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Based on observation and staff interview, the facility failed to provide approved exit signs were the exit was not obvious and clearly identifiable. The findings were:

Observation of the direction of travel through the corridor next to the CFO office heading away from the main entrance on 05/03/2016 at 1:36 PM revealed the exit adjacent to Medical Records was not obvious and clearly identifiable from the CFO office corridor. At the time of the observation the Facility Maintenance Manager acknowledged the exit was not obvious and clearly identifiable.

Ref:
2000 NFPA 101, Sections 19.2.10.1 and 7.10.1.2

Based on observation and staff interview, the facility failed to ensure that automatic sprinkler systems are installed, and continuously maintained per the requirements of NFPA 13 and NFPA 25. The findings were:

1. Observation of the Anesthesia room in the O.R. area on 05/03/2016 at 12:20 PM revealed that a sprinkler head escutcheon was missing. Interview with the Facility Maintenance Manager at the time of the observation confirmed that the escutcheon was missing, and was not aware that it had been missing.

Ref:
2000 NFPA 101, Section Sections 18.3.5.1 and 9.7.1.
1999 NFPA 13, Section 3-2.7.2


2. Observation on 05/03/16 at 12:41 PM located in the outpatient area room #2 revealed that a ceiling tile was missing next to sprinkler head. Missing ceiling tiles will delay the response of the sprinkler and heat will flow to the above area. At the time of the observation the Facility Maintenance Manager acknowledged that there was a missing ceiling tile.

3. Observation on 05/03/16 at 12:45 PM located in the Data Room Storage of the outpatient recovery area revealed that a ceiling tile was missing next to sprinkler head. Missing ceiling tiles will delay the response of the sprinkler and heat will flow to the above area. At the time of the observation the Facility Maintenance Manager acknowledged that there was a missing ceiling tile

Ref:
2000 NFPA 101, Sections 19.3.5.1 and 9.7.1.1
1999 NFPA 13, Sections 5-10.4.1.1

4. Observation on 05/03/16 at 1:45 PM of the sprinkler riser located in the main hospital boiler room revealed no hydraulics were posted. At the time of the observation the Facility Maintenance Manager acknowledged the hydraulics were not posted.

Ref:
2000 NFPA 101, Sections 19.3.5.1 and 9.7.1.1
1999 NFPA 13, Sections 5-15.4.6.2 and 10-5

Based on observation and staff interview, the facility failed to provide portable fire extinguishers in accordance with NFPA 10. The findings were:

1. Observation on 05/03/2016 at 1:05 PM of the lab room revealed a fire extinguisher mounted on the wall with the top of the fire extinguisher approximately 66 inches from the floor. At the time of the observation the Facility Maintenance Manager acknowledge the height of the extinguisher.

2. Observation on 05/03/16 at 1:25 PM of the pine ridge nurses station revealed a fire extinguisher mounted on the wall with the top of the fire extinguisher approximately 62 inches from the floor. At the time of the observation the Facility Maintenance Manager acknowledge the height of the extinguisher.

Ref:
2000 NFPA 101, Sections 19.3.5.6 and 9.7.4.1
1998 NFPA 10, Section 1-6.10

Based on observation and staff interview, the facility failed to ensure alcohol based hand rub (ABHR) dispensers were not installed over or adjacent to an ignition source. The findings were:

Observation on 05/03/16 at 1:15 PM revealed the ABHR dispenser in the rehab dining area was installed directly over a outlet. At the time of the observation the Facility Maintenance Manager acknowledged the location of the ABHR dispenser.

Ref;
CFR 485.623 (7)(iv)

Based on observation and staff interview, the facility failed to ensure alcohol based hand rub (ABHR) dispensers were not installed over or adjacent to an ignition source. The findings were:

Observation on 05/03/16 at 9:25 AM revealed the ABHR dispenser in the med surg. soiled utility room was installed directly over a light switch. At the time of the observation the Facility Maintenance Manager acknowledged the location of the ABHR dispenser.
Ref;
CFR 485.623 (7)(iv)

Based on observation and staff interview, the facility failed to provide approved exit signs were the exit was not obvious and clearly identifiable. The findings were:

Observation of the direction of travel through the corridor next to the CFO office heading away from the main entrance on 05/03/2016 at 1:36 PM revealed the exit adjacent to Medical Records was not obvious and clearly identifiable from the CFO office corridor. At the time of the observation the Facility Maintenance Manager acknowledged the exit was not obvious and clearly identifiable.

Ref:
2000 NFPA 101, Sections 19.2.10.1 and 7.10.1.2

Based on observation and staff interview, the facility failed to ensure that automatic sprinkler systems are installed, and continuously maintained per the requirements of NFPA 13 and NFPA 25. The findings were:

1. Observation of the Anesthesia room in the O.R. area on 05/03/2016 at 12:20 PM revealed that a sprinkler head escutcheon was missing. Interview with the Facility Maintenance Manager at the time of the observation confirmed that the escutcheon was missing, and was not aware that it had been missing.

Ref:
2000 NFPA 101, Section Sections 18.3.5.1 and 9.7.1.
1999 NFPA 13, Section 3-2.7.2


2. Observation on 05/03/16 at 12:41 PM located in the outpatient area room #2 revealed that a ceiling tile was missing next to sprinkler head. Missing ceiling tiles will delay the response of the sprinkler and heat will flow to the above area. At the time of the observation the Facility Maintenance Manager acknowledged that there was a missing ceiling tile.

3. Observation on 05/03/16 at 12:45 PM located in the Data Room Storage of the outpatient recovery area revealed that a ceiling tile was missing next to sprinkler head. Missing ceiling tiles will delay the response of the sprinkler and heat will flow to the above area. At the time of the observation the Facility Maintenance Manager acknowledged that there was a missing ceiling tile

Ref:
2000 NFPA 101, Sections 19.3.5.1 and 9.7.1.1
1999 NFPA 13, Sections 5-10.4.1.1

4. Observation on 05/03/16 at 1:45 PM of the sprinkler riser located in the main hospital boiler room revealed no hydraulics were posted. At the time of the observation the Facility Maintenance Manager acknowledged the hydraulics were not posted.

Ref:
2000 NFPA 101, Sections 19.3.5.1 and 9.7.1.1
1999 NFPA 13, Sections 5-15.4.6.2 and 10-5

Based on observation and staff interview, the facility failed to provide portable fire extinguishers in accordance with NFPA 10. The findings were:

1. Observation on 05/03/2016 at 1:05 PM of the lab room revealed a fire extinguisher mounted on the wall with the top of the fire extinguisher approximately 66 inches from the floor. At the time of the observation the Facility Maintenance Manager acknowledge the height of the extinguisher.

2. Observation on 05/03/16 at 1:25 PM of the pine ridge nurses station revealed a fire extinguisher mounted on the wall with the top of the fire extinguisher approximately 62 inches from the floor. At the time of the observation the Facility Maintenance Manager acknowledge the height of the extinguisher.

Ref:
2000 NFPA 101, Sections 19.3.5.6 and 9.7.4.1
1998 NFPA 10, Section 1-6.10