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Based on observation it was determined the facility failed to have smoke resistant Dutch doors.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.6.3.6, "Dutch doors shall be permitted where they conform to 18.3.6.3 or 19.3.6.3. In addition, both the upper leaf and lower leaf shall be equipped with a latching device and the meeting edges of the upper and lower leaves shall be equipped with an astragal, a rabbet, or a bevel. Dutch doors protecting openings in enclosures around hazardous areas shall comply with NFPA 80, Standard for Fire Doors and Fire Windows...."

NFPA 101 Life Safety Code 2000, Chapter 19, 19.3.6.3.1 " Doors protecting corridor openings in other than required enclosures of vertical openings, exit, or hazardous areas shall be substantial doors, such as those constructed of 1 3/4 in. thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke...."

Findings Include:

On October 19, 2015 the surveyor, accompanied by the Facility Manager, found the following:

1. Dutch door in the middle supply room for scopes not smoke tight.
2. Bone Densitometry office door tested three of three times would not positively latch.

During the exit conference on October 19, 2015, the above findings were again acknowledged by the Facility Manager and the Director of Infrastructure.

The facility failed to protect patients from heat and smoke.

Based on document review of the fire drills it was determined the facility failed to conduct the required fire drills.

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."

Findings include:

On October 19, 2015 the surveyor, accompanied by the Facility Manager, reviewed the facility's fire drill records. The facility did not have a fire drill for the third shift third quarter.

During the exit conference on October 19, 2015, the above findings were again acknowledged by the Facilitie Manager and the Director of Infrastructure.

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 maintain the sprinkler head in the walk in refrigerator in the kitchen.

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." 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." Chapter 3, Section 3-2.6.1 and 3-2.6.2, Listed "corrosion resistant sprinklers shall be installed in locations where chemicals, moisture, or other corrosive vapors sufficient to cause corrosion of such devices exist. Corrosion -resistant coatings shall be applied only by manufacturer of the sprinkler...."

Findings include:

On October 19, 2015, the surveyor, accompanied by the Facility Manager, observed the walk in refrigerator in the kitchen. The refrigerator had a corroded sprinkler head and frame assembly. This was apparent by the rust color around the assembly and the assembly was covered with lint.

During the exit conference on October 19, 2015, the above findings were again acknowledged by the Facilitie Manager and the Director of Infrastructure.

Failure to maintain sprinkler heads will not allow the head to operate correctly under fire conditions and will 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.

Based on Observation it was determined the facility failed to inspect and maintain the portable ABC or K type fire extinguishers.

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."

Chapter 4, Section 4-3.1, "Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30 day intervals..." Section 4-3.4.2, "At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded."

Findings include:

On October 19, 2015, the surveyor, accompanied by the Facility Manager, observed the following fire extinguishers:

1. Two of two fire extinguishers have not been checked and signed off since April 2015.
2. The ED fire extinguishers by the exit to the Heli pad was blocked by two wheel chairs.

During the exit conference on October 19, 2015, the above findings were again acknowledged by the Facilitie Manager and the Director of Infrastructure.

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

Failing to maintain fire extinguishers may cause injury to 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 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 October 19, 2015, the surveyor, accompanied by the Facility Manager, observed oxygen stored by combustibles in the following locations:

1. One E-O2 bottle stored in an unoccupied Endo office by combustibles.
2. One E-O2 bottle stored in an unoccupied Endo department next to electrical outlet and combustibles.
3. One E-O2 bottle stored in an unoccupied MRI trailer next to combustibles.

During the exit conference on October 19, 2015, the above findings were again acknowledged by the Facility Manager and the Director of Infrastructure.

Leaking oxygen could penetrate combustible materials and create an extreme fire hazard, which could cause harm to the patients. In an emergency, patients could be harmed if an empty medical gas cylinder was mistakenly taken from the storage area.

Based on observation it was determined the facility failed to provide protection from electrical shock and the facility allowed the use of a multiple outlet adapter/extension cord.

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 110-12 (a) Unused Openings. "Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment."

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 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 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 October 19, 2015, the surveyor, accompanied by the Facility Manager, observed the following electrical items:

1. 220 outlet pulled out of the wall and hanging in a Endo office.
2. ER Nurse manager office, refrigerator plugged into a power strip.
3. Respiratory break room, a microwave and refrigerator piggy backed into two power strips.
4. MRI trailer, 480 panel has two missing blanks covered with tape.

During the exit conference on October 19, 2015, the above findings were again acknowledged by the Facility Manager and the Director of Infrastructure.

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. Failing to protect energized electrical equipment or wiring can cause a shock or fire. A fire could cause harm to the patient.

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 have smoke resistant Dutch doors.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.6.3.6, "Dutch doors shall be permitted where they conform to 18.3.6.3 or 19.3.6.3. In addition, both the upper leaf and lower leaf shall be equipped with a latching device and the meeting edges of the upper and lower leaves shall be equipped with an astragal, a rabbet, or a bevel. Dutch doors protecting openings in enclosures around hazardous areas shall comply with NFPA 80, Standard for Fire Doors and Fire Windows...."

NFPA 101 Life Safety Code 2000, Chapter 19, 19.3.6.3.1 " Doors protecting corridor openings in other than required enclosures of vertical openings, exit, or hazardous areas shall be substantial doors, such as those constructed of 1 3/4 in. thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke...."

Findings Include:

On October 19, 2015 the surveyor, accompanied by the Facility Manager, found the following:

1. Dutch door in the middle supply room for scopes not smoke tight.
2. Bone Densitometry office door tested three of three times would not positively latch.

During the exit conference on October 19, 2015, the above findings were again acknowledged by the Facility Manager and the Director of Infrastructure.

The facility failed to protect patients from heat and smoke.

Based on document review of the fire drills it was determined the facility failed to conduct the required fire drills.

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."

Findings include:

On October 19, 2015 the surveyor, accompanied by the Facility Manager, reviewed the facility's fire drill records. The facility did not have a fire drill for the third shift third quarter.

During the exit conference on October 19, 2015, the above findings were again acknowledged by the Facilitie Manager and the Director of Infrastructure.

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 maintain the sprinkler head in the walk in refrigerator in the kitchen.

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." 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." Chapter 3, Section 3-2.6.1 and 3-2.6.2, Listed "corrosion resistant sprinklers shall be installed in locations where chemicals, moisture, or other corrosive vapors sufficient to cause corrosion of such devices exist. Corrosion -resistant coatings shall be applied only by manufacturer of the sprinkler...."

Findings include:

On October 19, 2015, the surveyor, accompanied by the Facility Manager, observed the walk in refrigerator in the kitchen. The refrigerator had a corroded sprinkler head and frame assembly. This was apparent by the rust color around the assembly and the assembly was covered with lint.

During the exit conference on October 19, 2015, the above findings were again acknowledged by the Facilitie Manager and the Director of Infrastructure.

Failure to maintain sprinkler heads will not allow the head to operate correctly under fire conditions and will 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.

Based on Observation it was determined the facility failed to inspect and maintain the portable ABC or K type fire extinguishers.

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."

Chapter 4, Section 4-3.1, "Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30 day intervals..." Section 4-3.4.2, "At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded."

Findings include:

On October 19, 2015, the surveyor, accompanied by the Facility Manager, observed the following fire extinguishers:

1. Two of two fire extinguishers have not been checked and signed off since April 2015.
2. The ED fire extinguishers by the exit to the Heli pad was blocked by two wheel chairs.

During the exit conference on October 19, 2015, the above findings were again acknowledged by the Facilitie Manager and the Director of Infrastructure.

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

Failing to maintain fire extinguishers may cause injury to 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 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 October 19, 2015, the surveyor, accompanied by the Facility Manager, observed oxygen stored by combustibles in the following locations:

1. One E-O2 bottle stored in an unoccupied Endo office by combustibles.
2. One E-O2 bottle stored in an unoccupied Endo department next to electrical outlet and combustibles.
3. One E-O2 bottle stored in an unoccupied MRI trailer next to combustibles.

During the exit conference on October 19, 2015, the above findings were again acknowledged by the Facility Manager and the Director of Infrastructure.

Leaking oxygen could penetrate combustible materials and create an extreme fire hazard, which could cause harm to the patients. In an emergency, patients could be harmed if an empty medical gas cylinder was mistakenly taken from the storage area.

Based on observation it was determined the facility failed to provide protection from electrical shock and the facility allowed the use of a multiple outlet adapter/extension cord.

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 110-12 (a) Unused Openings. "Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment."

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 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 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 October 19, 2015, the surveyor, accompanied by the Facility Manager, observed the following electrical items:

1. 220 outlet pulled out of the wall and hanging in a Endo office.
2. ER Nurse manager office, refrigerator plugged into a power strip.
3. Respiratory break room, a microwave and refrigerator piggy backed into two power strips.
4. MRI trailer, 480 panel has two missing blanks covered with tape.

During the exit conference on October 19, 2015, the above findings were again acknowledged by the Facility Manager and the Director of Infrastructure.

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. Failing to protect energized electrical equipment or wiring can cause a shock or fire. A fire could cause harm to the patient.

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.