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

Findings Include

On May 27, 2014, the surveyor, accompanied by the CFO; CEO; and the Maintenance Manager, observed the Nutrition room door had a hole through the door.

During the exit conference on May 27, 2014, the above findings were again acknowledged by the CFO; CEO; and the Maintenance Manager.

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

Based on observation, it was determined the facility did not maintain the integrity, smoke resistance, of walls in hazardous areas, or provide self-closing or an automatic-closing device in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 18, Section 18.3.2.1 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.
8.4.1. The automatic extinguishing shall be permitted to be in accordance with 18.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

Findings include:

On May 27, 2014, the surveyor, accompanied by the CFO; CEO; and the Maintenance Manager, observed and tested the following:

1. In-Pt. Hallway, by the kitchen smoke barrier, penetrations in the corridor walls.
2. North In-PT. smoke barrier, penetrations in the corridor walls.
3. North In-Pt. supply room. Storage of alcohol and combustibles, the door does not have a closing device.
3. Records and blue print combustible storage room. No door closing device.
4. Administration corridor, The North and South doors do not have closing devices. the area has combustibles throughout the corridor.
5. Medical records, no door closing device.
6. FACP/storage room, no door closing device. The room contains chemicals.
7. EVS/ICU, door has no closing device.
8. OR storage room by soiled linen contains combustibles. Door has no closing device.
9. Second floor air handler room, door tested three of three times will not positively latch and taped open.

During the exit conference on May 27, 2014, the above findings were again acknowledged by the CFO; CEO; and the Maintenance Manager.

The pipe chases or holes could allow heat and smoke to spread into walls, attics, or exit corridors which could cause harm to patients.
Failing to install self-closing hardware on a smoke/fire resistance door could cause harm to patients in time of a fire.

Based on observation and testing, it was determined the facility failed to maintain exit doors .

NPFA 101 Life Safety Code, 2000, Chapter 18, Section 18.2.2.2.1, " Doors complying with 7.2.1 shall be permitted." Section 7.2.1.4.5, " The forces required to fully open any door manually in a means of egress shall not exceed 15 lbf to release the latch, 30 lbf to set the door in motion, and 15 lbf to open the door to the minimum required width. Opening forces for interior side-hinged or pivoted-swinging doors without closer's shall not exceed 5 lbf. These forces shall be applied at the latch stile."

Findings include:

On May 27, 2014, the surveyor, accompanied by the CFO; CEO; and the Maintenance Manager, opened the South Emergency exit. The door was very hard to open and required more than 30 lbf to set the door in motion.

During the exit conference on May 27, 2014, the above findings were again acknowledged by the CFO; CEO; and the Maintenance Manager.

Failing to maintain emergency exit doors, which must be able to open with minimum force, will cause harm to the patients.

Based on record review, it was determined the facility failed to document the monthly and annual testing of battery back up emergency lighting.

NFPA 101 Life Safety Code, 2000 edition, Chapter 18, Section 18.2.9.1 "Emergency lighting shall be provided in accordance with Section 7.9". Section 7.9.3 "Periodic Testing of Emergency Lighting Equipment" " A functional test shall be conducted on every required emergency lighting system at 30 day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction."

Findings include:

On May 27, 2014, the surveyor, accompanied by the CFO; CEO; and the Maintenance Manager, requested the emergency lighting and battery back up exit sign testing documentation. No documentation was found indicating monthly or annual tests of the emergency lighting and exit signs.
The emergency light in X-Ray did not light when tested.

During the exit conference on May 27, 2014, the above findings were again acknowledged by the CFO; CEO; and the Maintenance Manager.

Failing to test and maintain emergency lighting units and battery back up exit signs will cause harm to the patients in a power outage.

Based on observation and record review it was determined the facility failed to maintain the installed automatic sprinkler system. 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 9.7." Section 9.7.1.1 "Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Installation of Sprinkler Systems, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems." NFPA 25, Chapter 2, Section 2-2.1.1 "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint and physical damage and shall be installed in the proper orientation."

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 May 27, 2014, the surveyor, accompanied by the CFO; CEO; and the Maintenance Manager, observed the following:

1. Rooms 12 and 13, each have one of one sprinkler covered with lint.
2 ER rooms; 1; 6; and 7, each have one of one sprinkler covered with lint.
3. The facility did not have the July 2013 sprinkler testing document for review.

During the exit conference on May 27, 2014, the above findings were again acknowledged by the CFO; CEO; and the Maintenance Manager.

Sprinkler heads are U.L. listed to respond to a calculated ceiling temperature. Lint on the head or a leaking sprinkler head could slow that response or disable the sprinkler head. This will cause harm to patients by allowing the fire to grow to a size uncontrollable by the remaining sprinkler heads.
Failure to inspect, test, and maintain the sprinkler system could result in harm to the patients and staff through the spread of smoke and fire.

Based on observation it was determined the facility failed to assure the fire extinguisher was readily available for use in an emergency

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.3.5.6 "Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1." Section 9.7.4.1, "Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed in accordance with NFPA 10 Standard for the Installation of Portable Fire Extinguishers. NFPA 10, Chapter 1, General Requirements, Section 1-6.3 "Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of a fire."

Findings include:

On May 27, 2014, the surveyor, accompanied by the CFO; CEO; and the Maintenance Manager, observed the following:

1. The fire extinguisher in the Lab was mounted greater than 60 inches above the floor.
2. The second floor K type extinguisher was not mounted on the wall and resting on the floor.
3. The second floor, Angus F10 wheeled extinguisher system was blocked by the helicopter air system.

During the exit conference on May 27, 2014, the above findings were again acknowledged by the CFO; CEO; and the Maintenance Manager.

Failing to make a fire extinguisher readily available in case of a fire will cause injury to residents/patients in time of a fire.

Based on observation, it was determined 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 May 27, 2014, the surveyor, accompanied by the CFO; CEO; and the Maintenance Manager, observed the following:

1. Storage room, 3 E O2 bottles stored next to combustibles.
2. Room 111, 1 E O2 bottle not secured in a rack by combustibles.

During the exit conference on May 27, 2014, the above findings were again acknowledged by the CFO; CEO; and the Maintenance Manager.

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

Based on observation, it was determined the facility failed to provide a guard on the light bulbs; the facility allowed the use of a multiple outlet adapters, power strips and did not use the wall outlet receptacles for appliances; and the facility failed to allow access to the electrical equipment/panel.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.5.1, "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.

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.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.5.1.1 "Utilities shall comply with the provisions of Section 9.1., Section 9.1.2 "Electrical wiring and equipment shall be in accordance with NFPA 70 "National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction." NEC, 1999, ARTICLE 110, SECTION 110-26 Spaces About Electrical Equipment. "Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons." Table 110-26(a) Working Space Minimum of three (3) feet in all directions.
( NO STORAGE ALLOWED IN THE WORKING SPACE)


Findings Include:

On May 27, 2014, the surveyor, accompanied by the CFO; CEO; and the Maintenance Manager, observed the following:

1. Lab has daisy chained power strips.
2. Compliance office has a refrigerator plugged into an extension cord.
3. I.V. prep room, one of one light, no cover.
4. Medical records, extension cord into a power strip with a micro wave and refrigerator plugged into it.
5. Main Nurses station, electrical panels; ELCA; LCB; and LCA blocked by a desk, two chairs and combustibles.
6. Finance office, microwave and refrigerator plugged into a power strip.

During the exit conference on May 27, 2014, the above findings were again acknowledged by the CFO; CEO; and the Maintenance Manager.

Failure to keep light guards on the light could cause accidental damage or possibly a fire, which could cause harm to the patients.
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.
Blocking of access to electrical panels or equipment may delay personnel from controlling an emergency situation. Residents/patients could be harmed if a fire should start because of a delay.