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The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See C-231

Based upon observation and record review it was determined that the facility failed to properly maintain ventilation, plumbing systems and the laboratory hood to ensure these systems are operating in a safe condition.
Findings include:
On 3/5/12 at approximately 9:50 AM, based upon observation it was discovered that the exhaust fan serving the patient bath, patient shower and soiled utility room was not exhausting any air from these rooms.
On 3/5/12 at approximately 10:30 AM based upon observation it was discovered that all chemical dispensing units installed in janitors closet throughout the facility are directly connected to the mop sink faucet, with shut off valves located downstream from the built in Atmospheric Vacuum Breaker (AVB) subjecting the AVB to constant pressure. Locations include: janitor's closet by the penthouse door, kitchen janitor's closet, and OR janitor's closet.
On 3/5/12 at approximately 10:40 AM based upon observation it was discovered that the ice machine located in the Equipment Room is not provided with an approved unobstructed air gap between the drain line and the sanitary drain to the sewer.
On 3/5/12 at approximately 12:00 PM based upon observation it was discovered that the biological hood located in the laboratory had a testing sticker dated 2009 on the unit. Further record review confirmed that this equipment had not been maintained or tested since 2009.

Based upon observation, it was determined that the facility failed to ensure a clean and orderly environment in the cardio storage room and ER exam room and ER storage room.

Findings include:
On 3/5/12 at approximately 10:20 AM based upon observation it was discovered that the room used for cardio storage has an accumulation of dust and debris in the corners of the room. The shelving located in this space is also constructed of wood and was at one time painted or varnished. The sealant on the wood has worn away over time rendering the surface of the shelves to no longer be easily cleanable.
On 3/5/12 at approximately 11:20 AM, based upon observation it was discovered that items are being stored in the cabinet underneath the handsink in the ER exam room. This cabinet contains unprotected sewer drain lines. Items stored in the cabinet included evidence collection kits marked for training purposes only and packaging materials for evidence collection kits, toilet paper, and paper towels.
On 3/5/12 at approximately 11:35 AM, based upon observation it was discovered that the ER storage room has cardboard boxes of supplies stored directly on the floor beneath the lowest shelf of the shelving unit.

Based upon observation and record review it was determined that the facility failed to provide proper humidity levels in the Operating Rooms.

Findings include:
On 3/5/12 at approximately 1:30 PM based upon observation it was discovered that the humidity monitor in the OR 1 was reading below 20%. Further record review of temperature and humidity logs confirmed that humidity levels reading between 17% and 25% are being recorded on the log sheets for the months of January, February and March.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors, which concluded on March 6, 2012, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated March 6, 2012 for Life Safety Code.