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

NFPA 101 Life Safety Code 2000, Chapter 19, 19.3.6.3.1 " Doors protecting corridor openings in other than required enclosures of vertical openings, exit, or hazardous areas shall be substantial doors, such as those constructed of 1 3/4 in. thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke...."

Findings Include:

On August 17, 2016 the surveyor, accompanied by the Director of Maintenance observed the following corridor doors did not positively latch when tested three of three times.

1. Ambulatory Surgery Treatment
2. Imaging
3. Smoke corridor doors to PACU

During the exit conference on August 17, 2016 the above findings were again acknowledged by the Chief Executive Officer and Director of Maintenance.

Failure to provide smoke resistant corridor doors could cause harm to the patients in time of a fire.

Based on observation and interview with staff it was determined the facility failed to provide a written plan for the protection of all patients in time of a fire or emergency, and train staff on locations of pull stations and types of fire extinguishers in the hospital.

Based on record review of the fire drills with the Director of Maintenance and Lead Technicians it was determined four third shift fire drills done in 2015 and 2016 did not show in the documentation, that a coded announcement was used for the third shifts in lieu of sounding the fire alarm.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.7.1.1 "The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of a fire, for their evacuation to areas of refuge, and from the evacuation from the building when necessary.
All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator's position or at the security center...."

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.7.1.2 "Fire exit drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions...."

Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. "When drills are conducted between 9:00 pm and 6:00 am a coded announcement shall be permitted to be used instead of audible alarms...."

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.7.1.3 "Employees of health care occupancies shall be instructed in life safety procedures and devices...."

NFPA 101 Life Safety Code Chapter 19, Section 19.7.2.2 "A written health care occupancy fire safety plan shall provide for the following:

1. Use of alarms
2. Transmission to the fire department
3. Response to alarms
4. Isolation of fire
5. Evacuation of immediate area
6. Evacuation of smoke compartment
7. Preparation of floors and building for evacuation
8. Extinguishment of fire...."

Findings include:

On August 17, 2016 the surveyor, accompanied by the Director of Maintenance asked to see the written emergency policy manual at the Emergency room nurse's station. The written fire and emergency policy was not found by the staff when asked at the nursing station at the time of survey.

In addition: a few employees throughout the hospital when asked about the location of either pull stations, the emergency preparedness manual, fire extinguisher types ABC and K in the facility did not either know or could not tell the surveyor where the pull stations or types of fire extinguishers were in the facility or locate the emergency preparedness manual.

The following fire drill third shifts did not have a coded announcement on the fire drills forms shown to the surveyor for the following third shifts.

1. 9-30-2015
2. 12-30-2015
3. 3-31-2016
4. 6-30-2016

During the exit conference on August 17, 2016, the above findings were again acknowledged by the Chief Executive Officer and Director of Maintenance.

In time of an emergency, an emergency policy manual must be readily available for the staff.
Patients will be harmed if the Staff is not trained or is unable to locate the emergency evacuation policy manual. Failure to train and drill the staff on fire procedures could result in harm to the patients.

Based on record review and interview with the Director of Maintenance it was determined the kitchen hood was not cleaned semi-annually in accordance with NFPA 96.

NFPA 101 Life Safety Code, 2000 Edition, Chapter 19, Section 19.3.2.6, "Cooking Facilities." "Cooking facilities shall be protected in accordance with 9.2.3." Section 9.2.3, "Commercial Cooking Equipment" "Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations...Chapter 8, Section 8-3 "Cleaning" "Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person (s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1." Table 8-3.1, Exhaust System Inspection Schedule "Type or Volume of Cooking Frequency" "Systems serving moderate-volume cooking operations." Frequency is Semiannually" Section 8-3.1.1 "Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified, and certified company or person (s) acceptable to the authority having jurisdiction in accordance with Section 8-3." Section 8-3.1.2 "When a vent cleaning service is used, a certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company. It shall also indicate areas not cleaned...."

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.2.6, "Cooking facilities shall be protected in accordance with 9.2.3". Section 9.2.3, "Commercial cooking equipment shall be installed in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations".NFPA 96, Chapter 8, Section 8-2." An inspection and servicing of the fire extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons...."

Findings include:

On August 17, 2016 the surveyor accompanied by the Director of Maintenance reviewed the 2015 documentation for the kitchen hood fire extinguishing system and exhaust hood.

The Maintenance Director was unable to provide documented evidence that the cooking hood and vents were inspected and cleaned in accordance with NFPA 96 semi-annually from January to June of 2016.

During the exit conference on August 17, 2016 the above findings were again acknowledged by the Chief Executive Officer and Director of Maintenance.

Failure to inspect, test, and maintain the kitchen hood fire protection system will result in harm to the patients through delayed detection and extinguishment of a fire.

Based on observation it was determined the facility failed to provide medical gas cylinders free of combustible materials.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99 Standard for Health Care Facilities" NFPA 99, Chapter 8, Section 8-3.1.11 "Storage Requirements" Section 8-3.1.11.2 "Storage of nonflammable gases less than 3000 cubic. feet.." (a) "Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. (c) "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by: (c) (2) A minimum distance of 5 ft. if the entire storage location is protected by an automatic sprinkler system...."

Findings include:

On August 17, 2016 the surveyor, accompanied by the Director of Maintenance observed Equipment rooms marked one and two had oxygen cylinders one or two E type cylinders being stored within five feet of equipment or medical supplies.

During the exit conference on August 17, 2016 the above findings were again acknowledged by the Chief Executive Officer and Director of Maintenance.

Leaking oxygen will penetrate combustible material and create an extreme fire hazard, which could cause harm to the patients.

Based on interview with the Director of Maintenance, Director of Support Services and Lead Technicians it was determined the facility failed to have the alarm annunciator monitored 24 hours at a regular work station in the hospital or at a nurses station.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.2.9.1, "Emergency lighting shall be provided in accordance with Section 7.9." Section 7.9.2.3 " Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems." NFPA 110, Chapter 3, Section 3-5.6. Remote Controls and Alarms. Section 3-5.6.1 "A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2(d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel." Section 3-5.5.2 (d) "Battery -powered individual alarm indication to annunciate visually at the control panel the occurrence of any to the conditions in Table 3-5.5.2(d); additional contacts or circuits for a common audible alarm that signals locally and remotely when any of the itemized conditions occurs. A lamp test switch (es) shall be provided to test the operation of all alarm lamps listed in Table 3-5.5.2 (d)...."

NFPA 99 "Standard for Health Care Facilities."Chapter #3 Electrical Systems, Section 3-4.1.1.14 Requirements for Safety Devices. Section 3-4.1.1.15 Alarm Annunciator."A remote annunciator storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station.(see NFPA 70,National Electrical code, 700-12). The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:

(a) Individual visual signals shall indicate the following:
(1) When the emergency or auxiliary power source is operating to supply power to load.
(2) When the battery charger is malfunctioning.
(b) Individual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
(1) Low lubricating oil pressure
(2) Low water temperature(below those required in (3-4.1.1.9)
(3) Excessive water temperature
(4) Low fuel-when the main fuel storage tank contains less than a 3 hour operating supply.
(5) Overcrank (failed to start)
(6) Overspeed...."

Findings include:

On August 17, 2016 the surveyor, accompanied by the Director of Maintenance, Director of Support Services and Lead Technicians it was determined from questions asked about the new and existing generators for the the facility that the existing generator alarm annunciator was not monitored 24 hours at a regular work station in the hospital or at a nurses station.

During the exit conference on August 17, 2016 the above findings were again acknowledged by the Chief Executive Officer and Director of Maintenance.

Failing to annunciate the emergency generator safety indications could cause harm to the patients in time of an emergency.

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

NFPA 101 Life Safety Code 2000, Chapter 19, 19.3.6.3.1 " Doors protecting corridor openings in other than required enclosures of vertical openings, exit, or hazardous areas shall be substantial doors, such as those constructed of 1 3/4 in. thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke...."

Findings Include:

On August 17, 2016 the surveyor, accompanied by the Director of Maintenance observed the following corridor doors did not positively latch when tested three of three times.

1. Ambulatory Surgery Treatment
2. Imaging
3. Smoke corridor doors to PACU

During the exit conference on August 17, 2016 the above findings were again acknowledged by the Chief Executive Officer and Director of Maintenance.

Failure to provide smoke resistant corridor doors could cause harm to the patients in time of a fire.

Based on observation and interview with staff it was determined the facility failed to provide a written plan for the protection of all patients in time of a fire or emergency, and train staff on locations of pull stations and types of fire extinguishers in the hospital.

Based on record review of the fire drills with the Director of Maintenance and Lead Technicians it was determined four third shift fire drills done in 2015 and 2016 did not show in the documentation, that a coded announcement was used for the third shifts in lieu of sounding the fire alarm.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.7.1.1 "The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of a fire, for their evacuation to areas of refuge, and from the evacuation from the building when necessary.
All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator's position or at the security center...."

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.7.1.2 "Fire exit drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions...."

Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. "When drills are conducted between 9:00 pm and 6:00 am a coded announcement shall be permitted to be used instead of audible alarms...."

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.7.1.3 "Employees of health care occupancies shall be instructed in life safety procedures and devices...."

NFPA 101 Life Safety Code Chapter 19, Section 19.7.2.2 "A written health care occupancy fire safety plan shall provide for the following:

1. Use of alarms
2. Transmission to the fire department
3. Response to alarms
4. Isolation of fire
5. Evacuation of immediate area
6. Evacuation of smoke compartment
7. Preparation of floors and building for evacuation
8. Extinguishment of fire...."

Findings include:

On August 17, 2016 the surveyor, accompanied by the Director of Maintenance asked to see the written emergency policy manual at the Emergency room nurse's station. The written fire and emergency policy was not found by the staff when asked at the nursing station at the time of survey.

In addition: a few employees throughout the hospital when asked about the location of either pull stations, the emergency preparedness manual, fire extinguisher types ABC and K in the facility did not either know or could not tell the surveyor where the pull stations or types of fire extinguishers were in the facility or locate the emergency preparedness manual.

The following fire drill third shifts did not have a coded announcement on the fire drills forms shown to the surveyor for the following third shifts.

1. 9-30-2015
2. 12-30-2015
3. 3-31-2016
4. 6-30-2016

During the exit conference on August 17, 2016, the above findings were again acknowledged by the Chief Executive Officer and Director of Maintenance.

In time of an emergency, an emergency policy manual must be readily available for the staff.
Patients will be harmed if the Staff is not trained or is unable to locate the emergency evacuation policy manual. Failure to train and drill the staff on fire procedures could result in harm to the patients.

Based on record review and interview with the Director of Maintenance it was determined the kitchen hood was not cleaned semi-annually in accordance with NFPA 96.

NFPA 101 Life Safety Code, 2000 Edition, Chapter 19, Section 19.3.2.6, "Cooking Facilities." "Cooking facilities shall be protected in accordance with 9.2.3." Section 9.2.3, "Commercial Cooking Equipment" "Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations...Chapter 8, Section 8-3 "Cleaning" "Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person (s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1." Table 8-3.1, Exhaust System Inspection Schedule "Type or Volume of Cooking Frequency" "Systems serving moderate-volume cooking operations." Frequency is Semiannually" Section 8-3.1.1 "Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified, and certified company or person (s) acceptable to the authority having jurisdiction in accordance with Section 8-3." Section 8-3.1.2 "When a vent cleaning service is used, a certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company. It shall also indicate areas not cleaned...."

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.2.6, "Cooking facilities shall be protected in accordance with 9.2.3". Section 9.2.3, "Commercial cooking equipment shall be installed in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations".NFPA 96, Chapter 8, Section 8-2." An inspection and servicing of the fire extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons...."

Findings include:

On August 17, 2016 the surveyor accompanied by the Director of Maintenance reviewed the 2015 documentation for the kitchen hood fire extinguishing system and exhaust hood.

The Maintenance Director was unable to provide documented evidence that the cooking hood and vents were inspected and cleaned in accordance with NFPA 96 semi-annually from January to June of 2016.

During the exit conference on August 17, 2016 the above findings were again acknowledged by the Chief Executive Officer and Director of Maintenance.

Failure to inspect, test, and maintain the kitchen hood fire protection system will result in harm to the patients through delayed detection and extinguishment of a fire.

Based on observation it was determined the facility failed to provide medical gas cylinders free of combustible materials.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99 Standard for Health Care Facilities" NFPA 99, Chapter 8, Section 8-3.1.11 "Storage Requirements" Section 8-3.1.11.2 "Storage of nonflammable gases less than 3000 cubic. feet.." (a) "Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. (c) "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by: (c) (2) A minimum distance of 5 ft. if the entire storage location is protected by an automatic sprinkler system...."

Findings include:

On August 17, 2016 the surveyor, accompanied by the Director of Maintenance observed Equipment rooms marked one and two had oxygen cylinders one or two E type cylinders being stored within five feet of equipment or medical supplies.

During the exit conference on August 17, 2016 the above findings were again acknowledged by the Chief Executive Officer and Director of Maintenance.

Leaking oxygen will penetrate combustible material and create an extreme fire hazard, which could cause harm to the patients.

Based on interview with the Director of Maintenance, Director of Support Services and Lead Technicians it was determined the facility failed to have the alarm annunciator monitored 24 hours at a regular work station in the hospital or at a nurses station.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.2.9.1, "Emergency lighting shall be provided in accordance with Section 7.9." Section 7.9.2.3 " Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems." NFPA 110, Chapter 3, Section 3-5.6. Remote Controls and Alarms. Section 3-5.6.1 "A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2(d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel." Section 3-5.5.2 (d) "Battery -powered individual alarm indication to annunciate visually at the control panel the occurrence of any to the conditions in Table 3-5.5.2(d); additional contacts or circuits for a common audible alarm that signals locally and remotely when any of the itemized conditions occurs. A lamp test switch (es) shall be provided to test the operation of all alarm lamps listed in Table 3-5.5.2 (d)...."

NFPA 99 "Standard for Health Care Facilities."Chapter #3 Electrical Systems, Section 3-4.1.1.14 Requirements for Safety Devices. Section 3-4.1.1.15 Alarm Annunciator."A remote annunciator storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station.(see NFPA 70,National Electrical code, 700-12). The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:

(a) Individual visual signals shall indicate the following:
(1) When the emergency or auxiliary power source is operating to supply power to load.
(2) When the battery charger is malfunctioning.
(b) Individual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
(1) Low lubricating oil pressure
(2) Low water temperature(below those required in (3-4.1.1.9)
(3) Excessive water temperature
(4) Low fuel-when the main fuel storage tank contains less than a 3 hour operating supply.
(5) Overcrank (failed to start)
(6) Overspeed...."

Findings include:

On August 17, 2016 the surveyor, accompanied by the Director of Maintenance, Director of Support Services and Lead Technicians it was determined from questions asked about the new and existing generators for the the facility that the existing generator alarm annunciator was not monitored 24 hours at a regular work station in the hospital or at a nurses station.

During the exit conference on August 17, 2016 the above findings were again acknowledged by the Chief Executive Officer and Director of Maintenance.

Failing to annunciate the emergency generator safety indications could cause harm to the patients in time of an emergency.