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Facility failed to maintain corridor and hazardous area doors in accordance with the NFPA 101. Findings included the following observsations between 10:00 am and 2:00 pm on 5/20/14 :

1. Surveyor observed that in the Emergency Department, double doors to electrical closet and Resucitation Room were not equipped with gasket to provide smoke seal.

2. Surveyor observed door chocks used to hold open doors in dietary on dry storage room and in trash hold room near mechanical room

Facility failed to maintain smoke barrier integrity in accordance with NFPA 101. Findings include the following:

Surveyor observed between 10:00 and 11:00 am on 5/20/14 that above the double doors between patient wing and lobby that conduit penetration of smoke barrier was not sealed.

Facility failed to maintain smoke barrier door openings in accordance with NFPA 101 and NFPA 72. Findings included the following:

Surveyor observed between 11:00 and 11:30 am on 5/20/14 that double doors in smoke barrier between emergency walk-in waiting and emergency department corridor did not have smoke detectors located within 5 feet of the doors on hold-opens.

Facility failed to maintain hazardous areas in accordance with the 2000 edition of the Life Safety Code NPFA (National Fire Protection Association) 101. Findings included the following:

1. Surveyor observed between 10:00 am and 2:00 pm on 5/20/14 that numerous door openings to hazardous rooms with 1 hr ratings on all three levels were not protected with 45 min rated doors including soil utility, shelled spaces, and storage rooms.

2. Surveyor observed on the third floor room IC316 labeld "soiled workroom" that the door was not rated 45 min.

Facility failed to maintain exit access in accordance with NFPA 101. Findings included the following:

Surveyor observed between 10 am and 2:00 pm on 5/20/14 the following:

1. In pharmacy, door hardware from two required exits did not release with one action due the presence of deadbolt locks.

2. In emergency department, exterior sliding doors to outside had thumblock on 24 hrs walk-in entrance and cooridor double doors between walk-in alcove and main lobby became locked following excercise of fire alarm.

Facility failed to maintain fire alarm labeling in accordance with the National Fire Alarm Code, NFPA 72. Findings included the following:

Surveyor observed between 11:00 am and 12:00 pm on 5/20/14 that in the first floor communications room that the fire alarm control panel and 3 booster panels were not labeled completely. The fire alarm circuit disconnect was not identified at the fire alarm control panel. This does not meet the requirements of the NFPA 72, 1996: 1-5.2.8.2. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

Facility failed to maintain cooking equipment in good working order. Findings included the following:

Surveyor observed between 11:00 am and 12:00 pm on 5/20/14 that one of two kitchen hoods had noticeable grease buid-up to the touch on inside surfaces.

Facility failed to maintain electrical receptacles in the patient care areas in accordance with the 1999 edition of the Standard for Health Care Facilities, NFPA 99. Findings included:

Surveyor observed between 9:00 and 10:00 am on 5/20/14 that facility records did not include grounding system tests in patient care areas. Receptacles shall be tested in Patient Care areas as follows:

Physical integrity of each receptacle (visual)
Continuity of the grounding of each receptacle (test)
Correct polarity of hot and neutral connections in each receptacle (test)
The retention force of the grounding blade shall be not less than 4 oz. (test)

Testing intervals:
General care areas tested annually
Critical care areas tested semi-annually
wet location tested annually.

Facility failed to maintain corridor and hazardous area doors in accordance with the NFPA 101. Findings included the following observsations between 10:00 am and 2:00 pm on 5/20/14 :

1. Surveyor observed that in the Emergency Department, double doors to electrical closet and Resucitation Room were not equipped with gasket to provide smoke seal.

2. Surveyor observed door chocks used to hold open doors in dietary on dry storage room and in trash hold room near mechanical room

Facility failed to maintain smoke barrier integrity in accordance with NFPA 101. Findings include the following:

Surveyor observed between 10:00 and 11:00 am on 5/20/14 that above the double doors between patient wing and lobby that conduit penetration of smoke barrier was not sealed.

Facility failed to maintain smoke barrier door openings in accordance with NFPA 101 and NFPA 72. Findings included the following:

Surveyor observed between 11:00 and 11:30 am on 5/20/14 that double doors in smoke barrier between emergency walk-in waiting and emergency department corridor did not have smoke detectors located within 5 feet of the doors on hold-opens.

Facility failed to maintain hazardous areas in accordance with the 2000 edition of the Life Safety Code NPFA (National Fire Protection Association) 101. Findings included the following:

1. Surveyor observed between 10:00 am and 2:00 pm on 5/20/14 that numerous door openings to hazardous rooms with 1 hr ratings on all three levels were not protected with 45 min rated doors including soil utility, shelled spaces, and storage rooms.

2. Surveyor observed on the third floor room IC316 labeld "soiled workroom" that the door was not rated 45 min.

Facility failed to maintain exit access in accordance with NFPA 101. Findings included the following:

Surveyor observed between 10 am and 2:00 pm on 5/20/14 the following:

1. In pharmacy, door hardware from two required exits did not release with one action due the presence of deadbolt locks.

2. In emergency department, exterior sliding doors to outside had thumblock on 24 hrs walk-in entrance and cooridor double doors between walk-in alcove and main lobby became locked following excercise of fire alarm.

Facility failed to maintain fire alarm labeling in accordance with the National Fire Alarm Code, NFPA 72. Findings included the following:

Surveyor observed between 11:00 am and 12:00 pm on 5/20/14 that in the first floor communications room that the fire alarm control panel and 3 booster panels were not labeled completely. The fire alarm circuit disconnect was not identified at the fire alarm control panel. This does not meet the requirements of the NFPA 72, 1996: 1-5.2.8.2. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

Facility failed to maintain cooking equipment in good working order. Findings included the following:

Surveyor observed between 11:00 am and 12:00 pm on 5/20/14 that one of two kitchen hoods had noticeable grease buid-up to the touch on inside surfaces.

Facility failed to maintain electrical receptacles in the patient care areas in accordance with the 1999 edition of the Standard for Health Care Facilities, NFPA 99. Findings included:

Surveyor observed between 9:00 and 10:00 am on 5/20/14 that facility records did not include grounding system tests in patient care areas. Receptacles shall be tested in Patient Care areas as follows:

Physical integrity of each receptacle (visual)
Continuity of the grounding of each receptacle (test)
Correct polarity of hot and neutral connections in each receptacle (test)
The retention force of the grounding blade shall be not less than 4 oz. (test)

Testing intervals:
General care areas tested annually
Critical care areas tested semi-annually
wet location tested annually.