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Based on observation and interview with staff, the facility failed to have communicating openings in a common wall with a nonconforming building only in corridors and are protected by approved self-closing fire doors. Finding:

The door separating purchasing (general storage) from the doctors' office building (office in basement) is located between two rooms and not in a public corridor.

Based on review of the Health Care Emergency Preparedness and interview with The CEO, the facility failed to provide a written plan for the protection of all patients. Finding:


Emergency Water Plan:

The policy for loss of water (DS5.121out of Policy &Procedure Book) failed to identify who would supply water or how much water was required for 96 hours.

Based on review of the fire drill records and interview with staff, the facility failed to ensure staff is familiar with procedures and is aware that drills are part of established routine. Findings:

The Fire drill report failed to document if staff showed up with fire extinguishers, etc., who participated or did not participate, and the performance of staff in accordance with the hospitals Code Red (Fire) Procedures (P&P DS 5.112 Revised 11-14-2008).

Based on observation and interview with staff, the facility failed to maintain electronic or written records of tests. Finding: The last two fire alarm annual inspections were not available for review.

Based on observation and interview with staff, the facility failed to provide an automatic sprinkler system to provide complete coverage for all portions of the building. Findings:
(1) There is no coverage over the covered opening to the basement (dietary service entrance) where empty Oxygen Bottles were stored.
(2) There is no coverage in the foyer of the front lobby on first floor.

Based on observation and interview with staff, the facility failed to provide piped in medical gas systems that comply with NFPA 99, Chapter 4. Findings:

The medical gas liquid oxygen storage tank is leaking and is located beneath the main electrical lines for the incoming power for the building. NFPA 55 (Medical Gas Storage) 9.3.2 - (17 b) requires that the vertical plain of the distance from hazards shall be greater than 5 feet.

Based on observation and interview with staff, the facility failed to ensure flammable and combustible liquids are used from and stored in approved containers in accordance with NFPA 30, Flammable and Combustible Liquids Code.
Findings:

(1) Twelve 5-gallon buckets of combustible roof paint was stored in the purchasing department.

(2) A gasoline powered weed eater is stored in the boiler room.

Based on review of the generator logs, it could not be determined that generators are inspected weekly and exercised under load for 30 minutes per month in accordance with NFPA 99. Finding:

The logs fail to provide information that is required in NFPA 110, i.e. who conducted the test, percentage of load, temperature, pressure, etc.

Based on observation and interview with the CEO, the facility failed to provide electrical wiring and equipment in accordance with NFPA 101 Chapter 9. Findings:

(1) Electrical J-Boxes located in the boiler room were open and wire was bare with no wire nuts attached.
(2) Remote Generator Enunciators are not provided for the Type 1 Essential Electrical System.
(3) There are no ground fault receptacles located next to sinks in the lab and in the nurses station.

Based on observation and interview with staff, the facility failed to have communicating openings in a common wall with a nonconforming building only in corridors and are protected by approved self-closing fire doors. Finding:

The door separating purchasing (general storage) from the doctors' office building (office in basement) is located between two rooms and not in a public corridor.

Based on review of the Health Care Emergency Preparedness and interview with The CEO, the facility failed to provide a written plan for the protection of all patients. Finding:


Emergency Water Plan:

The policy for loss of water (DS5.121out of Policy &Procedure Book) failed to identify who would supply water or how much water was required for 96 hours.

Based on review of the fire drill records and interview with staff, the facility failed to ensure staff is familiar with procedures and is aware that drills are part of established routine. Findings:

The Fire drill report failed to document if staff showed up with fire extinguishers, etc., who participated or did not participate, and the performance of staff in accordance with the hospitals Code Red (Fire) Procedures (P&P DS 5.112 Revised 11-14-2008).

Based on observation and interview with staff, the facility failed to maintain electronic or written records of tests. Finding: The last two fire alarm annual inspections were not available for review.

Based on observation and interview with staff, the facility failed to provide an automatic sprinkler system to provide complete coverage for all portions of the building. Findings:
(1) There is no coverage over the covered opening to the basement (dietary service entrance) where empty Oxygen Bottles were stored.
(2) There is no coverage in the foyer of the front lobby on first floor.

Based on observation and interview with staff, the facility failed to provide piped in medical gas systems that comply with NFPA 99, Chapter 4. Findings:

The medical gas liquid oxygen storage tank is leaking and is located beneath the main electrical lines for the incoming power for the building. NFPA 55 (Medical Gas Storage) 9.3.2 - (17 b) requires that the vertical plain of the distance from hazards shall be greater than 5 feet.

Based on observation and interview with staff, the facility failed to ensure flammable and combustible liquids are used from and stored in approved containers in accordance with NFPA 30, Flammable and Combustible Liquids Code.
Findings:

(1) Twelve 5-gallon buckets of combustible roof paint was stored in the purchasing department.

(2) A gasoline powered weed eater is stored in the boiler room.

Based on review of the generator logs, it could not be determined that generators are inspected weekly and exercised under load for 30 minutes per month in accordance with NFPA 99. Finding:

The logs fail to provide information that is required in NFPA 110, i.e. who conducted the test, percentage of load, temperature, pressure, etc.

Based on observation and interview with the CEO, the facility failed to provide electrical wiring and equipment in accordance with NFPA 101 Chapter 9. Findings:

(1) Electrical J-Boxes located in the boiler room were open and wire was bare with no wire nuts attached.
(2) Remote Generator Enunciators are not provided for the Type 1 Essential Electrical System.
(3) There are no ground fault receptacles located next to sinks in the lab and in the nurses station.