documentation for a current annual forward flow test and five-year, III-C test of the fire sprinkler system.

3. On June 27, 2011 at 2:38 p.m., the air compressor serving the dry fire sprinkler system was not listed for use with a fire sprinkler system per UL 2125.

4. On June 27, 2011 at 2:42 p.m., there was no fire sprinkler protection under the air duct that measured over 4-feet in width in the Mezzanine.

5. On June 27, 2011 at 3:25 p.m., a dirty fire sprinkler head was found in the Lab bathroom.

6. On June 27, 2011 at 3:50 p.m., there were no fire sprinklers found protecting the exterior overhang by Room 130 (Med/Surg Hallway).

7. On June 27, 2011 at 3:57 p.m., there were no fire sprinklers found protecting the Oxygen Storage Room.

8. On June 27, 2011 at 4:00 p.m., the upper exterior overhang above the Main Entrance of the facility had no fire sprinkler protection.

Based on observations, record review and interviews it was determined that the facility failed to ensure that sprinkler system is continuously maintained & in reliable operating condition. This resulted in the potential for system failure during fire emergencies (LSC 4.6.12.1, NFPA 13 3-2.91, .2, .3, NFPA 25 9.6.2.1, .2 & 8.17.4.6). Findings include, but are not limited to:

1. On June 27, 2011 at 2:32 p.m., a wrench was missing in the spare fire sprinkler head box.

2. On June 27, 2011 at 2:33 p.m., a dirty fire sprinkler head was found in the Maintenance Office.

3. On June 27, 2011 at 2:53 p.m., the overhang outside of Materials Management was not protected by fire sprinklers.

4. On June 27, 2011 at 3:02 p.m., there was a corroded fire sprinkler head above the dishwasher sink.

Based on observations and interview it was determined that the facility failed to maintain fire extinguishers. This resulted in the potential for fires to progress beyond incipient stage (LSC 19.3.5.6, 4.6.12.1, 9.7.4.1, NFPA 10). Findings include, but are not limited to:

1. On June 27, 2011 at 1:11 p.m., the Maintenance Assistant indicated that the facility did not have access to the adopted standard NFPA 10, 1998 Edition, for maintaining, testing, & inspecting fire extinguishers; therefore facility was not documenting maintenance, testing, & inspections in accordance with this standard.

2. On June 27, 2011 at 1:30 p.m., the fire extinguisher tags were missing documentation of being checked monthly, per the adopted standards.

Based on observations and interview it was determined that the facility failed to maintain fire extinguishers. This resulted in the potential for fires to progress beyond incipient stage (LSC 19.3.5.6, 4.6.12.1, 9.7.4.1, NFPA 10). Findings include, but are not limited to:

1. On June 27, 2011 at 2:54 p.m., the K-class fire extinguisher in the Kitchen was overcharged and installed over 60-inches from the floor.

2. On June 27, 2011 at 2:58 p.m., a fire extinguisher by the sink in the Kitchen was found to be mounted over 60-inches from the floor.

Based on observations and interview it was determined that the facility failed to install an approved ventilation hood and duct system. This resulted in the potential for fire spread due to inappropriate and/or inadequate fire protection (LSC 4.6.12.1, 9.2.3, 19.3.2.6, NFPA 96 A.1.1.4, UL300). Findings include, but are not limited to:

1. On June 27, 2011 at 3:00 p.m., the kitchen hood suppression pull station was found to be 8-feet from protected appliances and mounted 53-inches above the floor.

Based on observations, record review and interviews it was determined that the facility failed to ensure that exit egress remained clear & unobstructed to the constructed clear width with no projections exceeding 6" up to 80" above the floor. This resulted in the potential for impeding full instant use of the exit system in case of fire or other emergency (LSC 7.1.10, S&C). Findings include, but are not limited to:

1. On June 27, 2011 at 3:17 p.m., the corridor through the Lobby was found to be reduced to 5'8" in width between the Gift Shop counter and furnishings placed along the wall.

2. On June 27, 2011 at 3:27 p.m., a scale, carts and blood pressure machines (plugged in and charging) were found unattended in the corridor.

3. On June 27, 2011 at 3:51 p.m., the rear exit from the Operating Room corridor was found to be obstructed by a gurney and a lift.

Based on observations, record review and interviews it was determined that the facility failed to provide safe storage for compressed gas. This resulted in the potential for damage to electrical switches and receptacles during the movement of oxygen tanks (LSC 19.3.2.4, 4.3.1.1.2). Findings include, but are not limited to:

1. On June 27, 2011 at 3:57 p.m., compressed gas cylinders in the Oxygen Storage Room were secured with only a single chain.

Based on observations, record review and interviews it was determined that the facility failed to ensure that piped-in medical gas systems comply with NFPA 99. This resulted in the potential for injury to patients during medical procedures. Findings include, but are not limited to:

1. On June 27, 2011 at 1:30 p.m., the facility was not able to provide current documentation from a third-party contractor indicating that the medical gas system for the facility passed annual certification testing.

Based on observations, record review and interviews it was determined that the facility failed to ensure anesthetizing locations were protected in accordance with NFPA 99. This resulted in the potential for injury to the patients during medical procedures. Findings include, but are not limited to:

1. On June 27, 2011 at 1:30 p.m., a review of the records dated February 21, 2011 through May 12, 2011, indicated that the humidity levels of the Operating Room were under the minimum limit of 35% (facility's policy indicates 30 % to 60%) on the following dates: 2/21- 28.24%, 2/22- 32.94%, 2/23- 33.34%, 2/24- 26.67%, 2/28- 23.92%, 3/17- 32.94%, 3/18- 32.55%, 3/22- 28.24%, 4/12- 25.1%, 4/18- 34.12%, 4/19- 27.06%, 4/21- 34.51%, 4/22- 26.28%, 5/10- 34.12%, 5/12- 30.2%. The facility's policy did not include steps for shutting down the Operating Room when the humidity level was not acceptable.

Based on observations, record review and interviews it was determined that the facility failed to properly maintain the generator. This resulted in the potential for the lack of emergency electrical power (LSC 4.6.12.1, NFPA 110, NFPA 99, 3.4.4.1, 6.4.2) Findings include, but are not limited to:

1. On June 27, 2011 at 1:11 p.m., the Maintenance Assistant indicated that the facility did not have access to the adopted standard NFPA 110, 1999 Edition, for maintaining, testing, & inspecting generators; therefore facility was not documenting maintenance, testing, & inspections in accordance with this standard.

2. On June 27, 2011 at 1:11 p.m., the facility did not have documentation of the three-year, four-hour load bank test of the generator.

3. On June 27, 2011 at 1:30 p.m., a review of the facility's records of fuel levels for the generator indicated that from January to March of 2011 the fuel levels were below 80 percent.

4. On June 27, 2011 at 2:39 p.m., there was no battery-powered emergency light found at the generator transfer switch.

5. On June 27, 2011 at 4:06 p.m., the emergency shut off switch for the generator was not located outside of the cabinet.

6. On June 27, 2011 at 4:07 p.m., there was no battery-powered emergency light found at the generator.

7. On June 27, 2011 at 4:08 p.m., maintenance-free batteries were found to be installed at the generator.

Based on observations, record review and interviews it was determined that the facility failed to ensure that electrical wiring & equipment was used/maintained and in accordance with NFPA 70. This resulted in the potential for injury to residents & staff (NFPA 70 550.13 (B), 9.1.2, NEC 110-3.8) (for light switch in oxygen storage room/ref. NFPA 99, A-4-3.1.1.2(a)2 #4). Findings include, but are not limited to:

1. On June 27, 2011 at 2:38 p.m., the air compressor serving the dry fire sprinkler system was found to be plugged into an extension cord in the Mezzanine.

2. On June 27, 2011 at 2:40 p.m., an extension cord was found connected to a relocatable power tap serving the STAEFA Control System.

3. On June 27, 2011 at 2:42 p.m., a relocatable power tap was found serving the Emergency Broadcast System and the phone system.

4. On June 27, 2011 at 2:44 p.m., a transformer serving the PA Amplifier was found to be rated at an improper amperage.

5. On June 27, 2011 at 3:07 p.m., three relocatable power taps were found in the Admitting area, one was found in the Reading room of Radiology, one in the Dark room in Radiology, one in the Director of Imaging office, one in the Pharmacy office, two in the Respiratory Treatment room, one in the Operating room break room, and multiple relocatable power taps at the Nurse's station.

6. On June 27, 2011 at 3:23 p.m., the electrical outlets near the Lab sink were found to not have GFCI protection.

7. On June 27, 2011 at 3:24 p.m., a broken wire mould with exposed electrical wiring was found in the Lab near the microscopes.

8. On June 27, 2011 at 3:24 p.m., a household-use microwave was found in the Lab.

9. On June 27, 2011 at 3:33 p.m., a relocatable power tap was found on the floor of the Operating Room and was not rated for patient areas.

10. On June 27, 2011 at 3:36 p.m., a household-use microwave was found in the Nursing break room.

17. On June 27, 2011 at 3:53 p.m., a household-use microwave and coffee maker were found in the Operating Room break room.

20. On June 27, 2011 at 3:59 p.m., an electrical outlet in the Oxygen Storage Room was found to be less than 60-inches from the floor.

Based on observations, record review and interviews it was determined that the facility failed to ensure that electrical wiring & equipment was used/maintained and in accordance with NFPA 70. This resulted in the potential for injury to residents & staff (NFPA 70 550.13 (B), 9.1.2, NEC 110-3.8). Findings include, but are not limited to:

1. On June 27, 2011 at 2:48 p.m., a relocatable power tap was found in the Environmental Services Office.

2. On June 27, 2011 at 2:50 p.m., two relocatable power taps were found serving a radio and a computer in Materials Management.

3. On June 27, 2011 at 2:58 p.m., a household-use microwave was found in the Kitchen.

4. On June 27, 2011 at 3:03 p.m., a relocatable power tap was found serving the computer in Dietary.

5. On June 27, 2011 at 3:03 p.m., a household-use microwave was found in the Dining Room.

6. On June 27, 2011 at 3:04 p.m., a relocatable power tap was found in the IS Department.

7. On June 27, 2011 at 3:05 p.m., an extension cord was connected to a relocatable power tap at the Administration Reception desk and a relocatable power tap was found at the copier.