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Based on observation the facility did not maintain the fire resistive ratings of corridor walls, ceilings, or room walls.

NFPA 101 Life Safety Code, 2000, Chapter 19, Sections 19.1.6.2, 19.1.6.3, 19.1.6.4, or 19.3.5.1. "Section 19.1.6.2," "Health Care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2." Walls and ceilings must be one hour rated or a minimum of smoke proof.

Findings Include:

On February 29, 2012 the surveyors, accompanied by the Safety Officer, Assistant Chief Operating Officer and Maintenance Technician observed conduit penetrations not sealed that went through the corridor walls in the following data rooms.

1. Palo Verde A 133
2. Ironwood C1143

During the exit conference on February 29, 2012 the above findings were again acknowledged by the Chief Operating Officer, Assistant Chief Operating Officer and Safety Officer.

The facility failed to fill holes in a fire resistive/smoke resistive wall. Failing to contain smoke or heat from a fire will could harm to the patients.

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

NFPA 101 Life Safety Code, 2000, Chapter 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." Section 19. 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 18. 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On February 29, 2012 the surveyors, accompanied by the Safety Officer, Assistant Chief Operating Officer and Maintenance Technician observed the following corridor doors would not positively latch when tested three of three times or or had impediments propping the doors open.

1. Palo Verde A 1087
2. Palo Verde the corridor door leading to the Administration area had four 1/4 inch holes in the rated door, the door closure was removed.
3. F Building room F146 and F147 impediments garbage container and chair

During the exit conference on February 29, 2012 the above findings were again acknowledged by the Chief Operating Officer, Assistant Chief Operating Officer and Safety Officer.

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

Based on Record review and conversation with employees and staff the facility failed to conduct the required fire drills, sound the fire alarm during fire drills on the first and second shifts and train the staff on life safety procedures and devices.

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."

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.

Findings include:

On February 29, 2012 the surveyors, accompanied by the Safety Officer, Assistant Chief Operating Officer and Security reviewed the facility's fire drill records for 2011. The surveyor observed and noted their was no fire drills completed or documentation shown to the surveyor for the third quarter second shift of August 2011.

Upon further review of the fire drills and based on the documentation and conversation with the staff the fire drill forms for the year 2011 did not include sounding of the fire alarm during the fire drills for the following:

Second quarter first shift April 2011
Third quarter first shift July 2011
Fourth quarter second shift November 2011.

In addition, a couple of employees from all the buildings inspected when asked to identify rhe key or keys to activate the fire alarm pull station panel and to identify the key to the fire extinguisher box in the corridors could not identify the keys they had in their possession marked A-14 for fire alarm pull station panel and A-16 for the fire extinguisher box when asked by the surveyors.

The Assistant Chief Operating Officer or Safety Officer who accompanied the surveyors had to tell the personnel which key (s) was for either the pull station panel or fire extinguisher. One employee could not locate the fire extinguisher box when asked by a surveyor and had to be shown where the ABC fire extinguisher was located by the Assistant Chief Operating Officer.

During the exit conference on February 29, 2012 the above findings were again acknowledged by the Chief Operating Officer, Assistant Chief Operating Officer and Safety Officer.

Failure to train and drill the staff on fire procedures could result in harm to the patients.

Based on observation the facility failed to maintain the sprinkler heads and assure that all parts of the sprinkler system were in accordance with the UL Listing.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.5.1 "Buildings containing health care facilities shall be protected throughout by and approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection systems. NFPA 25, Section 2-2.1.1 "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign material , paint, and physical damage and shall be installed in the proper orientation..." 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 February 29, 2012 the surveyors, accompanied by the Safety Officer, Assistant Chief Operating Officer and Maintenance Technician observed the following:

Desert Sage

1. Room B 1102 one corroded sprinkler
2. Room B 1107 escutcheon plate missing from one sprinkler
3. Room B 1126 one painted sprinkler

F building

1. Kitchen prep paper supplies room had an escutcheon plate missing and one painted sprinkler
2. Room F151 two of four escutcheon plates were missing and two of four sprinklers had paint on the sprinklers

Ironwood Administration

Room C1130 and one sprinkler in the corridor either had paint or stucco on sprinklers

During the exit conference on February 29, 2012 the above findings were again acknowledged by the Chief Operating Officer, Assistant Chief Operating Officer and Safety Officer.

Failing to maintain sprinkler heads, missing escutcheon plates, which are part of the UL Listing of the sprinkler assembly, could allow heat and smoke to effect other areas of the building. This could cause harm to the patients.

Based on Record review the facility failed to document the required testing of the emergency generator transfer time from normal power to emergency power. (10 seconds or less)

NFPA 101 Life Safety Code, 2000, Chapter 9, Section 19.7.6 " Maintenance and Testing (See 4.6.12) Section 4.6.12.2 " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 99 "HEALTH CARE FACILITIES". Chapter 3, Section 3-5.4.1.1 (a) and Section 3-4.4.1.1 (b) "Generator sets shall be tested twelve (12) times a year... Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Chapter 6, Section 6-4.1 "Level 1 and Level 2 EPSSs, including all appurtenant components shall be inspected weekly and shall be exercised under load at least monthly. NFPA 110, Chapter 6, Section 6-4.2 "Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes...
Chapter 3, Section 3-4.1.1.8. (Level/Type 1) "The generator sets shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power.
or Section 3-5.3.1 (Level/Type 2) "The emergency system shall be installed and connected to the alternate source of power specified in 3-4.1.1.2 and 3-4.1.1.3 so that all functions specified herein for the emergency system will be automatically restored to operation within 10 seconds after interruption of the normal source."

On February 29, 2012 the surveyor, accompanied by the Safety Officer, Assistant Chief Operating Officer and Contractor reviewed the generator test records. The transfer time from normal power to emergency power number of seconds (10 seconds or less) on the generator forms shown to the surveyor on site from March 2011 through December 2011 except September 2011 load bank was not documented on either the weekly or Monthly forms.

Failure to test the emergency generator under load, inspect weekly, and document time from normal power to emergency power could result in harm to the patients during lighting system failures.

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 February 29, 2012 the surveyors, accompanied by the Safety Officer, Assistant Chief Operating Officer and Maintenance Technician observed microwaves and refrigerators plugged into multi-outlet power strips and not directly plugged in to the wall outlet receptacles in the following rooms.

1. Palo Verde room A 1109
2. Ironwood room C 1136, C 1139
3. F building room F146

During the exit conference on February 29, 2012 the above findings were again acknowledged by the Chief Operating Officer, Assistant Chief Operating Officer and Safety 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.