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Based on observation and interview with staff, the facility failed to provide that all doors protecting corridor openings are provided with a means suitable for keeping the door closed. 19.3.6.3 Findings,

The door to the Dining Room is not provided with positive latching hardware.

Based on observation and interview with staff, the facility failed to provide exit access that is arranged so that exits are readily accessible at all times in accordance with section 7.1. 19.2.1 Findings,

The exit out of the new addition fails to provide exit discharge for all occupants with safe access to a public way, per NFPA 101, Section 7.7.1. Provide a sidewalk or other approved surface for access in inclement weather

Based on observation and review of the last 12 Fire Drills, the facility failed to provide documentation that the staff is familiar with procedures under varying conditions in accordance with NFPA 101 19.7.1.2 Findings,

Based upon comments by the competent person conducting the drills, education is needed. In-service for staff was not effective and provided for all drills.

Based on observation and interview with staff, the facility failed to provide documentation that the fire alarm system is installed, tested, and maintained in accordance with NFPA 70 and NFPA 72, chapter 7 (Maintenance and Testing). Findings,

On 4-25-2012 the vendor doing the maintenance and testing of the fire alarm system failed to provide a re-acceptance test for the devices affected and an additional 10% of the devices, up to 50 devices.

Based on observation and interview with staff, the facility failed to provide a storage area for soiled linen or trash collection receptacles that exceed 32 gal. 19.7.5.5

3-trash receptacles located in the basement by the elevators were unattended and not kept in a room protected as a hazardous area and out of the egress corridor.

Based on observation and interview with staff, the facility failed to provide Anesthetizing locations that are protected in accordance with NFPA 99, Standard for Health Care Facilities.

The area gas alarm for the suite was removed and re-located to the Nurses station outside the OR Suite. The area alarms shall be up stream from the zone valves located outside the OR rooms that it serves.

Based on observation and interview staff, the facility failed to provide a Type I Essential Electrical System with remote enunciators in accordance with NFPA 99, NFPA 110. Findings,

The Remote enunciator does not meet the requirements of NFPA 110, there is only a light installed in the ER Admitting area (Remote enunciators are required to depict a variety of points that reflect how the generator is functioning). The ER Staff had not been trained to know where the remote light is and did not know the meaning if it was on. The light was covered up behind some papers on a desk.

Based on interview with the Surgery Director, the facility failed to conduct Fire Drill Training specific to the OR Suite that included Physicians and Surgeons in accordance with NFPA 99 1999 edition chapter 12.

Training of physicians and surgeons shall be conducted annually, incidents shall be reviewed monthly for Fire Loss Prevention in the Operating Suite NFPA 99, 12-4.1.2.10

The Nurse Call Enunciator located in the Soiled Utility was not functioning.

Based on review of the Generator Logs, the facility failed to exercise Generators weekly and run under load for 30 minutes per month in accordance with NFPA 99. 3.4.4.1. Findings,

The Generator run time for weekly test was not completed. The run time only reflected a start time of 9:52, with no end time.

Based on observation and interview with staff, the facility failed to ensure that equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2 Findings,

The electrical portable heater located in the OR Surgery Supervisor office had not been electrically safety tested.

The Air Pal Patient Transfer System located in the ER Suite had not been tested by bio-med since June of 2011, the equipment had not been taken out of service. Staff was not reviewing equipment bio-med stickers for test dates. Other equipment through out the facility did not have identifying bio-med stickers; such as, the IV Pumps.

The facility had not provided an impedance testing program for the hospital.

Based on observation and interview with staff, the facility failed to provide that all doors protecting corridor openings are provided with a means suitable for keeping the door closed. 19.3.6.3 Findings,

The door to the Dining Room is not provided with positive latching hardware.

Based on observation and interview with staff, the facility failed to provide exit access that is arranged so that exits are readily accessible at all times in accordance with section 7.1. 19.2.1 Findings,

The exit out of the new addition fails to provide exit discharge for all occupants with safe access to a public way, per NFPA 101, Section 7.7.1. Provide a sidewalk or other approved surface for access in inclement weather

Based on observation and review of the last 12 Fire Drills, the facility failed to provide documentation that the staff is familiar with procedures under varying conditions in accordance with NFPA 101 19.7.1.2 Findings,

Based upon comments by the competent person conducting the drills, education is needed. In-service for staff was not effective and provided for all drills.

Based on observation and interview with staff, the facility failed to provide documentation that the fire alarm system is installed, tested, and maintained in accordance with NFPA 70 and NFPA 72, chapter 7 (Maintenance and Testing). Findings,

On 4-25-2012 the vendor doing the maintenance and testing of the fire alarm system failed to provide a re-acceptance test for the devices affected and an additional 10% of the devices, up to 50 devices.

Based on observation and interview with staff, the facility failed to provide a storage area for soiled linen or trash collection receptacles that exceed 32 gal. 19.7.5.5

3-trash receptacles located in the basement by the elevators were unattended and not kept in a room protected as a hazardous area and out of the egress corridor.

Based on observation and interview with staff, the facility failed to provide Anesthetizing locations that are protected in accordance with NFPA 99, Standard for Health Care Facilities.

The area gas alarm for the suite was removed and re-located to the Nurses station outside the OR Suite. The area alarms shall be up stream from the zone valves located outside the OR rooms that it serves.

Based on observation and interview staff, the facility failed to provide a Type I Essential Electrical System with remote enunciators in accordance with NFPA 99, NFPA 110. Findings,

The Remote enunciator does not meet the requirements of NFPA 110, there is only a light installed in the ER Admitting area (Remote enunciators are required to depict a variety of points that reflect how the generator is functioning). The ER Staff had not been trained to know where the remote light is and did not know the meaning if it was on. The light was covered up behind some papers on a desk.

Based on interview with the Surgery Director, the facility failed to conduct Fire Drill Training specific to the OR Suite that included Physicians and Surgeons in accordance with NFPA 99 1999 edition chapter 12.

Training of physicians and surgeons shall be conducted annually, incidents shall be reviewed monthly for Fire Loss Prevention in the Operating Suite NFPA 99, 12-4.1.2.10

The Nurse Call Enunciator located in the Soiled Utility was not functioning.

Based on review of the Generator Logs, the facility failed to exercise Generators weekly and run under load for 30 minutes per month in accordance with NFPA 99. 3.4.4.1. Findings,

The Generator run time for weekly test was not completed. The run time only reflected a start time of 9:52, with no end time.

Based on observation and interview with staff, the facility failed to ensure that equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2 Findings,

The electrical portable heater located in the OR Surgery Supervisor office had not been electrically safety tested.

The Air Pal Patient Transfer System located in the ER Suite had not been tested by bio-med since June of 2011, the equipment had not been taken out of service. Staff was not reviewing equipment bio-med stickers for test dates. Other equipment through out the facility did not have identifying bio-med stickers; such as, the IV Pumps.

The facility had not provided an impedance testing program for the hospital.