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Based on observation, the facility failed to maintain their corriders. A transfer grille was installed above a corridor door.

Findings include:

While on tour August 22, 2013, at 2:30 PM, in the corridor at room 219, with the Maintenance Director, a transfer grille was above the door into room 219. NFPA 101 (2000 edition) chapter 19.3.6.4 prohibits transfer grilles.

Based on record review, the facility failed to produce documentation of an approved CEMP (comprehensive emergency management plan) or documentation of disaster drills.

Findings include:

During record review August 22, 2013, from 2:30 PM to 3:30 PM, with the CNO, the facility failed to produce documentation for an approved CEMP or documentation of disaster drills. NFPA 99(1999 edition) chapter 11-4.3 requires a CEMP. Chapter 11-5.3.9 requires drills, with at least one semi-annual with mass casualties for health care facilities with emergency services.

Based on record review, the facility failed to properly test their fire alarm. On an annual fire alarm test, the alarm contractor failed to test the interface with the kitchen hood ansul system

Findings include:

During record review August 22, 2013, from 2:30 PM to 3:30 PM with the Maintenance Director, the facility produced documentation for an annual fire alarm test dated July 22, 2013 in which the contractor did not test the kitchen hood ansul system interface. NFPA 72 (1999 edition) table 7-3.2 (17) requires annual testing of interface devices,.

Based on observation, the facility failed to correctly install and maintain their fire sprinkler system. The laboratory has sprinkler heads with mixed thermal response.

Findings include:

While on tour August 22, 2013 at 1:57 PM, in the laboratory, with the Maintenance Director, sprinkler heads with mixed thermal response were observed in the ceiling. NFPA 13 (1999 edition) chapters 5.3.1.5.2 requires all sprinklers in a compartment be quick response when light hazard heads are converted quick response. Mixed thermal response can cause the wrong head to operate and allow a fire to grow.

Based on observation the facility failed to maintain the building exterior. A roof leak is allowing storm water to enter the pre-operating room.

Findings include:

While on tour August 22, 2013, at 2:55 PM, in the pre-operating room, with the Maintenance Director, during a thunderstorm, rain water had filled the light fixtures and was falling to the floor.