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Based on observation and record review, the provider failed to meet the minimum construction standards of the 2000 Life Safety Code (LSC). Findings include:

1. Observation on 3/23/10 at 9:00 a.m. revealed the building was a two story, protected, non-combustible, Type II (111) structure without a complete automatic sprinkler system. Record review of the previous survey confirmed that finding.

The building meets the FSES. Please mark an "F" in the completion date column (X5).

Based on observation, testing, and interview, the provider failed to maintain the smoke tight rating of corridor wall assemblies for the north wing. One randomly observed door to the corridor would not close and latch. Findings include:

1. Observation and testing at 1:39 p.m. revealed the door from the tub room to the corridor would not latch into the door frame with a reasonable amount of force when tested. Interview with the maintenance supervisor at the time of the observation confirmed that condition.

Based on observation and interview, the provider failed to ensure exits were readily accessible at all times for seven randomly observed room doors (medication room, office room 101, the former pediatric room, room 114, computer room, laundry room, and patient room 105). Findings include:

1. Observation and interview beginning at 9:30 a.m. on 3/23/10 with the maintenance supervisor revealed the doors for the following rooms had a deadbolt locking mechanism: medication room, office room 101, and the former pediatric room. The deadbolt locking mechanism would impede opening the doors in a fire emergency. Interview with the maintenance supervisor at the time of the observation confirmed the findings. He indicated he would remove the deadbolt locking mechanisms.

2. Observation and interview beginning at 10:05 a.m. on 3/23/10 with the maintenance supervisor revealed the doors for the following rooms had double-action latching hardware: room 114, computer room, and laundry room. The double-action hardware would impede opening the doors in a fire emergency. Interview with the maintenance supervisor at the time of the observation confirmed the findings. He indicated appropriate single-action hardware would be installed.

3. Observation and interview beginning at 10:05 a.m. on 3/23/10 with the maintenance supervisor revealed the door for the patient room 105 restroom had locking hardware. That locking hardware would not allow access into the bathroom in an emergency without the use of a key. Interview with the maintenance supervisor and the director of nursing at the time of the observation confirmed that finding and revealed none of the staff had a key that would unlock that door. Further interview revealed all patient rooms had the same configuration.

Based on observation and interview, the provider failed to maintain adequate illumination of the means of egress in the south exit stair enclosure. The failure of any single lighting fixture (bulb) must not leave the area in darkness. Only one lamp was working in the fixture at the top of the stair enclosure. Findings include:

1. Observation at 12:30 p.m. revealed the incandescent fixture at the top of the exit stair enclosure only had one of two bulbs functioning. That area would be left in darkness in an egress emergency if the remaining operating bulb were to burn out. Interview with the maintenance supervisor at the time of the observation confirmed a bulb had burned out in the incandescent fixture. He stated he believed one of the two bulbs had recently burned out.

Based on observation and interview, the provider failed to furnish exit signs to ensure the path of egress to exits were identified. One randomly observed location (exit door for the exit stair enclosure) was not provided with an exit sign. Findings include:

1. Observation at 9:30 a.m. revealed the exit door for the buildings only exit stair enclosure was not provided with an exit sign indicating the path of egress to the exterior of the building. The exit stair enclosure must be provided with an exit sign directing egress to the south exit. Interview with the maintenance supervisor at the time of the observation revealed the existing exit sign had fell down and not been replaced.

Based on observation and interview, the provider failed to ensure staff were familiar with one of one fire drill procedure. Findings include:

1. Observation during the facility fire drill at 3:00 p.m. revealed the nurse responding to the simulated fire did not activate the fire alarm system. That nurse did not follow the facility's fire response procedure. Other staff responding to the fire drill did not pull the fire alarm either. The fire alarm was not sounded for the duration of the fire drill. Interview with the maintenance supervisor at the time of the observation confirmed those findings.

Based on observation and record review, the provider failed to meet the minimum construction standards of the 2000 Life Safety Code (LSC). The building must be equipped with a complete automatic sprinkler system. Findings include:

1. Observation on 3/23/10 at 9:00 a.m. revealed the building was a two story, protected, non-combustible, Type II (111) structure without a complete automatic sprinkler system. Record review of the previous survey confirmed that finding.

The building meets the FSES. Please mark and "F" in the completion date column (X5).

The provider must comply with the National Fire Protection Association (NFPA 13), Health Care Facilities section 5-6.6 Obstructions that Prevent Sprinkler Discharge from Reaching the Hazard.

Based on observation, measurement, and interview, the provider failed to maintain at least 18 inches of unobstructed space under one randomly observed sprinkler deflector. The shower room in the east wing was observed to be obstructed. (See attached section 5-6.6, Obstructions that Prevent Sprinkler Discharge from Reaching the Hazard.) Findings include:

1. Observation at 1:10 p.m. on 3/23/10 revealed a sprinkler head in the central supply storage room was obstructed by cardboard boxes. Those boxes were approximately eight inches from the bottom of the sprinkler deflector. Those boxes would interrupt the proper discharge and operation of the sprinkler. Interview with the maintenance supervisor at the time of the observation revealed he was not aware of the obstructed sprinkler.

Based on random observation and interview, the provider failed to perform monthly checks of fire extinguishers in accordance with NFPA 10. Monthly checks had not been performed on three extinguishers (bottom of the stairwell, the computer room, and the boiler room) for six of six months. Findings include:

1. Random observation on 3/23/10 from 10:50 a.m. to 12:30 p.m. revealed three fire extinguishers did not have monthly maintenance checks written on the fire extinguisher tags. One extinguisher at the bottom of the stairwell had not been checked since October 2009. Another extinguisher in the computer room had also not been checked since October 2009. The other extinguisher in the boiler room had not been checked since October 2006.

Interview with the maintenance supervisor at the time of the observation confirmed that finding. He indicated he had apparently missed those three while walking around and performing the monthly inspection of fire extinguishers.

Based on observation and interview, the provider failed to ensure the safety of occupants from possible burns and/or fire. Portable space heaters were located in the central supply storage room, the tub room, and the pharmacy. Findings include:

1. a.Observation at 1:07 p.m. on 3/23/10 revealed a portable space heater was located on the floor of the central supply storage room. That space heater was in use and had the control knob turned to high heat setting. Interview at that same time with the maintenance supervisor confirmed that finding. He stated he was not aware the space heater was in that room or how long it had been there. He further stated he was aware space heaters were not allowed in healthcare facilities. He removed the space heater from that room at that time. Interview with the supply manager at the same time as the above interview revealed the space heater had been installed in that room to prevent intravenous fluids from freezing.

b. Observation at 1:16 p.m. on 3/23/10 revealed a portable space heater was located in the main floor tub room. That space heater was not currently in use or plugged in, but presented a hazard if a patient or staff person were to use it. Interview with the maintenance supervisor at the time of the observation confirmed that finding.

2. Observation at 2:00 p.m. on 3/23/10 revealed a milk house style portable space heater located in pharmacy. Interview with the director of nursing at the time of observation confirmed that finding. She stated the pharmacy technician probably used that space heater when it was cold outside and the wind would blow through the opening around the window air conditioner.

3. Observation at 2:17 p.m. on 3/23/10 revealed a window air conditioner in the double-bed emergency room with an air-diffuser that appeared to have melted. Further observation revealed that air conditioner had a built-in space heater. Interview with the maintenance supervisor at the time of the observation confirmed that finding. He stated he did not think the space heater portion of that air conditioner would get hot enough to cause any problems.

Based on observation and interview, the provider failed to maintain an exit door free of decoration that could create an impediment to full and instant exiting in an emergency. The top half of the glass cross-corridor doors in the south wing were covered with roll-up shades masking the exit door. Findings include:

1. Observation at 9:54 a.m. on 3/23/10 revealed the cross-corridor doors leading to the exit on the south wing had opaque roll up shades that completely covered the glass panel in top half of the door. Those roll-up shades prevented the exit from being visible. Interview with the maintenance supervisor at the time of the observation confirmed that condition. He revealed those doors had been covered so patients in the dental clinic would not look into the hospital. He further stated he did not realize those shades created that condition.

The provider must comply with the National Fire Protection Association Standard for Emergency and standby power systems (NFPA 110) sections 5-7.4 and 5-10 (see attached).

Based on observation, testing, and interview, the provider failed to furnish the emergency generator located at the bottom of the south exit stair enclosure with adequate combustion air during operation and an exhaust system that prevented exhaust from entering an inhabited building. Findings include:

1. Observation at 10:50 a.m. on 3/23/10 revealed a 25KW Kato Engineering generator installed in the generator room. Testing of that generator at 1:38 p.m. revealed the louvers for the combustion air intake in the generator room were not open while the generator was running.

Observation also revealed a pronounced exhaust odor in the generator room as well as the south exit stair enclosure. Interview with the maintenance supervisor at the time of the testing revealed those louvers were thermostatically controlled and did not open until the temperature of the generator was at a set point. The maintenance supervisor demonstrated that by turning down the thermostat until the louvers opened. Interview with the supply manager during the generator test revealed the exhaust smell was normally present in the south exit stair enclosure anytime the generator was being run.

Based on observation, interview, and record review, the provider failed to install a paved path of exit discharge to the public way at one exit (south exit stair enclosure)of the building. Findings include:

1. Observation at 10:42 a.m. on 3/23/10 revealed the exit from the south exit stair enclosure had a landing that ended approximately 75 feet from the nearest street. Interview with the maintenance supervisor at the time of the observation confirmed that condition. The maintenance supervisor also stated he believed the facility had always been that way.

The building meets the FSES. Please mark an "F" in the completion date column (X5) to indicate correction of the deficiencies identified in K000

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The provider must comply with National Fire Protection Association (NFPA) 70 article 305-Temporary Wiring and article 110-12 Mechanical Execution of Work. (See the above attachments.)

A. Based on observation and interview, the provider failed to furnish parts to ensure the safe operation of electrical equipment. A switch plate cover was missing in the housekeeping room/janitors closet. Findings include:

1. Observation at 10:41 a.m. revealed the light switch in the housekeeping room/janitors closet did not have a switch plate cover installed. That missing switch plate cover presented a shock hazard by allowing access to live wiring by fingers or water from the janitors sink. Interview with the maintenance supervisor at the time of the observation confirmed that condition. He stated he was unaware that light switch was missing the switch plate cover.

B. Based on observation and interview, the provider failed to furnish permanent wiring. *Extension cords were in use in place of permanent wiring in the boiler room, maintenance office, and the lobby.
*Power strips were in use in place of permanent wiring in the maintenance office and the single-bed emergency room.
*Multiple tap adaptors were in use in the admissions office and in patient room 106. Findings include:

1. Observation at 11:15 a.m. revealed a multiple outlet extension cord was affixed to conduit on the south side of the boiler room door. Interview with the maintenance supervisor at the time of the observation confirmed that condition.

2. Observation at 11:25 a.m. revealed an extension cord affixed to the ceiling in the maintenance office. That extension cord was used to power a fluorescent light fixture over one of the maintenance office desks. Interview with the maintenance supervisor at the time of the observation confirmed that condition.

3. Observation at 2:35 p.m. revealed an extension cord in the lobby was used to power a Coke machine. Interview with the maintenance supervisor at the time of the observation confirmed that condition.

4. Observation at 11:27 a.m. revealed a power strip in use in place of permanent wiring in the maintenance office. That power strip was used to power a carbon monoxide detector and a fan. Interview with the maintenance supervisor at the time of the observation confirmed that condition.

5. Observation at 9:15 a.m. revealed a multiple tap adaptor in the admissions office. That multiple tap adaptor was used to power a fan. Interview with the maintenance supervisor at the time of the observation confirmed that condition.