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Based on observation during tour and staff verification, this facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. The requirement is located in the National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all patient's, staff and visitors utilizing the facility. The facility census was 168 at the beginning of the survey.

Findings include:

Facility tour took place with staff Sand T on the days of 03/27/12 through 03/29/12. During tour observation was made of smoke detectors which were located near air flow devices in the following areas:

First Floor:
*Within the dish room storage room # 1-981
*At the employee entry vestibule
*At the behavioral health main entrance
*Near the high risk dining room
*At the north behavioral heath entrance

Second floor:
*Between endoscopy rooms, specifically room #2-548C
*Soiled utility room # 2-119
*Within cath lab # 3
*Cath lab nurse's station
*Pharmacy, by room #'s 2-275 and 2-214
*Within room # 2-505

Third floor:
*Corridor between room #'s 314 and 315
*Room # 3-210

Fourth floor:
*Connector corridor leading to the medical office building
*Corridor between the mechanical and waiting room

Fifth floor:
*Within the rehab storage
*Corridor by room # 047-06

These findings were verified by staff S and T during tour of the facility on 03/27/12 through 03/29/12. Corrections have been initiated with a professional contracting company during the survey.

Based on observation during tour and staff verification it was determined this facility failed to ensure the sprinkler system was installed to provide complete coverage of all portions of the facility. This had the potential to affect all those utilizing these areas of this facility. The facility census was 168 at the beginning of the survey.

Findings include:

Facility tour took place with staff Sand T on the days of 03/27/12 through 03/29/12. During tour of the facility observation was made of several alcove areas which had a divider extending from the floor to the ceiling made of wood and glass. This divider separated the corridor from the alcove which was used by staff for charting areas and was not equipped with sprinkler coverage. Additionally, observation was made of an enclosed closet within a corridor which lacked sprinkler coverage. This closet and alcoves were identified at the following areas:

Second floor:
*Within the cath lab area at room #2-177 (closet)

Third floor:
*Between room #'s 314 and 315
*Between room #'s 321 and 322
*Between room #'s 323 and 324
*Between room #'s 350 and 351
*Between room #'s 359 and 360

Fourth floor:
*Between room #'s 416 and 417
*Between room #'s 450 and 451
*Between room #'s 454 and 455

These findings were verified by staff S and J during tour and corrections have been initiated with a professional contracting company during the survey process.

Based on observation during tour and staff verification it was determined this facility failed to ensure the required automatic sprinkler system was continuously maintained in reliable operating condition in regards to preventive maintenance of sprinkler heads. This had the potential to affect all those utilizing this facility. The facility census at the beginning of the survey was 168.

Findings include:

Facility tour took place with staff members S and T on 03/27/12 to 03/29/12. During tour observation was made of several sprinkler heads that were coated/covered with tape, paint, dust and/or debris in the following areas:

Ground floor:
*Medical gas storage room # 0-302 sprinkler head covered with tape

First floor:
*Room # 1-286 was observed to have a sprinkler head with paint
*Staff lounge room # 1-473 dirty sprinkler head
*Supervisor's office room # 1-455 dirty sprinkler head
*Kitchen prep area, two dirty sprinkler heads
*Grill service area, dirty sprinkler head
*Service area, two dirty sprinkler heads

Second floor:
*Surgery department nurse's station, dirty sprinkler head
*Nutritional galley # 2-560, dirty sprinkler head
*Post anesthesia care unit, dirty sprinkler head
*Pre and post operating area #2-520, dirty sprinkler head
*Alcove by room # 214, pain on sprinkler head
*Alcove by electrical room, dirty sprinkler head

Third floor:
*Dirty sprinkler head at room # 3-142
*At the NW nurse's station by the waiting area, dirty sprinkler head
*At the south nurse's station, dirty sprinkler head
*In the nutrition room # 3-390, dirty sprinkler head

Fourth floor:
*Room # 4-373, dirty sprinkler head
*Corridor by room # 418, dirty sprinkler head
*Corridor by room # 424, dirty sprinkler head
*Corridor by room # 425, dirty sprinkler head
*Corridor by nurse's station, dirty sprinkler head
*Staff restroom # 4-334, dirty sprinkler head
*Corridor by room # 438, dirty sprinkler head
*Nutrition room across from room #454, dirty sprinkler head
*Soiled utility room near nutrition room, dirty sprinkler head
*Nutrition room across from room #469, dirty sprinkler head
*By stair # 1, dirty sprinkler head
*Corridor by room # 473, dirty sprinkler head
*Soiled utility room # 4-577, dirty sprinkler head
*Dirty sprinkle head in waiting room and vending room near mechanical room

These findings were acknowledged by staff S and T during tour. On 03/27/12 staff S was questioned by this surveyor if they had a preventive maintenance program to clean the sprinkle heads and staff S stated "no, but we will have one". Facility staff was observed by this surveyor cleaning sprinkler heads during the survey.

Based on observation and staff verification it was determined this facility failed to ensure the room for trash and linen chutes were designed and used exclusively for accessing the chute opening as required by the National Fire Protection Association (NFPA) 2000, Chapter 9.5, specifically 9.5.1. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 168.

Findings include:

Facility tour took place on 03/27/12 to 03/29/12 with staff members S and T. During tour of the trash and laundry chute access rooms on floors one through four, observation was made of a large open room which was partially constructed with at least the required one hour fire resistance rating. The double doors accessing these rooms were not fire rated on floors one, two and four. Additionally, the double doors on each floor had a gap greater than 1/8 inch between the door leafs when in the closed position.
This open room was also used as a staff service elevator vestibule which had a bank of two elevators. Both the laundry and chute doors on each of the mentioned floors were located adjacent to the elevators. Additionally, this room was also used to access an environmental storage room through another door located at the back of the room.
During the time of these observations, this surveyor noted several staff members coming and going into these rooms moving supplies and large mobile bins while utilizing the elevators.

This finding was observed by both staff members during the tour of these areas. Staff S questioned as to why other surveyors and inspectors failed to mention this finding and this surveyor reviewed the written NFPA regulations with staff members S and J and also the local fire Marshall and construction supervisor on 03/30/12.

Based on observation during tour and staff verification it was determined this facility failed to ensure medical gasses designated as "in use" and located in smoke compartments did not exceed the maximum allowable amount as stated in the National Fire Protection Association (NFPA) 99. This had the potential to affect all those utilizing these areas of the facility. The patient census was 168 at the beginning of the survey.

Findings include:

Facility tour took place on 03/27/12 to 03/29/12 with staff members S and T. During tour of the fourth floor west smoke compartments of both the north and south wings, observation was made of E size oxygen tanks in numbers above the limit of 12 and designated as "in use" stored in rooms of each smoke compartment. In room # 4-132, observation was made of 14 E tanks of oxygen and in room # 4-246 observation was made of 15 E tanks of oxygen. Additionally, above each of the oxygen storage areas observation was made of a sign which had in highlight, a limit of 12 oxygen tanks as storage.

This observation was verified by both staff members during tour.

Based on observation during tour and staff verification it was determined this facility failed to ensure all anesthetizing locations were equipped with battery powered emergency lighting as required by the National Fire Protection Association (NFPA) 101 Chapter 18.2.9.2. This had the potential to affect all those utilizing these areas of the facility. The patient census was 168 at the beginning of the survey.

Findings include:

Facility tour took place with staff members S and T on 03/27/12 to 03/29/12. During tour of the second floor anesthetizing locations observation was made within cath lab number 3 and the cystoscopy room, which failed to be equipped with emergency battery powered lights. Interview with staff S on 03/28/12 regarding cath labs 1 and 2, the endoscopy and bronchoscopy rooms all of which were equipped for general anesthesia, revealed they also lacked emergency battery powered lights.

Based on observation during tour and staff verification, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. The requirement is located in the National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all patient's, staff and visitors utilizing the facility. The Women's Center facility census was 14 at the beginning of the survey.

Findings include:

Facility tour took place with staff Sand T on the days of 03/27/12 through 03/29/12. During tour observation was made of smoke detectors which were located near air flow devices in the following areas:

*By ultrasound 1
*By the north stairwell
*By storage room 4-136

These findings were verified by staff members S and T during tour of the Women's Center on 03/27/12.



Based on documentation review and staff verification it was determined this facility failed to ensure the fire alarm system including smoke detectors were tested in accordance with the National Fire Protection Association 72.

On 03/26/12 documentation review took place of the facility's fire and smoke alarm system. The last documented fire and smoke alarm test reports provided were dated for 01/24/11. Staff S stated they realized they were late and have scheduled a professional outside company to test their fire and smoke systems in April 2012.