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Based on observation the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On December 8, 2011 the surveyor, accompanied by the Chief Executive Officer observed that the following rated corridor doors would not tightly close when tested or had gaps/holes greater than approximately 1/8 th inch around the door frame/latch assemblies and will not resist the passage of smoke;

1. Rated door, by the Fire riser room, hole in door
2. Room 117, door will not positively latch when tested three of three times
3. ICU 6, door will not positively latch when tested three of three times
4. Mechanical/riser room, rated door, closure device disconnected
5. Business and Finance office doors have four holes each through the rated doors

During the exit conference on December 8, 2011, the above findings were again acknowledged by the Chief executive Officer.

In time of a fire failing to protect patients from heat and smoke could cause harm to the patients.

Based on observation the facility did not assure that all parts of the sprinkler system were in accordance with the UL Listing.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.1.5, "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.1.1 "Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, Chapter 3, Section 3-2.7.2, "Escutcheon Plates used with a recessed or flushed sprinkler shall be part of a listed sprinkler assembly."

Findings include:

On December 8, 2011, the surveyor, accompanied by the Chief Executive Officer observed the following Escutcheon plates missing from the sprinkler assembly.

1. Rooms: 209, 215, 219, Soiled utility by ICU, and ICU storage room

During the exit conference on December 8, 2011, the above findings were again acknowledged by the Chief executive Officer.

Failing to maintain the Escutcheon plate is part of the UL Listing of the sprinkler assembly. The missing escutcheon plate could allow heat and smoke to effect other areas of the building, which could cause harm to the residents/patients.

Based on Observation the facility allowed the use of a multiple outlet adapter, power strips and did not use the wall outlet receptacles for appliances.

NFPA 101, Life Safety Code, 2000, Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 1999 Edition. NFPA 99, Chapter 3, Section 3-3.2.1.2, "All Patient Care Areas," Section 3-3.2.1.2 (d) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings include:

On December 8, 2011, the surveyor, accompanied by the Chief Executive Officer, observed a refrigerator plugged into a multi-outlet power strips and not directly plugged in to the wall outlet receptacle. Location is the First floor Nursing office.
To include two power strips connected together in a daisy chain extension, to connect an appliance in the Case Management office.

During the exit conference on December 8, 2011, the above findings were again acknowledged by the Chief executive Officer.

The use of multiple outlet adapters could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.