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Based on observation, it was determined, the facility failed to maintain the smoke/fire resistive rating of corridor walls.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.1, "Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5 (See also 19.2.5.9) (See all Exceptions) Section 19.3.6.2 "Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour." (See all Exceptions}.

Findings Include:

On May 12, and 13, 2014 the surveyors, accompanied by the Facility VP, and staff, observed penetrations in the following areas:

1. West campus, electrical room, unsealed holes in walls and ceiling.
2. Sterile processing corridor wall, hole approximately twelve inches by six inches.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

Corridor walls must remain smoke tight/fire resistive to prevent smoke and heat from entering resident rooms. Smoke/heat will cause harm to the patients.

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 Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "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 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted." 19.3.6.4 "Transfer grilles, regardless of whether they are protected by fusible link-operated dampers, shall not be used in these walls or doors.

Findings Include:

On May 12, and 13, 2014 the surveyors, accompanied by the Facility VP, and staff, observed the following corridor doors would not tightly close when tested.

1. West Campus, Med/Surg 3rd floor North, patient room 3603, will not positively latch.
2. West Campus, Med/Surg 3rd floor West, patient room 3709 and 3712, will not positively latch.
3. Sterile Processing, Ethylene Oxide Room has a transfer grill in the door.
4. Anex, clean utility door has a kick down hold open device.
5. three South waiting room has a kick down hold open device.
6. Rooms 2048; 2049; and 2050 have kick down hold open device.
7. ED Pixis room, tested three of three times, will not positively latch.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

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 failed to protect a vertical opening for a service elevator.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.1.1 "Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating." Section 8.2.5.2 "Openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier.

Findings Include:

On May 12, and 13, 2014 the surveyors, accompanied by the Facility VP, and staff, observed the Elevator B doors will not close and secure.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

Failing to provide enclosures between floors will cause harm to patients and staff.

Based on observation and testing, it was determined, the facility failed to maintain doors or automatic closing devices in corridor doors.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.2.2.2.6. "Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility. Chapter 7, Section 7.2.1.8.1 " A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

Findings Include:

On May 12, and 13, 2014 the surveyors, accompanied by the Facility VP, and staff, observed the door (s) located at the third floor smoke barrier have an opening approximately 1-1/4 inch and would not close tightly when tested. The Auditorium rated double doors are not smoke tight.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

Fire doors that are not closed or will not close automatically will allow smoke and heat to spread throughout the facility which will cause harm to the patients.

Based on observation, it was determined, the facility failed to maintain self closing doors in a smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than I hour. (1/2 hour for existing) Section 8.3.4.1, " Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

Finding include:

On May 12, and 13, 2014 the surveyors, accompanied by the FacilityVP, and staff, observed the astragal was removed from the corridor smoke/fire doors within three South at the Sky Bridge three hour rated door. When closed the door was not smoke tight.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

This installation will allow smoke to contaminate smoke zones not directly effected by the fire, which will cause harm to patients.

Based on observation, it was determined, the facility failed to keep the laundry room dryers clean, and the facility did not maintain the integrity, smoke resistance, of doors in hazardous areas.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1.1, "Utilities shall comply with the provisions of Section 9.1. Section 9.1.1. "Equipment using gas and related gas piping shall be installed in accordance with NFPA 54 " National Fuel Gas Code" or NFPA 58 " Liquefied Petroleum Gas Code" , NFPA 54 Chapter 6, Section 6.4 "Clothes Dryers Section 6.4.5 (c) Type 2 Clothes Dryers shall be equipped or installed with lint controlling means. "

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.2.1 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. NFPA 80 "Fire Doors and Fire Windows" Chapter 2, Section 2-3.1.7 "The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. +/- 1/16 in for steel doors and shall not exceed 1/8 in. for wood doors.

Findings include:

On May 12, and 13, 2014 the surveyors, accompanied by the Facility VP, and staff, observed the following dryers and hazardous area doors:

1. West Campus Laundry, one of two dryers excessive lint.
2. West Campus, storage room next to EVS will not positively latch.
3. Laundry corridor door wedged open, will not positively latch.
4. Anesthesia Supply, door held open with an impediment, tested three of three times, will not positively latch.
5. OR housekeeping closet with chemicals, tested three of three times, will not positively latch.
6. Heart storage double doors, astragal torn and not smoke tight.
7. Sterile supply double doors, not smoke tight.
8. OR Maids EVS, door impeded by a roll of bags, will not close and latch.
9. PACU, Labor and delivery sterile hall, EVS door will not positively latch, tape stuffed into door latch.
10 Kitchen, mop room door, room contains chemicals, no closing device and impeded with equipment.
11. Door from kitchen to EVS, will not positively latch when tested three of three times.
12. Kitchen food storage, door will not positively latch when tested three of three times.
13. Nurses station, oxygen storage room no door closing device between utility and nursing.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

Failing to insure proper cleaning of the lint could cause a fire and cause harm to the patients.
Failing to prevent heat and smoke from spreading into the exit corridor will cause harm to patients.

Based on observation, it was determined, the facility did not keep exits readily accessible at all times.

NFPA 101 Life Safety Code, 2000, Chapter 19 Section 19.2.1, and Section 19.2.3.3. Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 19.2.3.3 "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 May 12, and 13, 2014 the surveyor, accompanied by the Facility VP, and staff, observed storage of the following in the exit access:

1. Five drawer filling cabinet reducing the exit access from eight feet to seven feet eight inches in the OR Nurse station.
2. Pre-OP, wheel chair scale reducing the exit access from eight feet seven inches to five feet three inches.
3. Pre-OP, folding table extended, six chairs, and a garbage can reducing the exit access from eight feet seven inches to six feet two inches.
4. ED, thirteen trash and bio receptacles in all exit access corridors, reducing the exit access from eight feet to approximately seven feet six inches.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

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

Ambulatory Surgical Center

Based on document review and observation, it was determined, the facility failed to provide a written plan for the protection of all patients in time of a fire or emergency.

NFPA 101 Life Safety Code, 2000, Chapter 21, Section 21.7.1.1 "The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of a fire, for their evacuation to areas of refuge, and from the evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator's position or at the security center.

Findings include:

On May 13, 2014, the surveyor, accompanied by the Maintenance Technician, asked to see the written emergency policy manual at the nurse's station. The written fire and emergency policy was not at the nursing station.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

In time of an emergency, an emergency policy manual must be readily available for the staff.
Patients will be harmed if the Staff is not trained or is unable to locate the emergency evacuation policy manual.

Hospital

The facility failed to provide a written plan for the protection of all patients in time of a fire or emergency.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.7.1.1 "The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of a fire, for their evacuation to areas of refuge, and from the evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator's position or at the security center.

Finding include:

On May 12, and 13, 2014 the surveyor, accompanied by the Facility VP, and staff, asked to see the written emergency policy manual at the nurse's station. The written fire and emergency policy was not at the nursing station in Pre Op.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

In time of an emergency, an emergency policy manual must be readily available for the staff.
Patients will be harmed if the Staff is not trained or is unable to locate the emergency evacuation policy manual.

Based on document review, and staff interview, it was determined, the facility failed to train the staff on life safety procedures and devices.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.7.1.2 Fire exit drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions." When drills are conducted between 9:00 p.m. and 6:00 a.m., a coded announcement shall be permitted to be used instead of a audible alarms.

Findings include:

On May 12, and 13, 2014 the surveyors, accompanied by the Facility VP, and staff, reviewed the Fire Prevention Management Plan, Fire Response Plan and the "Code RED DEPARTMENT/ZONE OBSERVER' EVALUATION REPORT" Drill documents. Staff members were interviewed about their participation during the facilities Fire Drill training.

The facilities third shift Fire Drills for all four quarters of 2013 and the first quarter of 2014 do not include a coded announcement, this was verified by a staff supervisor of the PBX area. The facility does not practice the elements required by there Management Plans and CMS. The facility only has a discussion about Fire procedures. A ten year employee stated they have never participated in a Fire Drill. A staff member who works the 1st shift (7-3) stated all Fire Drills are table top discussion.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

Failure to train and drill the staff on fire procedures could result in harm to the patients.

Based on observation, it was determined, the facility failed to repair the fire alarm system.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.4.1, "Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6." Section 9.6.1.4 " A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70 National Electric Code and NFPA 72 National Fire Alarm Code."

Finding include:

On May 12, and 13, 2014 the surveyors, accompanied by the Facility VP, and staff, observed the Main Fire Alarm Computer Screen in the Fire Alarm Center. At 9:10 AM on the 13th of May 2014, the fire alarm panel indicated twenty seven troubles; to include yellow lights that indicated it was in a trouble condition at all Fire Alarm panels.

The facilitie removed the smoke detectors from the areas that are being remolded or have construction in progress. The areas involved were Pharmacy, and Micro Lab.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

Failure to have the fire alarm panel working in the normal operating condition will result in harm to the patients. Staff and the off site monitoring company must be notified by the fire alarm system of a fire emergency.

Based on observation, it was determined, the facility failed to assure that all parts of the facility were provided sprinkler system coverage.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.5.1, "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." ." Chapter 9, Section 9.7.1.1, " Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems." NFPA 13, Chapter 5, Section 5-5.6, " The clearance between the deflector and the top of storage shall be 18 in. or greater."

Findings include:

On May 12, and 13, 2014 the surveyors, accompanied by the Facility VP, and staff, observed the Second floor East Pediatric equipment room has less than 18" clearance from the sprinkler deflector.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

Failing to provide sprinkler coverage in storage areas by blocking the sprinkler heads will result in injury to patients.

Based on observation, it was determined, the facility failed to maintain the sprinkler heads and assure that all parts of the sprinkler system were in accordance with the UL Listing.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.5.1 "Buildings containing health care facilities shall be protected throughout by and 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, Section 2-2.1.1 "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign material , paint, and physical damage and shall be installed in the proper orientation..." NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, Chapter 3, Section 3-2.7.2, "Escutcheon Plates used with a recessed or flushed sprinkler shall be part of a listed sprinkler assembly."

Findings Include:

On May 12, and 13, 2014 the surveyors, accompanied by the Facility VP and staff, observations included the following findings:

1. Sub. Sterile C, one of one sprinkler, no escutcheon plate.
2. Labor and delivery, Nurse station, one of two sprinklers, lint.
3. Labor and delivery, triage, two of seven sprinklers, lint.
4. Corridor by the Pharmacy, sprinkler missing escutcheon plate.
5. Third Floor, room 3002, sprinkler, no escutcheon plate, paint, and lint.
6. Room 3004, two of three sprinklers lint and paint.
7. Third Floor South, Care Coordination, sprinkler deflector recessed into escutcheon plate.
8. Kitchen, Walk in freezer, two of two escutcheon plates not smoke tight.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

Failing to maintain sprinkler heads and keep the fusible link clean could allow a fire to burn longer before the sprinkler head will activate. Failing to maintain sprinkler heads, missing escutcheon plates, which are part of the UL Listing of the sprinkler assembly, could allow heat and smoke to effect other areas of the building. This could cause harm to the patients.

Based on observation, it was determined, the facility did not assure that the fire extinguisher was readily available for use in an emergency.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.5.6, "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."

NFPA 10,Chapter 1,Section 1-6.10. "Fire extinguishers having a gross weight not exceeding 40 lbs. shall be installed so that the top of the fire extinguisher is not more than 5 ft. above the floor. Fire extinguishers having a gross weight greater that 40 lbs. shall be so installed that the top of the fire extinguisher is not more than 3 ? ft. above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 inches."

Finding include:

On May 12, and 13, 2014 the surveyors, accompanied by the Facility VP and staff, observed the fire extinguisher located in the OR #8 was blocked by the computer lines, and used as a device to hang equipment on and is not readily available for use in an emergency. The fire extinguisher in the kitchen/EVS measured 67-1/2 inches to the top of the handle.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

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

Based on observation and staff interview, it was determined, the facility failed to clean the kitchen exhaust hood system, filters and grease drip tray.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.3.2.6 "Cooking facilities shall be protected in accordance with 9-2.3" Section 9-2.3 "Commercial cooking equipment shall be installed in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations." , Chapter 8, Section 8-3.1, " Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge".

Findings include:

On May 12, and 13, 2014 the surveyors, accompanied by the Facility VP, and staff, observed the kitchen exhaust system hood, filters and grease drip tray area had an excessive amount of grease buildup at the Main cook line. (eight of eight filters)

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

Failing to keep the entire kitchen exhaust hood system clean from grease will cause a fire, which could cause damage to the kitchen and will cause harm to the patients.

Based on observation, it was determined, the facility allowed the use of a portable space heater.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.7.8" Portable space heating shall be prohibited in all health care occupancies."
Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212 Degrees F.

Findings include:

On May 12, and 13, 2014 the surveyors, accompanied by the Facility VP and staff, observed a portable space heater in the Financial Counseling office. The space heater did not turn off when tipped over.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

Allowing the use of portable space heaters, close to combustibles, will cause a fire which will cause harm to the patients.

Based on observation, it was determined, the facility failed to keep a 50 gallon receptacle in a hazardous area storage room.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.7.5.5,
"Soiled linen or trash collection receptacles shall not exceed 32 gal. in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gal/ft 2. A capacity of 32 gal. shall not be exceeded within an 64-ft 2 area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal. shall be located in a room protected as a hazardous area when not attended.

Findings include:

On May 12, and 13, 2014 the surveyors, accompanied by the Facility VP and staff, observed a 50 gallon paper recycling container stored in the corridor by stairwell C on the second floor.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

Allowing containers greater than 32 gallons within corridors and rooms will create a hazard greater than that associated with the normal furnishing of a health care occupancy room. In addition: containers must be attended by staff while collections occurs. Failing to follow procedures will cause harm to the patients.

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 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99 Standard for Health Care Facilities" NFPA 99, Chapter 8, Section 8-3.1.11 "Storage Requirements" Section 8-3.1.11.2 "Storage of nonflammable gases less than 3000 cubic. feet.." (a) "Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. (c) "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by: (c) (2) A minimum distance of 5 ft. if the entire storage location is protected by an automatic sprinkler system..."

Findings include:

On May 12, and 13, 2014 the surveyors, accompanied by the Facility VP and staff, observed oxygen stored buy combustibles in the following locations:

1. Med/Surg 3rd floor West, O2 within five feet of combustibles.
2. Bio Hazard soiled utility room, 1 EO2 stored by combustibles.
3. Third floor, soiled utility by room 3017, 1 EO2, not secured in a rack and stored by combustibles.
4. Three South, oxygen storage/clean utility, 1 EO2 stored within sixty inches of electrical and combustibles.
5. Step Down, clean utility, six EO2 bottles within sixty inches of combustibles.
6. Pedis, dirty utility, seven EO2 bottles not in a rack within sixty inches of combustibles.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

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

Based on observation and staff interview, it was determined, the facility failed to maintain a medical gas alarm.

NFPA 101, Life Safety Code, 2000, Chapter 19 Section 19.3.2.4, "Medical gas storage and administration areas shall be protected in accordance with NFPA 99 Standard for Health Care Facilities"
Chapter 4, 4-3.2.2.9, Area Alarm Systems for Vacuum systems (c) Alarm Panels. The visual and audible signal shall be installed at Nurses stations or other suitable locations in the areas described in 4-3.2.2.9(a) and be appropriately labeled.

Findings include:

On May 12, and 13, 2014 the surveyors, accompanied by the Facility VP and staff, witnessed the test of the Medical Gas alarms, located in the following Nurses stations; Third floor North medical gas monitor for rooms 3001-3021, turned off, and the Third floor South, obstetrics medical gas panels 3LL1-1 and 3LL1-L, turned off. A staff member identified the panels worked one week prior. The alarm (s) system (s) did not function when tested.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

Failing to provide operating medical gas warning systems which will notify the Staff, if a leak should occur, may cause harm to the patients.

Based on observation, it was determined, the facility failed to maintain the battery operated emergency lighting.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.2.9.1 " Emergency lighting shall be provided in accordance with Section 7.9."Section 7.9.2.4 "Battery-operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition."

Findings include:

On May 12, and 13, 2014 the surveyors, accompanied by the Facility VP and staff, observed, and tested the emergency lighting unit located at the OR front desk. The lighting unit would not light during the test.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

Failure to maintain emergency lighting units in proper operating condition will cause harm to the patients during a power outage.

Ambulatory Surgical Center

Based on observation it was determined, the facility allowed the use of a multiple outlet adapter/extension cord in the Ambulatory Surgical Center.

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 May 13, 2014, the surveyor, accompanied by the Maintenance Technician, observed the Business office, using a six way multiple outlet adapter.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

The facility failed to remove a multiple outlet adapter/extension cord from a receptacle. The use of multiple outlet adapters/extension cord will create an overload of the electrical system and will cause a fire or an electrical hazard. A fire will cause harm to the patients.

Hospital

Based on observation and record review, it was determined the facility failed to test and document the monthly testing of the Line Isolation Monitor tests/Isolated Electrical Panels. And the facility failed to provide a guard on the light bulbs. The facility failed to provide receptacle face plates.

NFPA 101, Life Safety Code, 2000 Edition, Maintenance and Testing (See 4.6.12) "Maintenance and Testing "Section 4.6.12.1, "Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction."

"NFPA 99 1999 Edition, Health Care Facilities Section 3-3.3.4.2 The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following: (b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch (see 3-3.2.2.3(f)) For a LIM circuit with automated self-test and self calibration capabilities this test shall be performed at intervals of not more that 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators."

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1, "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. "National Electrical Code." NEC, 1999, Article 410, Section 410-56 (e) Position of Receptacle Faces. "3. After installation, receptacle faces shall be flush with or project from faceplate of insulating material and shall project a minimum of 0.015 in. From metal faceplate. Faceplate shall be installed so as to completely cover the opening and seat against the mounting surface."


Findings include:

On May 12, and 13, 2014 the surveyors, accompanied by the Facility VP and staff, observed the following:

1. Tested the LIM in OR 5. The function test was inoperative.
2. The East MDF room has six of six lights with no covers.
3. Third floor oxygen storage room, broken electrical outlet.
4. Ortho. Tech. office, Refrigerator plugged into a power strip.
5. Third floor, room 3016, broken four plex outlet.
6. Triage, staff break room, six way adapter with a microwave plugged it.
7. Third floor bathroom, one of one light no cover.(by Elevator)
8. First floor, Care Coordinator office, extension cord daisy chained into a power strip with a micro wave and refrigerator plugged in.
9. Histology, extension cord daisy chained into a power strip with medical equipment plugged in.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

Failing to test and maintain documentation on the Line Isolation Tests/Isolated Electrical Panels could cause harm to the patients in an emergency or power outage.
Failure to keep light guards on the light could cause accidental damage or possibly a fire, which could cause harm to the patients.
Failing to repair broken receptacles and face plates may contribute to starting a fire by allowing the electrical wiring to short when an electrical appliance is plugged in or removed from the receptacle. A fire in the facility may cause harm to the patients.

Based on observation, it was determined, the facility failed to maintain the smoke/fire resistive rating of corridor walls.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.1, "Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5 (See also 19.2.5.9) (See all Exceptions) Section 19.3.6.2 "Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour." (See all Exceptions}.

Findings Include:

On May 12, and 13, 2014 the surveyors, accompanied by the Facility VP, and staff, observed penetrations in the following areas:

1. West campus, electrical room, unsealed holes in walls and ceiling.
2. Sterile processing corridor wall, hole approximately twelve inches by six inches.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

Corridor walls must remain smoke tight/fire resistive to prevent smoke and heat from entering resident rooms. Smoke/heat will cause harm to the patients.

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 Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "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 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted." 19.3.6.4 "Transfer grilles, regardless of whether they are protected by fusible link-operated dampers, shall not be used in these walls or doors.

Findings Include:

On May 12, and 13, 2014 the surveyors, accompanied by the Facility VP, and staff, observed the following corridor doors would not tightly close when tested.

1. West Campus, Med/Surg 3rd floor North, patient room 3603, will not positively latch.
2. West Campus, Med/Surg 3rd floor West, patient room 3709 and 3712, will not positively latch.
3. Sterile Processing, Ethylene Oxide Room has a transfer grill in the door.
4. Anex, clean utility door has a kick down hold open device.
5. three South waiting room has a kick down hold open device.
6. Rooms 2048; 2049; and 2050 have kick down hold open device.
7. ED Pixis room, tested three of three times, will not positively latch.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

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 failed to protect a vertical opening for a service elevator.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.1.1 "Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating." Section 8.2.5.2 "Openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier.

Findings Include:

On May 12, and 13, 2014 the surveyors, accompanied by the Facility VP, and staff, observed the Elevator B doors will not close and secure.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

Failing to provide enclosures between floors will cause harm to patients and staff.

Based on observation and testing, it was determined, the facility failed to maintain doors or automatic closing devices in corridor doors.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.2.2.2.6. "Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility. Chapter 7, Section 7.2.1.8.1 " A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

Findings Include:

On May 12, and 13, 2014 the surveyors, accompanied by the Facility VP, and staff, observed the door (s) located at the third floor smoke barrier have an opening approximately 1-1/4 inch and would not close tightly when tested. The Auditorium rated double doors are not smoke tight.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

Fire doors that are not closed or will not close automatically will allow smoke and heat to spread throughout the facility which will cause harm to the patients.

Based on observation, it was determined, the facility failed to maintain self closing doors in a smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than I hour. (1/2 hour for existing) Section 8.3.4.1, " Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

Finding include:

On May 12, and 13, 2014 the surveyors, accompanied by the FacilityVP, and staff, observed the astragal was removed from the corridor smoke/fire doors within three South at the Sky Bridge three hour rated door. When closed the door was not smoke tight.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

This installation will allow smoke to contaminate smoke zones not directly effected by the fire, which will cause harm to patients.

Based on observation, it was determined, the facility failed to keep the laundry room dryers clean, and the facility did not maintain the integrity, smoke resistance, of doors in hazardous areas.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1.1, "Utilities shall comply with the provisions of Section 9.1. Section 9.1.1. "Equipment using gas and related gas piping shall be installed in accordance with NFPA 54 " National Fuel Gas Code" or NFPA 58 " Liquefied Petroleum Gas Code" , NFPA 54 Chapter 6, Section 6.4 "Clothes Dryers Section 6.4.5 (c) Type 2 Clothes Dryers shall be equipped or installed with lint controlling means. "

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.2.1 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. NFPA 80 "Fire Doors and Fire Windows" Chapter 2, Section 2-3.1.7 "The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. +/- 1/16 in for steel doors and shall not exceed 1/8 in. for wood doors.

Findings include:

On May 12, and 13, 2014 the surveyors, accompanied by the Facility VP, and staff, observed the following dryers and hazardous area doors:

1. West Campus Laundry, one of two dryers excessive lint.
2. West Campus, storage room next to EVS will not positively latch.
3. Laundry corridor door wedged open, will not positively latch.
4. Anesthesia Supply, door held open with an impediment, tested three of three times, will not positively latch.
5. OR housekeeping closet with chemicals, tested three of three times, will not positively latch.
6. Heart storage double doors, astragal torn and not smoke tight.
7. Sterile supply double doors, not smoke tight.
8. OR Maids EVS, door impeded by a roll of bags, will not close and latch.
9. PACU, Labor and delivery sterile hall, EVS door will not positively latch, tape stuffed into door latch.
10 Kitchen, mop room door, room contains chemicals, no closing device and impeded with equipment.
11. Door from kitchen to EVS, will not positively latch when tested three of three times.
12. Kitchen food storage, door will not positively latch when tested three of three times.
13. Nurses station, oxygen storage room no door closing device between utility and nursing.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

Failing to insure proper cleaning of the lint could cause a fire and cause harm to the patients.
Failing to prevent heat and smoke from spreading into the exit corridor will cause harm to patients.

Based on observation, it was determined, the facility did not keep exits readily accessible at all times.

NFPA 101 Life Safety Code, 2000, Chapter 19 Section 19.2.1, and Section 19.2.3.3. Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 19.2.3.3 "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 May 12, and 13, 2014 the surveyor, accompanied by the Facility VP, and staff, observed storage of the following in the exit access:

1. Five drawer filling cabinet reducing the exit access from eight feet to seven feet eight inches in the OR Nurse station.
2. Pre-OP, wheel chair scale reducing the exit access from eight feet seven inches to five feet three inches.
3. Pre-OP, folding table extended, six chairs, and a garbage can reducing the exit access from eight feet seven inches to six feet two inches.
4. ED, thirteen trash and bio receptacles in all exit access corridors, reducing the exit access from eight feet to approximately seven feet six inches.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

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

Ambulatory Surgical Center

Based on document review and observation, it was determined, the facility failed to provide a written plan for the protection of all patients in time of a fire or emergency.

NFPA 101 Life Safety Code, 2000, Chapter 21, Section 21.7.1.1 "The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of a fire, for their evacuation to areas of refuge, and from the evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator's position or at the security center.

Findings include:

On May 13, 2014, the surveyor, accompanied by the Maintenance Technician, asked to see the written emergency policy manual at the nurse's station. The written fire and emergency policy was not at the nursing station.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

In time of an emergency, an emergency policy manual must be readily available for the staff.
Patients will be harmed if the Staff is not trained or is unable to locate the emergency evacuation policy manual.

Hospital

The facility failed to provide a written plan for the protection of all patients in time of a fire or emergency.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.7.1.1 "The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of a fire, for their evacuation to areas of refuge, and from the evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator's position or at the security center.

Finding include:

On May 12, and 13, 2014 the surveyor, accompanied by the Facility VP, and staff, asked to see the written emergency policy manual at the nurse's station. The written fire and emergency policy was not at the nursing station in Pre Op.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

In time of an emergency, an emergency policy manual must be readily available for the staff.
Patients will be harmed if the Staff is not trained or is unable to locate the emergency evacuation policy manual.

Based on document review, and staff interview, it was determined, the facility failed to train the staff on life safety procedures and devices.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.7.1.2 Fire exit drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions." When drills are conducted between 9:00 p.m. and 6:00 a.m., a coded announcement shall be permitted to be used instead of a audible alarms.

Findings include:

On May 12, and 13, 2014 the surveyors, accompanied by the Facility VP, and staff, reviewed the Fire Prevention Management Plan, Fire Response Plan and the "Code RED DEPARTMENT/ZONE OBSERVER' EVALUATION REPORT" Drill documents. Staff members were interviewed about their participation during the facilities Fire Drill training.

The facilities third shift Fire Drills for all four quarters of 2013 and the first quarter of 2014 do not include a coded announcement, this was verified by a staff supervisor of the PBX area. The facility does not practice the elements required by there Management Plans and CMS. The facility only has a discussion about Fire procedures. A ten year employee stated they have never participated in a Fire Drill. A staff member who works the 1st shift (7-3) stated all Fire Drills are table top discussion.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

Failure to train and drill the staff on fire procedures could result in harm to the patients.

Based on observation, it was determined, the facility failed to repair the fire alarm system.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.4.1, "Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6." Section 9.6.1.4 " A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70 National Electric Code and NFPA 72 National Fire Alarm Code."

Finding include:

On May 12, and 13, 2014 the surveyors, accompanied by the Facility VP, and staff, observed the Main Fire Alarm Computer Screen in the Fire Alarm Center. At 9:10 AM on the 13th of May 2014, the fire alarm panel indicated twenty seven troubles; to include yellow lights that indicated it was in a trouble condition at all Fire Alarm panels.

The facilitie removed the smoke detectors from the areas that are being remolded or have construction in progress. The areas involved were Pharmacy, and Micro Lab.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

Failure to have the fire alarm panel working in the normal operating condition will result in harm to the patients. Staff and the off site monitoring company must be notified by the fire alarm system of a fire emergency.

Based on observation, it was determined, the facility failed to assure that all parts of the facility were provided sprinkler system coverage.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.5.1, "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." ." Chapter 9, Section 9.7.1.1, " Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems." NFPA 13, Chapter 5, Section 5-5.6, " The clearance between the deflector and the top of storage shall be 18 in. or greater."

Findings include:

On May 12, and 13, 2014 the surveyors, accompanied by the Facility VP, and staff, observed the Second floor East Pediatric equipment room has less than 18" clearance from the sprinkler deflector.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

Failing to provide sprinkler coverage in storage areas by blocking the sprinkler heads will result in injury to patients.

Based on observation, it was determined, the facility failed to maintain the sprinkler heads and assure that all parts of the sprinkler system were in accordance with the UL Listing.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.5.1 "Buildings containing health care facilities shall be protected throughout by and 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, Section 2-2.1.1 "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign material , paint, and physical damage and shall be installed in the proper orientation..." NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, Chapter 3, Section 3-2.7.2, "Escutcheon Plates used with a recessed or flushed sprinkler shall be part of a listed sprinkler assembly."

Findings Include:

On May 12, and 13, 2014 the surveyors, accompanied by the Facility VP and staff, observations included the following findings:

1. Sub. Sterile C, one of one sprinkler, no escutcheon plate.
2. Labor and delivery, Nurse station, one of two sprinklers, lint.
3. Labor and delivery, triage, two of seven sprinklers, lint.
4. Corridor by the Pharmacy, sprinkler missing escutcheon plate.
5. Third Floor, room 3002, sprinkler, no escutcheon plate, paint, and lint.
6. Room 3004, two of three sprinklers lint and paint.
7. Third Floor South, Care Coordination, sprinkler deflector recessed into escutcheon plate.
8. Kitchen, Walk in freezer, two of two escutcheon plates not smoke tight.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

Failing to maintain sprinkler heads and keep the fusible link clean could allow a fire to burn longer before the sprinkler head will activate. Failing to maintain sprinkler heads, missing escutcheon plates, which are part of the UL Listing of the sprinkler assembly, could allow heat and smoke to effect other areas of the building. This could cause harm to the patients.

Based on observation, it was determined, the facility did not assure that the fire extinguisher was readily available for use in an emergency.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.5.6, "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."

NFPA 10,Chapter 1,Section 1-6.10. "Fire extinguishers having a gross weight not exceeding 40 lbs. shall be installed so that the top of the fire extinguisher is not more than 5 ft. above the floor. Fire extinguishers having a gross weight greater that 40 lbs. shall be so installed that the top of the fire extinguisher is not more than 3 ? ft. above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 inches."

Finding include:

On May 12, and 13, 2014 the surveyors, accompanied by the Facility VP and staff, observed the fire extinguisher located in the OR #8 was blocked by the computer lines, and used as a device to hang equipment on and is not readily available for use in an emergency. The fire extinguisher in the kitchen/EVS measured 67-1/2 inches to the top of the handle.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

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

Based on observation and staff interview, it was determined, the facility failed to clean the kitchen exhaust hood system, filters and grease drip tray.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.3.2.6 "Cooking facilities shall be protected in accordance with 9-2.3" Section 9-2.3 "Commercial cooking equipment shall be installed in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations." , Chapter 8, Section 8-3.1, " Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge".

Findings include:

On May 12, and 13, 2014 the surveyors, accompanied by the Facility VP, and staff, observed the kitchen exhaust system hood, filters and grease drip tray area had an excessive amount of grease buildup at the Main cook line. (eight of eight filters)

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

Failing to keep the entire kitchen exhaust hood system clean from grease will cause a fire, which could cause damage to the kitchen and will cause harm to the patients.

Based on observation, it was determined, the facility allowed the use of a portable space heater.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.7.8" Portable space heating shall be prohibited in all health care occupancies."
Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212 Degrees F.

Findings include:

On May 12, and 13, 2014 the surveyors, accompanied by the Facility VP and staff, observed a portable space heater in the Financial Counseling office. The space heater did not turn off when tipped over.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

Allowing the use of portable space heaters, close to combustibles, will cause a fire which will cause harm to the patients.

Based on observation, it was determined, the facility failed to keep a 50 gallon receptacle in a hazardous area storage room.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.7.5.5,
"Soiled linen or trash collection receptacles shall not exceed 32 gal. in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gal/ft 2. A capacity of 32 gal. shall not be exceeded within an 64-ft 2 area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal. shall be located in a room protected as a hazardous area when not attended.

Findings include:

On May 12, and 13, 2014 the surveyors, accompanied by the Facility VP and staff, observed a 50 gallon paper recycling container stored in the corridor by stairwell C on the second floor.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

Allowing containers greater than 32 gallons within corridors and rooms will create a hazard greater than that associated with the normal furnishing of a health care occupancy room. In addition: containers must be attended by staff while collections occurs. Failing to follow procedures will cause harm to the patients.

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 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99 Standard for Health Care Facilities" NFPA 99, Chapter 8, Section 8-3.1.11 "Storage Requirements" Section 8-3.1.11.2 "Storage of nonflammable gases less than 3000 cubic. feet.." (a) "Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. (c) "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by: (c) (2) A minimum distance of 5 ft. if the entire storage location is protected by an automatic sprinkler system..."

Findings include:

On May 12, and 13, 2014 the surveyors, accompanied by the Facility VP and staff, observed oxygen stored buy combustibles in the following locations:

1. Med/Surg 3rd floor West, O2 within five feet of combustibles.
2. Bio Hazard soiled utility room, 1 EO2 stored by combustibles.
3. Third floor, soiled utility by room 3017, 1 EO2, not secured in a rack and stored by combustibles.
4. Three South, oxygen storage/clean utility, 1 EO2 stored within sixty inches of electrical and combustibles.
5. Step Down, clean utility, six EO2 bottles within sixty inches of combustibles.
6. Pedis, dirty utility, seven EO2 bottles not in a rack within sixty inches of combustibles.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

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

Based on observation and staff interview, it was determined, the facility failed to maintain a medical gas alarm.

NFPA 101, Life Safety Code, 2000, Chapter 19 Section 19.3.2.4, "Medical gas storage and administration areas shall be protected in accordance with NFPA 99 Standard for Health Care Facilities"
Chapter 4, 4-3.2.2.9, Area Alarm Systems for Vacuum systems (c) Alarm Panels. The visual and audible signal shall be installed at Nurses stations or other suitable locations in the areas described in 4-3.2.2.9(a) and be appropriately labeled.

Findings include:

On May 12, and 13, 2014 the surveyors, accompanied by the Facility VP and staff, witnessed the test of the Medical Gas alarms, located in the following Nurses stations; Third floor North medical gas monitor for rooms 3001-3021, turned off, and the Third floor South, obstetrics medical gas panels 3LL1-1 and 3LL1-L, turned off. A staff member identified the panels worked one week prior. The alarm (s) system (s) did not function when tested.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

Failing to provide operating medical gas warning systems which will notify the Staff, if a leak should occur, may cause harm to the patients.

Based on observation, it was determined, the facility failed to maintain the battery operated emergency lighting.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.2.9.1 " Emergency lighting shall be provided in accordance with Section 7.9."Section 7.9.2.4 "Battery-operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition."

Findings include:

On May 12, and 13, 2014 the surveyors, accompanied by the Facility VP and staff, observed, and tested the emergency lighting unit located at the OR front desk. The lighting unit would not light during the test.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

Failure to maintain emergency lighting units in proper operating condition will cause harm to the patients during a power outage.

Ambulatory Surgical Center

Based on observation it was determined, the facility allowed the use of a multiple outlet adapter/extension cord in the Ambulatory Surgical Center.

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 May 13, 2014, the surveyor, accompanied by the Maintenance Technician, observed the Business office, using a six way multiple outlet adapter.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

The facility failed to remove a multiple outlet adapter/extension cord from a receptacle. The use of multiple outlet adapters/extension cord will create an overload of the electrical system and will cause a fire or an electrical hazard. A fire will cause harm to the patients.

Hospital

Based on observation and record review, it was determined the facility failed to test and document the monthly testing of the Line Isolation Monitor tests/Isolated Electrical Panels. And the facility failed to provide a guard on the light bulbs. The facility failed to provide receptacle face plates.

NFPA 101, Life Safety Code, 2000 Edition, Maintenance and Testing (See 4.6.12) "Maintenance and Testing "Section 4.6.12.1, "Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction."

"NFPA 99 1999 Edition, Health Care Facilities Section 3-3.3.4.2 The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following: (b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch (see 3-3.2.2.3(f)) For a LIM circuit with automated self-test and self calibration capabilities this test shall be performed at intervals of not more that 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators."

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1, "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. "National Electrical Code." NEC, 1999, Article 410, Section 410-56 (e) Position of Receptacle Faces. "3. After installation, receptacle faces shall be flush with or project from faceplate of insulating material and shall project a minimum of 0.015 in. From metal faceplate. Faceplate shall be installed so as to completely cover the opening and seat against the mounting surface."


Findings include:

On May 12, and 13, 2014 the surveyors, accompanied by the Facility VP and staff, observed the following:

1. Tested the LIM in OR 5. The function test was inoperative.
2. The East MDF room has six of six lights with no covers.
3. Third floor oxygen storage room, broken electrical outlet.
4. Ortho. Tech. office, Refrigerator plugged into a power strip.
5. Third floor, room 3016, broken four plex outlet.
6. Triage, staff break room, six way adapter with a microwave plugged it.
7. Third floor bathroom, one of one light no cover.(by Elevator)
8. First floor, Care Coordinator office, extension cord daisy chained into a power strip with a micro wave and refrigerator plugged in.
9. Histology, extension cord daisy chained into a power strip with medical equipment plugged in.

During the Exit conference on May 14, 2014 the above findings were again acknowledged by the CNO/VP, and Management Staff.

Failing to test and maintain documentation on the Line Isolation Tests/Isolated Electrical Panels could cause harm to the patients in an emergency or power outage.
Failure to keep light guards on the light could cause accidental damage or possibly a fire, which could cause harm to the patients.
Failing to repair broken receptacles and face plates may contribute to starting a fire by allowing the electrical wiring to short when an electrical appliance is plugged in or removed from the receptacle. A fire in the facility may cause harm to the patients.