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Based on visual observation the facility failed to provide corridor doors that were closing and latching in the frame. When the doors latch a smoke resistive seal is formed to protect the room's occupants. The deficient practice had the potential to affect of residents. Finding: During the facility tour, on 3/28/2013 observation revealed (A) Kick stops on doors leading into step down area (B) Door to soiled Linen room thirties hall have no latch. (C) Door to ladies dressing room surgery have no latch.

Based on visual observation the facility failed to assure that the smoke barrier doors in the facility properly protected the smoke compartment. The smoke barrier doors restrict the movement of smoke from one compartment to another.
Finding:
During facility on 3/27/2013 observation revealed, (A) Barrier doors by courtyard did latch during testing of latching mechanism. (B) Barrier doors did latch on thirties hall when testing latching mechanism.

Based on visual observation the facility failed to maintain the separation of hazardous areas from other parts of the building, including the egress corridor . Hazardous areas are required to be constructed to resist the passage of smoke compartments have hazardous areas that are not separated. Finding: During the facility tour, on 3/28/2013 observation revealed door to oxygen storage room thirties hall have no door closure on it.

Based on visual observation the facility failed to provide exterior and interior emergency lighting with two bulbs in order to prevent total darkness when one bulb fails. Additionally , the exit discharge and exit egress shall be provided with lighting in emergency situations during day time or night time hours. Finding: During the facility tour 3/28/2013 observation revealed, (A) rear exit did not have two light sources. (B) Smoking exit did not have two light sources.

Findings:
K46 Interior Emergency Lighting
Based on visual observation the facility failed to provide emergency lighting along the entire length of a corridor. Emergency lighting provides visual assurance where evacuation would be necessary during nighttime hours.
Finding:
During facility tour on 3/26 /2013 observation revealed no emergency lights in this facility working at this time.

Based on visual observation the facility failed to provide exit lighting along the entire length of the exit access.
Exit lights provide visual assurance of the direction of the exit door.
Finding:
During the facility on 3/26/2013 observation revealed no exit signs working in the facility at time of survey.

Based on visual observation the facility failed to assure that the fire alarm system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 72. The fire alarm system gives a sense of security to offer an advance warning in fire and /or smoke emergency.
Finding:
During the facility tour on 3/28/2013 observation revealed, that the breaker for the fire alarm system was not posted on the fire alarm panel.

Based on visual observation the facility failed to assure that the fire extinguishers were inspected and tested in accordance with the Life Safety Code and NFPA 10.Fire extinguishers are available to extinguish small fire or smoke emergencies.
Finding:
During the facility tour, on 3/28/2013 observation revealed no signs identifying location of fire extinguishes in the hospital.

Based on visual observation the facility failed to assure that the fire extinguishers were inspected and tested in accordance with the Life Safety Code and NFPA 10.Fire extinguishers are available to extinguish small fire or smoke emergencies.
Finding:
During facility tour and record review the fire extinguishers did not have a continual monthly inspection to assure current inspection/certification and continual charge.

Based on visual observation, the facility failed to assure that all smoking areas were supplied with a metal, self-closing container. cigarette butts shall be extinguished in an approved container in order to prevent accidental combustion.
Finding:
During the facility on 3/27/2013 observation revealed combustible type ashtrays in smoking area.

Based on visual observation the facility failed to assure that semi-annual inspections and routine cleanings were conducted by a licensed contractor on the commercial hood/suppression system. The removal of grease laden vapors from the air is essential to decrease the risk of fire and maintain the air flow within the hood system.
During the facility tour on 3/28/2013 observation revealed, 9A) Unsealed hood penetration open holes. (B) No sign stating exhaust fan shall continue to run during an emergency.

Based on visual observation the facility failed to maintain no smoking or non-smoking signs in areas where oxygen is in use. Oxygen is flammable in nature and when bottles are placed to close to an ignition source it could result in a fire emergency.
Finding:
During the facility tour on 3/28/2013 observation revealed there were no non-smoking or no smoking signs in the oxygen storage areas, oxygen transferring area and oxygen area that is in use.

Based on visual observation and record review, the facility failed to assure that the weekly inspection and monthly testing program on emergency generator was conducted and documented. In case of a power outage the emergency generator powers essential life safety equipment for the facility. Finding: During the facility tour on 3/28/2013 observation revealed there were not any (A) no smoking signs on generator (B) There were no fire extinguisher within 30 ft. of generator.

Based on visual observation and record review, the facility failed to assure that the weekly inspection and monthly testing program on emergency generator was conducted and documented. In case of a power outage the emergency generator powers essential life safety equipment for the facility. Finding: During the facility tour on 3/26/2013 observation revealed, there was not a No Smoking sign on the generator, no light for generator during power failure and no fire extinguisher with 30 ft. of the generation.

Based on observation this facility failed to assure electrical wiring and electrical panels were secure in a safety manor, that will allow operating and maintenance without danger to technical personal or residents.
Finding:
During facility tour on 3/27/2013 observation revealed (A) No cover on junction box electrical room downstairs. (B) Open breaker slot electrical panel P5 downstairs electrical room, (C) Open breaker slot panel P4 in kitchen area.

Based on observation this facility failed to assure electrical wiring and electrical panels were secure in a safety manor, that will allow operating and maintenance without danger to technical personal or residents.
Finding;
During the facility tour, observation revealed no GFI plugs for electrical outlets within 6 ft. of water source at these locations. Kitchen, nurse's toilet and front lobby restrooms.

Based on visual observation the facility failed to provide corridor doors that were closing and latching in the frame. When the doors latch a smoke resistive seal is formed to protect the room's occupants. The deficient practice had the potential to affect of residents. Finding: During the facility tour, on 3/28/2013 observation revealed (A) Kick stops on doors leading into step down area (B) Door to soiled Linen room thirties hall have no latch. (C) Door to ladies dressing room surgery have no latch.

Based on visual observation the facility failed to assure that the smoke barrier doors in the facility properly protected the smoke compartment. The smoke barrier doors restrict the movement of smoke from one compartment to another.
Finding:
During facility on 3/27/2013 observation revealed, (A) Barrier doors by courtyard did latch during testing of latching mechanism. (B) Barrier doors did latch on thirties hall when testing latching mechanism.

Based on visual observation the facility failed to maintain the separation of hazardous areas from other parts of the building, including the egress corridor . Hazardous areas are required to be constructed to resist the passage of smoke compartments have hazardous areas that are not separated. Finding: During the facility tour, on 3/28/2013 observation revealed door to oxygen storage room thirties hall have no door closure on it.

Based on visual observation the facility failed to provide exterior and interior emergency lighting with two bulbs in order to prevent total darkness when one bulb fails. Additionally , the exit discharge and exit egress shall be provided with lighting in emergency situations during day time or night time hours. Finding: During the facility tour 3/28/2013 observation revealed, (A) rear exit did not have two light sources. (B) Smoking exit did not have two light sources.

Findings:
K46 Interior Emergency Lighting
Based on visual observation the facility failed to provide emergency lighting along the entire length of a corridor. Emergency lighting provides visual assurance where evacuation would be necessary during nighttime hours.
Finding:
During facility tour on 3/26 /2013 observation revealed no emergency lights in this facility working at this time.

Based on visual observation the facility failed to provide exit lighting along the entire length of the exit access.
Exit lights provide visual assurance of the direction of the exit door.
Finding:
During the facility on 3/26/2013 observation revealed no exit signs working in the facility at time of survey.

Based on visual observation the facility failed to assure that the fire alarm system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 72. The fire alarm system gives a sense of security to offer an advance warning in fire and /or smoke emergency.
Finding:
During the facility tour on 3/28/2013 observation revealed, that the breaker for the fire alarm system was not posted on the fire alarm panel.

Based on visual observation the facility failed to assure that the fire extinguishers were inspected and tested in accordance with the Life Safety Code and NFPA 10.Fire extinguishers are available to extinguish small fire or smoke emergencies.
Finding:
During the facility tour, on 3/28/2013 observation revealed no signs identifying location of fire extinguishes in the hospital.

Based on visual observation the facility failed to assure that the fire extinguishers were inspected and tested in accordance with the Life Safety Code and NFPA 10.Fire extinguishers are available to extinguish small fire or smoke emergencies.
Finding:
During facility tour and record review the fire extinguishers did not have a continual monthly inspection to assure current inspection/certification and continual charge.

Based on visual observation, the facility failed to assure that all smoking areas were supplied with a metal, self-closing container. cigarette butts shall be extinguished in an approved container in order to prevent accidental combustion.
Finding:
During the facility on 3/27/2013 observation revealed combustible type ashtrays in smoking area.

Based on visual observation the facility failed to assure that semi-annual inspections and routine cleanings were conducted by a licensed contractor on the commercial hood/suppression system. The removal of grease laden vapors from the air is essential to decrease the risk of fire and maintain the air flow within the hood system.
During the facility tour on 3/28/2013 observation revealed, 9A) Unsealed hood penetration open holes. (B) No sign stating exhaust fan shall continue to run during an emergency.

Based on visual observation the facility failed to maintain no smoking or non-smoking signs in areas where oxygen is in use. Oxygen is flammable in nature and when bottles are placed to close to an ignition source it could result in a fire emergency.
Finding:
During the facility tour on 3/28/2013 observation revealed there were no non-smoking or no smoking signs in the oxygen storage areas, oxygen transferring area and oxygen area that is in use.

Based on visual observation and record review, the facility failed to assure that the weekly inspection and monthly testing program on emergency generator was conducted and documented. In case of a power outage the emergency generator powers essential life safety equipment for the facility. Finding: During the facility tour on 3/28/2013 observation revealed there were not any (A) no smoking signs on generator (B) There were no fire extinguisher within 30 ft. of generator.

Based on visual observation and record review, the facility failed to assure that the weekly inspection and monthly testing program on emergency generator was conducted and documented. In case of a power outage the emergency generator powers essential life safety equipment for the facility. Finding: During the facility tour on 3/26/2013 observation revealed, there was not a No Smoking sign on the generator, no light for generator during power failure and no fire extinguisher with 30 ft. of the generation.

Based on observation this facility failed to assure electrical wiring and electrical panels were secure in a safety manor, that will allow operating and maintenance without danger to technical personal or residents.
Finding:
During facility tour on 3/27/2013 observation revealed (A) No cover on junction box electrical room downstairs. (B) Open breaker slot electrical panel P5 downstairs electrical room, (C) Open breaker slot panel P4 in kitchen area.

Based on observation this facility failed to assure electrical wiring and electrical panels were secure in a safety manor, that will allow operating and maintenance without danger to technical personal or residents.
Finding;
During the facility tour, observation revealed no GFI plugs for electrical outlets within 6 ft. of water source at these locations. Kitchen, nurse's toilet and front lobby restrooms.