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Based on observation, it was determined the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.3.6.3.1, 18.3.6.3.2, 18.3.6.3.3. Section 18. 18.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. There is no impediment to closing of the doors. 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...."

Findings Include

On June 17, 2016 the surveyor, accompanied by the Manager of Plant Operations observed the following corridor doors.

1. The upstairs second floor Native air day room, pilots quarters the rated door was on a door closure on the fire alarm system which had an impediment, door chalk holding the door in the open position.

2. The corridor ICU double doors the smoke seal was torn and not smoke proof.

3. The Bio-medical storage room did not close and latch when tested three of three times.

During the exit conference on June 17, 2016 the above findings were again acknowledged by the Chief Financial Officer; Chief Operating Officer; the Chief Nursing Officer; Director of Quality and Performance Improvement and the Manager of Plant Operations.

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

1. Based on observation the facility failed to maintain the installed automatic sprinkler heads clean from lint buildup on the sprinkler frame and assembly.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.3.5.1, "Buildings containing health care facilities shall be protected throughout by an approved supervised automatic sprinkler system in accordance with 9.7." . Section 9.7.1.1 "Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Installation of Sprinkler Systems, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems." NFPA 25, Chapter 2, Section 2-2.1.1 "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint and physical damage and shall be installed in the proper orientation..."

Findings include:

On June 17, 2016, the surveyor accompanied by the Manager of Plant Operations observed the following sprinkler heads had lint on the entire sprinkler frame and assembly.

Rooms 13, 101,102,105, 106, 212, Employee Lounge and MDF room one of two sprinklers had lint buildup on the sprinkler frame and assembly.

During the exit conference on June 17, 2016 the above findings were again acknowledged by the Chief Financial Officer; Chief Operating Officer; the Chief Nursing Officer; Director of Quality and Performance Improvement; and the Manager of Plant Operations.

Sprinkler heads are U.L. listed to respond to a calculated ceiling temperature. Lint on the sprinkler head could slow the response or disable the sprinkler head. This could cause harm to the patients by allowing the fire to grow to a size uncontrollable by the remaining sprinkler heads.

2.Based on observation the facility failed to assure that all parts of the facility were provided sprinkler system coverage.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.3.5.1 "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with 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." Chapter 5, Section 5-5.6, " The clearance between the deflector and the top of storage shall be 18 inches or greater...."

Findings include:

On June 17, 2016 the surveyor and Manager of Plant Operations observed the Native air room, pilots quarters had storage; medical respiratory plastic tubing in bags within a couple of inches of the sprinkler deflectors. The horn strobe was also blocked and not visible.

During the exit conference on June 17, 2016 the above findings were again acknowledged by the Chief Financial Officer; Chief Operating Officer; the Chief Nursing Officer; Director of Quality and Performance Improvement and the Manager of Plant Operations.

The blocking of sprinkler head could result in delay of the sprinkler going off and the blocking the horn strobe in the room the pilots may not know the alarm is going off and could result in injury to the staff and patients.

Based on observation it was determined the facility failed to assure the fire extinguisher was readily available for use in an emergency and visual Monthly checks of the ABC fire extinguishers were not completed and documented on the Annual fire extinguisher tag.

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

NFPA 10, 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 June 17, 2016 the surveyor, accompanied by the Manager of Plant Operations observed the following for the fire extinguishers in the hospital.

1. The helicopter landing area had one ABC fire extinguisher that was not mounted on the wall and resting on the floor.

2. The stairwell by the elevator to the helicopter landing the ABC fire extinguisher was missing the Monthly visual inspections not documented on the Annual tag for June through May of 2016.

3. The helicopter landing purple K fire extinguisher was missing the Annual fire inspection tag.

4. The ABC fire extinguishers by room one and Ambulance entrance was missing the Monthly visual inspections and was not documented on the tag.

During the exit conference on June 17, 2016 the above findings were again acknowledged by the Chief Financial Officer; Chief Operating Officer; the Chief Nursing Officer; Director of Quality and Performance Improvement and the Manager of Plant Operations.

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

Based on observation the facility allowed the use of a multiple outlet adapters or extension cords for appliances power strips and did not use the wall outlet receptacles for appliances.

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 June 17, 2016 the surveyor, accompanied by the Manager of Plant Operations observed refrigerators and microwave plugged into multi-outlet power strips or an extension cord and not directly plugged into the wall outlet receptacles in the following locations in the hospital.

1. The IT office.
2. MRI.
3. Administration office.

During the exit conference on June 17, 2016 the above findings were again acknowledged by the Chief Financial Officer; Chief Operating Officer; the Chief Nursing Officer; Director of Quality and Performance Improvement and the Manager of Plant Operations.

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.

Based on record review the facility failed to provide documentation of the Monthly elevator recall testing for a few months in 2015 and 2016.

NFPA 101 Life Safety Code, Chapter 18, Section 18.5.3. Elevators, Escalators and Conveyors. Elevators, escalators and conveyors shall comply with the provisions of Section 9.4 Section 9.4.6 Elevator testing Elevators shall be subject to routine and periodic inspections and tests as specified in ASME/ANSI A17.1, Safety Code for Elevators and Escalators. All elevators equipped with firefighter service in accordance with 9.44 and 9.4.5 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASME/ANSI A17.1 Safety Code for Elevators and Escalators.

Findings include:

On June 17, 2016 the surveyor, accompanied by the Manager of Plant Operations reviewed the Monthly elevator fire service testing log sheet the facility provided for review since the last survey. The elevator recall was not tested Monthly according to the documentation shown to the surveyor from January through March and May of 2015 to include February through April of 2016.

During the exit conference on June 17, 2016 the above findings were again acknowledged by the Chief Financial Officer; Chief Operating Officer; the Chief Nursing Officer; Director of Quality and Performance Improvement and the Manager of Plant Operations.

Failure to test and document the Monthly elevator recall testing could result in harm to the patients if the elevator is not working in an emergency.