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Based on tests to doors and observations made during the survey for life safety from fire with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2), it was determined that patient's doors protecting corridors at rooms #203, #209, #215 and #223 do not close completely (do not latch) as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.3.6.3.

Findings include:

During the tour for life safety from fire of patient's rooms on 9/29/10 from 3:30 pm till 4:00 pm and on 9/30/10 from 8:30 am till 10:00 am, patient's sleeping room doors were tested with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2) and it was found that patient's sleeping room doors #203, #209, #215 and #223 do not latch when the doors are closed, this can permit smoke, fire and noxious gases to enter the rooms in the event of a fire. All patient room doors at the hospital must be verified at least monthly and appropriate documentation must be available upon request.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2), it was determined that the facility failed to ensure that a written plan was found at all nursing stations for staff to follow with respect to their duties in the event of an emergency as required by the 2000 edition of the Life Safety Code of the NFPA Section 18.7.1.1.

Findings include:

No evidence was found on 9/29/10 and 9/30/10 from 8:00 am till 4:00 pm with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2) that personnel have a plan or assignments with specific tasks in the event of an emergency (for example: extinguisher use, circuit breaker shut off, oxygen valve shut off, placing patients in their rooms, closing patient's room doors, etc). All personnel trained related to emergency procedures must be instructed related to their assignments and periodically tested for its implementation and the assignment must be posted for review by staff.

Based on the review of written documents related to conducted fire drills during the survey for life safety from fire with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2), it was determined that the facility failed to ensure that fire drills are conducted under varying conditions related to initial fire location, early rate of growth in the fire severity and smoke generation as required by LSC 2000 section 19.7.1.2 and section 5.5.

Findings include:

1. Written documents about conducted fire drills for the facility were reviewed with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2) on 9/30/10 at 2:40 pm and provided evidence that fire drill documentation does not include evidence that they are performed under varying conditions related to:
a. Initial fire location.
b. Early rate of growth in the fire severity.
c. Smoke generation.
LSC 2000 section 5.5 has eight "Design Fire Scenarios" that should be considered to comply with the above. Fire drills provide opportunities to improve on tasks during emergency and hurried events and should be used to constantly improve.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2), it was determined that the facility failed to ensure that smoke detectors are available in the housekeeping closet located near operating suite #1 and data closet near the X-ray room, smoke detector sensitivity documentation was not found, strobe lights are needed in public bathrooms and smoke detectors are located within three feet of air conditioner and return vents which is not in accordance with the applicable requirements of NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include:

1. Smoke detectors connected to the fire alarm panel are needed in the following area as observed with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2) on 9/29/10 at 11:55 am and 2:00 pm:
a. The housekeeping closet near operating suite #1.
b. In the data closet located near the X-ray room.

2. The facility has an outside company that services the fire alarm system and they provide the facility with a certification once a year as evidenced on 9/30/10 at 2:35 pm with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2), however no evidence was found of the following:
a. Smoke detector sensitivity tests.

3. Patient's and visitor's public bathrooms (both male and female) at the emergency room waiting area were visited on 9/29/10 at 9:20 am with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2) and provided evidence that they do not have strobe lights to alert deaf persons using these bathrooms in the event that the fire alarm is activated.

4. The smoke detectors located on the ceiling near the medical evaluation room of the emergency room and medical record department were found on 9/29/10 at 9:50 am and on 9/30/10 at 11:00 am located within one foot from ceiling air conditioner vents and return vents; due to the air flow from these vents at least three feet is needed.

Based on the review of written documents related to the preventive maintenance of the fire alarm system and its components during the survey for life safety from fire with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2), it was determined that the facility is not performing visual inspections, sensing chamber tests or battery tests to the fire alarm system in accordance with NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include:

1. Written evidence reviewed on 9/30/10 at 2:25 pm with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2) about the tests to the fire alarm system and its components indicates that the facility is not performing the following tests:

a. Visual inspections to the main control panel to verify trouble signals and check battery electrolyte level (monthly).

b. All smoke detectors must be tested in place to ensure smoke entry into sensing chamber and an alarm response which includes the smoke detectors in the air conditioner system (twice a year).

c. Ability of batteries to meet standby and alarm requirements shall be verified, corrosion and leakage, tightness of connections and battery terminals shall be cleaned (monthly).

d. Location of pull-down stations and tests (monthly).

e. Visible (strobe lights) and audible signal tests (monthly).

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2), it was determined that the facility failed to ensure that a patient's room (room #223) has adequate outside ventilation as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.3.8.

Findings include:

Patient's sleeping room windows were observed on 9/29/10 from 3:30 pm till 4:00 pm and on 9/30/10 from 9:00 am till 10:00 am with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2) and provided evidence that the windows in room #223 do not communicate to the outside. The windows of this room are on the second floor and open into an interior alcove of the facility. Outside windows in patient's sleeping rooms helps keep patients oriented to the time of day related to sun light, night and rain viewed from these windows, help patients' sense of well being and is important for their circadian cycle and can provide ventilation if desired.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2), it was determined that the facility failed to ensure that the automatic extinguishing system above the stove is appropriately designed and maintained as required by the 2000 edition of the Life Safety Code of the NFPA Section 9.2.3, 19.3.2.6 and NFPA 96.

Findings include:

1. The automatic extinguishing system above the stove was observed on 9/30/10 at 9:00 am with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2) and evidence of the following was not provided:

a. Verification that activation of the extinguishing system activates the facility's fire alarm.

Based on observations during the survey for Life safety from fire with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2), it was found that this facility does not comply with other Life Safety Code requirements not in CMS-2786-R related to oxygen cylinders found in areas that do not comply with NFPA 99, two large propane gas tanks do not have seismic shut off devices and no evidence was found that the facility has spare sprinkler heads.

Findings include:

1. When oxygen cylinders are not in use (connected to a patient), they are to be stored in an appropriate area as stated in the National Fire Protection Association (NFPA) 99, 1999 edition, section 4-3.1.1.2. However, during the observational tour of the facility with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2) on 9/29/10 and 9/30/10 from 8:00 am till 4:00 pm, type H oxygen cylinders were found in areas that do not meet minimum requirements:
a. Two type H oxygen cylinders were found in the pre-induction area of the operating suites.

2. Type E oxygen cylinders attached to the crash carts were observed on 9/29/10 and 9/30/10 from 9:00 am till 4:00 pm with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2) at the emergency room and at the medicine ward with their oxygen regulators pushed up against the wall and handrail. The position of these regulators and the tight area that they were placed in exposes them to be damaged.

3. Two large propane gas tanks located at the back of the hospital were visited on 9/30/10 at 10:00 am with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2) and provided evidence that they are not prepared to turn off in the event of an earthquake. The movement from an earthquake can cause metal tubing to crack which may leak gas and can cause an explosion. Seismic shut off devices which automatically turns off the gas at the source is required.

4. During observations of the sprinkler system on 9/30/10 at 11:00 am with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2), the following was determined related with NFPA 13 for the hospital:
a. No evidence was found that the facility has spare sprinklers (at least six), a sprinkler wrench or a cabinet to place them in.

Based on the review of written documents during the survey for life safety from fire with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2), it was determined that the facility failed to ensure that personnel perform weekly inspections of the electrical generator as required by the NFPA 99, section 3.4.4.1.

Findings include:

The facility lacks written evidence of the weekly inspections of the generator as reviewed with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2) on 9/30/10 at 3:05 pm. The facility did not have a check list which includes batteries condition, coolant level, belts, oil pressure and oil change, battery contacts, hoses and pipes, main fuel tank level, leaks if any, oil filter, air filter and other checks from NFPA-99.