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Based on observation and interview, it was determined the facility failed to ensure hazardous areas were protected, according to NFPA standards. The deficiency has the potential to affect one (1) smoke compartment. The facility is licensed for twenty five (25) beds, with a census of twelve (12) the day of the survey.

The findings include:

Observation on 04/06/11 at 10:35 AM, revealed a total of fourteen (14) one gallon paint cans stored in a corridor utility closet, without a self-closing device on the door.

Interview with the Maintenance Director at 10:35 AM, indicated that the painting contractor was using the closet as a staging area for repainting. The Maintenance Director also stated that he would have the paint cans removed to a proper location.

Based on observation and interview it was determined the facility failed to ensure, portable space heaters used in the facility were according to NFPA standards. Portable space heaters used in health care facilities must be of an approved type to limit the risk of fire. The deficiency affected all smoke compartments. The facility is licensed for 25 beds with a census of twelve (12) the day of the survey.

The findings include:

Observation on 04/06/11 between the hours of 9:45 AM and 3:30 PM, revealed portable space heaters used throughout the facility in offices, doctor sleeping room, exam rooms, and nurses stations. The observation was confirmed with the Maintenance Director.

Interview on 04/06/11 with the Maintenance Director, revealed he was not aware that portable heaters had to be of approved type and could only achieve a maximum temperature of 212 degrees.

Reference: NFPA 101 (2000 edition)
19.7.8 Portable Space-Heating Devices. Portable space-heating
devices 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?F (100?C).

Based on observation and interview, it was determined the facility failed to ensure oxygen cylinders were stored according to NFPA standards. This deficiency has the potential to affect one (1) smoke compartment. The facility has the capacity for twenty five beds; the census on the day of the survey was twelve (12).

The findings include:

Observation on 04/06/2011 at 10:07 AM, with the Maintenance Director, revealed five (5) full and two (2) empty, not separated, oxygen cylinder tanks stored in the Biomedical Engineering storage room located in the Med Surg Wing. The oxygen tanks were stored within five (5) feet of combustible materials. There were no signs indicated hazardous storage within the room. This observation was confirmed with the Maintenance Director who stated the cylinders should have been stored in the designated, oxygen storage room located elsewhere on the first floor.

Interview with the Maintenance Director on 04/06/2011 at 11:07 AM, indicated he was unaware of the tanks being stored within the room, and they would be removed and relocated in the designated oxygen storage room.



Reference: NFPA 99 (1999 edition)
8-3.1.11.2
Storage for nonflammable gases greater than 8.5 m3 (300 ft3) but less than 85 m3 (3000 ft3)
(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.
(B) Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor.
(C) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following:
(1) A minimum distance of 6.1 m (20 ft)
(2) A minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems
(3) An enclosed cabinet of noncombustible construction having a minimum fire protection rating of ? hour. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.


8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:
CAUTION OXIDIZING GAS(ES) STORED WITHIN NO SMOKING

Based on observation and interview, it was determined the facility failed to ensure electrical wiring was maintained according to NFPA standards. This deficient practice affected four (4) smoke compartments, staff, and visitors. The facility is licensed for twenty five (25) beds, with a census of twelve (12) the day of the survey.

The findings include:


Observations on 04/06/11 between the hours of 9:45 AM and 3:30 PM, with the Director of Maintenance revealed:

1) Laboratory break room: power strip in use powering a refrigerator, microwave, toaster, and a coffee pot.

2) Traction Wench plugged into a power strip in the Physical Therapy Department, room #2.

3) Piggy backed power strips in the Physical Therapy work room.

4) An E-stem machine, and an ultrasound machine plugged into a power strip in the Physical Therapy Department, treatment room #1.

5) A breathalyzer machine and a floor lamp plugged into a power strip in Exam Room #2, OCC MED.

6) An extension cord was found to be in use in the Medical Records office.







(1) Reference: NFPA 99 (1999 edition)

3-3.2.1.2 D

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

Based on observation and interview on 04/06/11, it was determined the facility failed to ensure that Alcohol Based Hand Rub dispensers were not installed over or adjacent to an ignition source.

The findings include:

The Life Safety Code Tour conducted on 04/06/11 at 11:22 AM, with the Director of Maintenance, revealed Alcohol Based Hand Rub dispensers were installed over the light switch in Exam Room #2 located in the ER.

An interview conducted with the Maintenance Director on 04/06/11 at 11:22 AM revealed he was not aware of the regulatory requirement.

Based on observation and interview, it was determined the facility failed to ensure hazardous areas were protected, according to NFPA standards. The deficiency has the potential to affect one (1) smoke compartment. The facility is licensed for twenty five (25) beds, with a census of twelve (12) the day of the survey.

The findings include:

Observation on 04/06/11 at 10:35 AM, revealed a total of fourteen (14) one gallon paint cans stored in a corridor utility closet, without a self-closing device on the door.

Interview with the Maintenance Director at 10:35 AM, indicated that the painting contractor was using the closet as a staging area for repainting. The Maintenance Director also stated that he would have the paint cans removed to a proper location.

Based on observation and interview it was determined the facility failed to ensure, portable space heaters used in the facility were according to NFPA standards. Portable space heaters used in health care facilities must be of an approved type to limit the risk of fire. The deficiency affected all smoke compartments. The facility is licensed for 25 beds with a census of twelve (12) the day of the survey.

The findings include:

Observation on 04/06/11 between the hours of 9:45 AM and 3:30 PM, revealed portable space heaters used throughout the facility in offices, doctor sleeping room, exam rooms, and nurses stations. The observation was confirmed with the Maintenance Director.

Interview on 04/06/11 with the Maintenance Director, revealed he was not aware that portable heaters had to be of approved type and could only achieve a maximum temperature of 212 degrees.

Reference: NFPA 101 (2000 edition)
19.7.8 Portable Space-Heating Devices. Portable space-heating
devices 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?F (100?C).

Based on observation and interview, it was determined the facility failed to ensure oxygen cylinders were stored according to NFPA standards. This deficiency has the potential to affect one (1) smoke compartment. The facility has the capacity for twenty five beds; the census on the day of the survey was twelve (12).

The findings include:

Observation on 04/06/2011 at 10:07 AM, with the Maintenance Director, revealed five (5) full and two (2) empty, not separated, oxygen cylinder tanks stored in the Biomedical Engineering storage room located in the Med Surg Wing. The oxygen tanks were stored within five (5) feet of combustible materials. There were no signs indicated hazardous storage within the room. This observation was confirmed with the Maintenance Director who stated the cylinders should have been stored in the designated, oxygen storage room located elsewhere on the first floor.

Interview with the Maintenance Director on 04/06/2011 at 11:07 AM, indicated he was unaware of the tanks being stored within the room, and they would be removed and relocated in the designated oxygen storage room.



Reference: NFPA 99 (1999 edition)
8-3.1.11.2
Storage for nonflammable gases greater than 8.5 m3 (300 ft3) but less than 85 m3 (3000 ft3)
(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.
(B) Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor.
(C) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following:
(1) A minimum distance of 6.1 m (20 ft)
(2) A minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems
(3) An enclosed cabinet of noncombustible construction having a minimum fire protection rating of ? hour. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.


8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:
CAUTION OXIDIZING GAS(ES) STORED WITHIN NO SMOKING

Based on observation and interview, it was determined the facility failed to ensure electrical wiring was maintained according to NFPA standards. This deficient practice affected four (4) smoke compartments, staff, and visitors. The facility is licensed for twenty five (25) beds, with a census of twelve (12) the day of the survey.

The findings include:


Observations on 04/06/11 between the hours of 9:45 AM and 3:30 PM, with the Director of Maintenance revealed:

1) Laboratory break room: power strip in use powering a refrigerator, microwave, toaster, and a coffee pot.

2) Traction Wench plugged into a power strip in the Physical Therapy Department, room #2.

3) Piggy backed power strips in the Physical Therapy work room.

4) An E-stem machine, and an ultrasound machine plugged into a power strip in the Physical Therapy Department, treatment room #1.

5) A breathalyzer machine and a floor lamp plugged into a power strip in Exam Room #2, OCC MED.

6) An extension cord was found to be in use in the Medical Records office.







(1) Reference: NFPA 99 (1999 edition)

3-3.2.1.2 D

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