HospitalInspections.org

Based on observation and staff interview during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to properly separate occupancies in accordance with NFPA 101. The following evidenced this:
During the walk through of the facility with the Maintenance Supervisor, Facilities Director and Risk Manager; three rooms were not accessible during the survey due to locked doors. The rooms were not included in this survey and cannot be determined to be the same occupancy.
The maintenance staff acknowledged no key was available during the survey.


30844

Based on observation and staff interview during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to properly separate occupancies in accordance with NFPA 101. The following evidenced this:
During the walk through of the facility with the Maintenance Supervisor, Facilities Director and Risk Manager; three rooms were not accessible during the survey due to locked doors. The rooms were not included in this survey and cannot be determined to be the same occupancy.
The maintenance staff acknowledged no key was available during the survey.

Based on observation during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to maintain the interior finishes for corridors and exit ways in accordance with NFPA 101. The following evidenced this:
During the walk-through, with the Maintenance Supervisor, Facilities Director and Risk Manager; the corridor located adjacent to the Director of Nursing office and room 106 contains cork board as part of the wall finish. Documentation was not available showing the flame spread rating of the cork board.
The maintenance staff acknowledged the presence of cork board.

Based on observation during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to maintain the interior finishes for rooms and spaces not used for corridors and exit ways in accordance with NFPA 101. The following evidenced this:
During the walk-through with the maintenance supervisor, facilities director and risk manager; the Emergency Room overflow area had walls that were covered with wood paneling. Documentation was not available showing the flame spread rating of the paneling.
The maintenance staff acknowledged the presence of the wood paneling.

Based on observation during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to maintain the separation of use areas from the corridor in accordance with NFPA 101.
During the walk-through with the Maintenance Supervisor, Facilities Director and Risk Manager:
1. Waiting area located by front entrance is open to the corridor without supervision.
2. The vestibule from the ambulance entrance and the ED contained storage not separated from the corridor.
3. Director of Nurse ' s office adjacent to room 106 is open to the corridor without supervision.
These three areas are an example of areas open to the corridor that do not meet any of the exceptions of NFPA 101 Section 19.3.6.1; the facility shall verify all use areas are properly separated from the corridors.
The maintenance staff acknowledged the above items.

Based on observation during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to maintain the doors that protect corridors in accordance with NFPA 101. The following evidenced this:
During the walk-through with the Maintenance Supervisor, Facilities Director and Risk Manager:
1. Corridor doors were held open where they could not be closed with a push or a pull
a. Dining room door was held open with a wooden wedge.
b. Chapel door was held open with a rock at the base of the door.
2. The Dutch door to the IT department was not equipped with a positive latching mechanism for both leaves of the door. The facility also failed to equip this door with an astragal, rabbet, bevel, or other means for maintaining the smoke seal between the upper portion and the lower portion of the door.
3. Positive latching mechanisms were not provided on doors to the corridor; this includes both north and south doors for the dining room
The maintenance staff acknowledged the above items during the survey.

Based on observation during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to provide supervision of the automatic closing doors that protect smoke barrier corridor openings in accordance with NFPA 101. The following evidenced this:
During the walk-through with the Maintenance Supervisor, Facilities Director and Risk Manager; the smoke detector at the smoke barrier doors by room 107 was located 1.5-inches from the doors; this smoke detector shall be located no closer than 12-inches if spot detection is used for automatic closing.
This is an example of where doors were held open by a magnetic device without proper supervision; the facility shall verify all doors electronically held open are supervised by one of the allowed two methods.
The maintenance staff acknowledged the above items during the survey.

Based on observation during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to maintain the smoke barriers in accordance with NFPA 101. The following evidenced this:
During the walk-through with the Maintenance Supervisor, Facilities Director and Risk Manager; smoke barrier walls contained wire openings or openings without fire caulking or other approved method of maintaining the rating of the wall. The following smoke barriers are located by:
1. South area of facility adjacent the TV Room
2. Southwest of facility adjacent to the Tub Room
3. East center of facility adjacent to Room 101
4. South center of facility adjacent to the Dining Room
5. North center of facility adjacent to the Dining Room
6. Pantry has pipes covered with insulation that are not sealed properly
The maintenance staff acknowledged the penetrations in the smoke barrier.

Based on observation during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to maintain the smoke barrier doors in accordance with NFPA 101. The following evidenced this:
During the walk-through with the Maintenance Supervisor, Facilities Director and Risk Manager:
1. The smoke doors located adjacent to North side of the Dining room did not contain a door sequencer. During testing of the fire alarm system, the door with the astragal shut prior to the door without the astragal. When this occurred the door would not maintain a positive smoke seal.
2. The self-closing device for the smoke barrier doors did not close the doors completely. These doors would not maintain a smoke seal.
a. South area of facility adjacent the TV Room
b. Southwest of facility adjacent to the Tub Room
3. Dishwasher area has an opening through a smoke barrier wall which allows clean dishes to be passed through the barrier to the other side; the opening has a door held open by a counter weight without any means to automatically close upon an alarm event.
The maintenance staff acknowledged the above items during the survey.

Based on observation during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to maintain hazardous areas in accordance with NFPA 101. The following evidenced this:
During the walk-through with the Maintenance Supervisor, Facilities Director and Risk Manager:
1. The following doors were held open with a magnetic device that was not part of the fire alarm system to meet automatic closing requirements.
a. Materials storage room
b. Kitchen
2. The following doors had self closures but would not positively latch; over 50 square feet in area and utilized by the facility for storage of combustibles.
a. Room 120 currently used for storage
b. Room 122 currently used for storage
3. The following areas were not equipped with self closures; over 50 square feet in size and utilized by the facility for storage of combustibles.
a. Room 124
b. Large conference room
The maintenance staff acknowledged the above items during the survey.

Based on observation and staff interview during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to maintain the travel distance to exits in accordance with NFPA 101. The following evidenced this:
During the walk-through with the Maintenance Supervisor, Facilities Director and Risk Manager; Both the OR suite and OB-GYN suite has more than two intervening rooms within the suite to an exit access door.
The maintenance staff acknowledged the above item during the survey.

Based on observation and staff interview during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to maintain the means of egress in accordance with NFPA 101. The following evidenced this:
During the walk-through with the Maintenance Supervisor, Facilities Director and Risk Manager:
1. The south leading to the public way was blocked by a large tree branch that according to staff was cut down by staff and had been there for a few weeks; the tree branch was present at the start and end of this two day survey.
2. The following doors contained more than one releasing operation in accordance with 7.2.1.5.4
a. CT scan room
b. Entry to surgery rooms
c. Door adjacent to room 106
d. Dry Storage exit has hasp on screen door
3. The dictation room corridor door had releasing mechanism that was located greater than 48 " above the finished floor.
4. The corridor door to the clean linen room was more than 7-inches away from the wall when fully opened.
The maintenance staff acknowledged the above items.

Based on record review and staff interview during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to maintain emergency lighting in accordance with NFPA 101. The following evidenced this:
During the review of facility records with the Maintenance Supervisor, Facilities Director and Risk Manager; the documentation provided for the monthly and annual battery testing of the emergency lighting system did not acknowledge or indicated who had been performing the tests.
The maintenance staff acknowledged the lack of additional documentation.

Based on observation and staff interview during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to maintain the exit and directional signs in accordance with NFPA 101. The following evidenced this:
During the walk through with the Maintenance Supervisor, Facilities Director and Risk Manager:
1. Signs on two doors entering into the Chapel courtyard located within the outer walls of the facility were improperly labeled. Signs are required to read "NO EXIT", (NO in letters 2-inches high with 3/8-inch wide stroke, and EXIT below the word NO in 1-inch high letters).
2. Exit signs were not illuminated in the following locations during the survey:
a. Corridor adjacent to the TV room
b. Corridor for Dietary Services
The maintenance staff acknowledged the above items.

Based on record review and staff interview during the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to maintain a complete and current plan for the evacuation and protection of all persons in the event of an emergency in accordance with NFPA 101. This was evidenced by the following:
During the review of the facility records with the Maintenance Supervisor, Facilities Director and Risk Manager:
1. Multiple versions of emergency plans were presented in emergency binders available to facility staff; during the review of available manuals it could not be determined which set of plans the facility was currently using during discussions with staff. The facility shall review and update emergency procedures for accuracy as it pertains to their facility and current processes.
2. Emergency plans available during the survey referred to outdated systems and procedures; there were three versions of verbal codes provided, these verbal codes were not consistent between the three versions. Additionally, there was a policy provided for the use of pager radios and had an outdated call tree without updated numbers; these numbers were not updated due to the system no longer being used based on discussion with facility staff.
The maintenance staff acknowledged the lack of proper paperwork for emergency procedures.

Based on record review during the survey, conducted May 3rd & 4th 2012, it was determined the facility failed to conduct fire drills in accordance with NFPA 101. This was evidenced by the following:
During the review of the facility records with the Maintenance Supervisor, Facilities Director and Risk Manager the second shift fire drills were not conducted at unexpected times and under varying conditions; of the twelve hour shift, fire drills were only conducted during a four hour window and three of the five documented drills were on the same day of the week.
The documentation provided showed the fire drills were conducted as follows; second shift (1500-0300): 06/16/11 @ 2000 (Thursday) - 08/18/11 @ 1925 (Thursday) - 10/03/11 @ 1800 (Monday) - 12/08/11 @ 1600 (Thursday) - 03/07/12 @ 1818 (Wednesday).
The maintenance staff acknowledged the above item.

Based on observation during the survey, conducted on May 3rd & 4th 2012, it was determined the facility failed to install and maintain the fire alarm system in accordance with NFPA 101. This was evidenced by the following:
During the walk through with the Maintenance Supervisor, Facilities Director and Risk Manager, corridor smoke detectors were not properly spaced in the following areas from corridor walls or exceeded the maximum spacing requirements.
1. Distance between smoke detectors by room 122 exceeded 30 '
2. TV room smoke detector is located too far from the wall
The maintenance staff acknowledged the above items.

Based on observation, record review and staff interview during the survey, conducted on May 3rd & 4th 2012, it was determined the facility failed to maintain the fire alarm system in accordance with NFPA 101. This was evidenced by the following:
During review of the facility records with the Maintenance Supervisor, Facilities Director and Risk Manager; the fire alarm system secondary power supply sealed lead-acid batteries were not load voltage tested semiannually, as required. The fire alarm system annual inspection report dated February 20, 2012 documented load voltage testing of the fire alarm control panel batteries. There was no documentation of a semi-annual load test being performed in accordance with NFPA 72, Section 7.3.2 subsection 6d.
The maintenance staff acknowledged the above items.

Based on observation and staff interview during the survey, conducted on May 3rd & 4th 2012, it was determined the facility failed to install the automatic fire sprinkler system in accordance with NFPA 101. This was evidenced by the following:
During the walk through with the Maintenance Supervisor, Facilities Director and Risk Manager:
1. The main electric room has two fire sprinkler heads spaced less than the required minimum distance between sprinklers of 6 feet.
2. The material storage and air compressor room has a 1" branch line supplying four sprinkler heads, documentation is required that will support the adequate water demand from the branch line in these locations.
3. The joining of pipe and fittings for the fire department connection and main drain located in the boiler room does not meet the requirements of NFPA 13 through the use of non-listed rubber type couplings.
4. The attached ambulance canopy did not have fire sprinkler protection.
5. The canopy at the employee entrance did not have fire sprinkler protection.
6. The canopy at the loading dock did not have fire sprinkler protection.
7. Sprinkler heads are located closer than 4 " from a wall or exceed the maximum listed spacing from walls; this was observed in the following locations: corridors adjacent to room 104 and 107, sun room adjacent to the Dining room, the dietary office, patient care supply room, the maintenance office, the CT scan control room, materials storage area, the garage/maintenance shop, the chapel, in the bathroom of patient room 126, and the janitor ' s closet by patient room 105.
8. The facility was not fully sprinklered throughout, this was observed in the following locations: corridor adjacent to copy room in front office area, an alcove in the ED administrative area, the vestibule from the ambulance entrance, the x-ray room closet, the IT storage room by a nurse station, the IT office, the bathroom of patient room 100 and above the false fire place in the small conference room.
The maintenance staff acknowledged the above items.

Based on observation during the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to provide supervisory devices for automatic sprinkler system components and valves in accordance with NFPA 101. This was evidenced by the following:
During the walk-through with the Maintenance Supervisor, Facilities Director and Risk Manager;
The control valve on antifreeze loop located in boiler room did not have a provision to monitor conditions of sprinkler system control valve.
The maintenance staff acknowledged the above item.

Based on observation, record review and staff interview during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 101. This was evidenced by the following:
1. During the review of facility records with the Maintenance Supervisor, Facilities Director and Risk Manager:
a. Annual fire sprinkler inspection report dated February 20, 2012 did not indicate any sampling or testing of the antifreeze solution for the loop located in the southwest corner of the boiler room.
b. Documentation was not provided to indicate that any five year internal inspections have been performed on system check valves.
2. During the walk-through of the facility with the Maintenance Supervisor, Facilities Director and Risk Manager:
a. Boiler room has a sprinkler branch line missing a hanger to support the pipe.
b. The spare sprinkler head cabinet did not have a minimum of two sprinkler heads of each type utilized in the facility including a sprinkler wrench for each type.
c. Sprinklers shall be replaced that are painted, corroded, damaged, loaded, or in the improper orientation; in the dining room, patient room 114 and the kitchen area sprinkler heads were loaded with debris and in the materials office there were painted sprinkler heads.
d. A sprinkler head in the drug screening room and small room off ED overflow were missing the escutcheon plate for the sprinkler head.
e. Sprinkler head is obstructed by HVAC duct work in the scope cleaning room.
f. A standard response sprinkler head in the copier room was within 1-foot of the ceiling diffuser; this head shall be of intermediate response.
g. In the Heart Risk Prevention room, patient room 113 and the PA ' s room the sprinkler head was pushed below the ceiling leaving a gap between the drywall and the sprinkler head.
h. One of the sprinkler heads in patient room 109 appeared to be without fluid in the frangible bulb.
The maintenance staff acknowledged the above items during the survey.

Based on observation during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to install and maintain portable fire extinguishers in accordance with NFPA 101. This was evidenced by the following:
During the walk-through with the Maintenance Supervisor, Facilities Director and Risk Manager:
1. Portable fire extinguisher located in the Maintenance shop was sitting on the floor.
2. Kitchen was not equipped with an A-B-C rated portable fire extinguisher in case of an emergency other than of a grease fire.
The maintenance staff acknowledged the above items.

Based on observation, record review and staff interview during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to provide a current smoking policy in accordance with NFPA 101. This was evidenced by the following:
During the review of the facility records with the Maintenance Supervisor, Facilities Director and Risk Manager; the Smoking policy did not correctly identify the current procedures that are in place for the facility's patients, staff and visitors.
The maintenance staff acknowledged the above item; a new policy was created and reviewed for compliance with current procedures prior to exiting the survey.

Based on observation and staff interview during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility did not provide commercial cooking equipment in accordance with NFPA 101. The following evidenced this:
During the walk-through with the Maintenance Supervisor, Facilities Director and Risk Manager:
1. Mesh type grease filters were present and are not tested, listed or acceptable for UL-300 commercial cooking systems.
2. Kitchen was equipped with a class "K" portable extinguisher but failed to maintain the required signage to indicate its use in case of an emergency.
3. Kitchen hood and ductwork appeared to be galvanized and did not conform to requirements of stainless or carbide steel composition, including seams, joints and penetrations of the hood and enclosures.
The maintenance staff acknowledged the above items during the survey.

Based on observation and staff interview during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to maintain egress corridors that were clear and unobstructed in accordance with NFPA 101. This was evidenced by the following:
During the walk-through with the Maintenance Supervisor, Facilities Director and Risk Manager:
1. The required 8 ft. wide egress corridor clear width was not maintained outside of the Lab and ED. The corridor was obstructed with furniture that included six chairs, coffee table, couch and a wall mounted drinking fountain that projected 14 inches from the corridor wall.
2. The facility contained "chart keepers" mounted onto the wall of the corridor. The "chart keepers" are mounted on the corridor wall outside various patient rooms at forty-four inches (44") off of the floor and when fully closed protrude into the corridor only three and a half inches (3 1/2"). When the doors to the "chart keepers" are opened, the door protrudes into the corridor eighteen inches (18") and does not have the means to automatically close and remain close after each use as required. The following are areas where the keepers were observed, room 101, 102, 103, 104, 105 and 107.
The maintenance staff acknowledged the above during the survey.

Based on observation and staff interview during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to install curtains that were flame resistant in accordance with NFPA 101. This was evidenced by the following:
During the walk-through with the Maintenance Supervisor, Facilities Director and Risk Manager; the curtains in patient room 116 did not have a tag to show the curtains were inherently fire retardant. Documentation was not provided during the survey to show the curtains had been treated with an aftermarket product.
The maintenance staff acknowledged the above during the survey.

Based on observation, record review and staff interview during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to maintain the medical gas system in accordance with NFPA 101. The following evidenced this:
1. During the review of facility records with the Maintenance Supervisor, Facilities Director and Risk Manager:
a. Annual medical gas reports dated April 06, 2010 and November 22, 2011 did not indicate all of the station outlets and associated equipment located inside the building for patient use were tested. Additionally, the testing reports did not include a valid signature by the person conducting the services at the time of inspection.
b. Annual medical gas report dated November 22, 2011 noted that the outside oxygen storage area had weeds throughout and should be removed to reduce the potential hazard of combustibles within the storage area. Dried plant growth was present during the site survey.
2. During the walk through with the Maintenance Supervisor, Facilities Director and Risk Manager:
a. Portable tanks stored within the oxygen storage area were not properly secured in racks or adequately fastened to prevent the cylinders from tipping over.
b. Various oxygen station outlets were not legibly identified for oxygen; this was observed in patient rooms 110, 112, 114, 115, 116, 117, 118 and the large conference room.
The maintenance staff acknowledged the above items.

Based on observation and staff interview during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to install the Type I essential electrical system in accordance with NFPA 101. The following evidenced this:
During the walk through of the facility with the Maintenance Supervisor, Facilities Director and Risk Manager; the emergency power off (EPO) for the generator was not able to be located during the survey.
The maintenance staff acknowledged the lack of an EPO during the survey.

Based on record review and staff interview during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed provide continued education and supervision to laboratory personal in accordance with NFPA 101. The following evidenced this:
During the review of the facility records with the Maintenance Supervisor, Facilities Director and Risk Manager, documentation was not provided to show incidents had been reviewed monthly and procedures were reviewed annually.
The maintenance staff acknowledged the lack of documentation during the survey.

Based on record review and staff interview during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to provide emergency procedures for laboratory personnel in accordance with NFPA 101. The following evidenced this:
During the review of the facility records with the Maintenance Supervisor, Facilities Director and Risk Manager, facility staff was not able to provide procedures for laboratory emergencies to include alarm actuation, evacuation, equipment shutdown procedures, provisions for control of emergencies that could occur in the laboratory to including specific detailed plans for control operations by an emergency control group within the organization or a public fire department.
The maintenance staff acknowledged the lack of documentation during the survey.

Based on record review and staff interview during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to maintain emergency power systems in accordance with NFPA 101. This was evidenced by the following:
During the review of facility records with the Maintenance Supervisor, Facilities Director and Risk Manager:
1. Documentation provided for the monthly inspections and operation of the generator system did not acknowledge or indicated who had been performing the tests.
2. Documentation indicated the diesel emergency generator was operated weekly at a 26% load capacity. Generator shall operate at 30% of rated load capacity per month or an NFPA 110 annual load bank test must be performed.
3. Annual generator service report indicated the load bank test conducted did not meet the minimum NFPA 110 required load levels of 25% for 30 minutes, 50% for 30 minutes and 75% for one hour.
The maintenance staff acknowledged the above items during the survey.

Based on observation and staff interview during the course of the survey conducted on May 3rd & 4th, 2012, it was determined the facility failed to maintain electrical wiring and equipment in accordance with NFPA 101. The following evidenced this:
During the walk through of the facility with the Maintenance Supervisor, Facilities Director and Risk Manager:
1. Zip cords (flexible cable) were not being used on a temporary basis and as allowed by NFPA 70:
a. In the laboratory area an extension cord was being utilized as a substitute for the permanent wiring of the structure.
b. In the materials room an emergency light was " hard wired " using an altered extension cord.
c. The large conference room has an extension cord plugged into a surge suppressor, and then the extension cord proceeded to enter through a hole in the drywall covering a column and disappeared. It would appear the extension cord is used to supply power to a projector mounted to the ceiling grid approximately 8 feet away from the same column that the extension cord is run into. Also within this same drywall column is a station outlet for medical gas which appears to be a functioning outlet.
2. In the dictation room and the admin work room a power strip was installed as a substitute of permanent wiring of the facility.
3. In the IT office, the small conference room and the maintenance office there were power strips plugged into each other " piggy-backed " to extend the permanent wiring of the structure
4. The main electrical room and the administration electrical room were being used for storage of boxes and misc equipment.
The maintenance staff acknowledged the above items during the survey.

Based on observation and staff interview during the course of the survey conducted on May 3rd & 4th, 2012, it was determined the facility failed to install alcohol based hand rub dispensers in accordance with NFPA 101. This was evidenced by the following:
During the walk through of the facility with the Maintenance Supervisor, Facilities Director and Risk Manager:
1. An alcohol based hand rub dispenser was observed to be installed above an electrical component consisting of a push button for activating an automatic door opener feature adjacent to room 101.
2. A portable alcohol based hand rub dispenser was observed to be sitting in a metal basket directly above an electrical outlet just inside the entry of room 101.
The maintenance staff acknowledged the above items during the survey.

Based on observation and staff interview during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to properly separate occupancies in accordance with NFPA 101. The following evidenced this:
During the walk through of the facility with the Maintenance Supervisor, Facilities Director and Risk Manager; three rooms were not accessible during the survey due to locked doors. The rooms were not included in this survey and cannot be determined to be the same occupancy.
The maintenance staff acknowledged no key was available during the survey.


30844

Based on observation and staff interview during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to properly separate occupancies in accordance with NFPA 101. The following evidenced this:
During the walk through of the facility with the Maintenance Supervisor, Facilities Director and Risk Manager; three rooms were not accessible during the survey due to locked doors. The rooms were not included in this survey and cannot be determined to be the same occupancy.
The maintenance staff acknowledged no key was available during the survey.

Based on observation during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to maintain the interior finishes for corridors and exit ways in accordance with NFPA 101. The following evidenced this:
During the walk-through, with the Maintenance Supervisor, Facilities Director and Risk Manager; the corridor located adjacent to the Director of Nursing office and room 106 contains cork board as part of the wall finish. Documentation was not available showing the flame spread rating of the cork board.
The maintenance staff acknowledged the presence of cork board.

Based on observation during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to maintain the interior finishes for rooms and spaces not used for corridors and exit ways in accordance with NFPA 101. The following evidenced this:
During the walk-through with the maintenance supervisor, facilities director and risk manager; the Emergency Room overflow area had walls that were covered with wood paneling. Documentation was not available showing the flame spread rating of the paneling.
The maintenance staff acknowledged the presence of the wood paneling.

Based on observation during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to maintain the separation of use areas from the corridor in accordance with NFPA 101.
During the walk-through with the Maintenance Supervisor, Facilities Director and Risk Manager:
1. Waiting area located by front entrance is open to the corridor without supervision.
2. The vestibule from the ambulance entrance and the ED contained storage not separated from the corridor.
3. Director of Nurse ' s office adjacent to room 106 is open to the corridor without supervision.
These three areas are an example of areas open to the corridor that do not meet any of the exceptions of NFPA 101 Section 19.3.6.1; the facility shall verify all use areas are properly separated from the corridors.
The maintenance staff acknowledged the above items.

Based on observation during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to maintain the doors that protect corridors in accordance with NFPA 101. The following evidenced this:
During the walk-through with the Maintenance Supervisor, Facilities Director and Risk Manager:
1. Corridor doors were held open where they could not be closed with a push or a pull
a. Dining room door was held open with a wooden wedge.
b. Chapel door was held open with a rock at the base of the door.
2. The Dutch door to the IT department was not equipped with a positive latching mechanism for both leaves of the door. The facility also failed to equip this door with an astragal, rabbet, bevel, or other means for maintaining the smoke seal between the upper portion and the lower portion of the door.
3. Positive latching mechanisms were not provided on doors to the corridor; this includes both north and south doors for the dining room
The maintenance staff acknowledged the above items during the survey.

Based on observation during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to provide supervision of the automatic closing doors that protect smoke barrier corridor openings in accordance with NFPA 101. The following evidenced this:
During the walk-through with the Maintenance Supervisor, Facilities Director and Risk Manager; the smoke detector at the smoke barrier doors by room 107 was located 1.5-inches from the doors; this smoke detector shall be located no closer than 12-inches if spot detection is used for automatic closing.
This is an example of where doors were held open by a magnetic device without proper supervision; the facility shall verify all doors electronically held open are supervised by one of the allowed two methods.
The maintenance staff acknowledged the above items during the survey.

Based on observation during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to maintain the smoke barriers in accordance with NFPA 101. The following evidenced this:
During the walk-through with the Maintenance Supervisor, Facilities Director and Risk Manager; smoke barrier walls contained wire openings or openings without fire caulking or other approved method of maintaining the rating of the wall. The following smoke barriers are located by:
1. South area of facility adjacent the TV Room
2. Southwest of facility adjacent to the Tub Room
3. East center of facility adjacent to Room 101
4. South center of facility adjacent to the Dining Room
5. North center of facility adjacent to the Dining Room
6. Pantry has pipes covered with insulation that are not sealed properly
The maintenance staff acknowledged the penetrations in the smoke barrier.

Based on observation during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to maintain the smoke barrier doors in accordance with NFPA 101. The following evidenced this:
During the walk-through with the Maintenance Supervisor, Facilities Director and Risk Manager:
1. The smoke doors located adjacent to North side of the Dining room did not contain a door sequencer. During testing of the fire alarm system, the door with the astragal shut prior to the door without the astragal. When this occurred the door would not maintain a positive smoke seal.
2. The self-closing device for the smoke barrier doors did not close the doors completely. These doors would not maintain a smoke seal.
a. South area of facility adjacent the TV Room
b. Southwest of facility adjacent to the Tub Room
3. Dishwasher area has an opening through a smoke barrier wall which allows clean dishes to be passed through the barrier to the other side; the opening has a door held open by a counter weight without any means to automatically close upon an alarm event.
The maintenance staff acknowledged the above items during the survey.

Based on observation during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to maintain hazardous areas in accordance with NFPA 101. The following evidenced this:
During the walk-through with the Maintenance Supervisor, Facilities Director and Risk Manager:
1. The following doors were held open with a magnetic device that was not part of the fire alarm system to meet automatic closing requirements.
a. Materials storage room
b. Kitchen
2. The following doors had self closures but would not positively latch; over 50 square feet in area and utilized by the facility for storage of combustibles.
a. Room 120 currently used for storage
b. Room 122 currently used for storage
3. The following areas were not equipped with self closures; over 50 square feet in size and utilized by the facility for storage of combustibles.
a. Room 124
b. Large conference room
The maintenance staff acknowledged the above items during the survey.

Based on observation and staff interview during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to maintain the travel distance to exits in accordance with NFPA 101. The following evidenced this:
During the walk-through with the Maintenance Supervisor, Facilities Director and Risk Manager; Both the OR suite and OB-GYN suite has more than two intervening rooms within the suite to an exit access door.
The maintenance staff acknowledged the above item during the survey.

Based on observation and staff interview during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to maintain the means of egress in accordance with NFPA 101. The following evidenced this:
During the walk-through with the Maintenance Supervisor, Facilities Director and Risk Manager:
1. The south leading to the public way was blocked by a large tree branch that according to staff was cut down by staff and had been there for a few weeks; the tree branch was present at the start and end of this two day survey.
2. The following doors contained more than one releasing operation in accordance with 7.2.1.5.4
a. CT scan room
b. Entry to surgery rooms
c. Door adjacent to room 106
d. Dry Storage exit has hasp on screen door
3. The dictation room corridor door had releasing mechanism that was located greater than 48 " above the finished floor.
4. The corridor door to the clean linen room was more than 7-inches away from the wall when fully opened.
The maintenance staff acknowledged the above items.

Based on record review and staff interview during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to maintain emergency lighting in accordance with NFPA 101. The following evidenced this:
During the review of facility records with the Maintenance Supervisor, Facilities Director and Risk Manager; the documentation provided for the monthly and annual battery testing of the emergency lighting system did not acknowledge or indicated who had been performing the tests.
The maintenance staff acknowledged the lack of additional documentation.

Based on observation and staff interview during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to maintain the exit and directional signs in accordance with NFPA 101. The following evidenced this:
During the walk through with the Maintenance Supervisor, Facilities Director and Risk Manager:
1. Signs on two doors entering into the Chapel courtyard located within the outer walls of the facility were improperly labeled. Signs are required to read "NO EXIT", (NO in letters 2-inches high with 3/8-inch wide stroke, and EXIT below the word NO in 1-inch high letters).
2. Exit signs were not illuminated in the following locations during the survey:
a. Corridor adjacent to the TV room
b. Corridor for Dietary Services
The maintenance staff acknowledged the above items.

Based on record review and staff interview during the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to maintain a complete and current plan for the evacuation and protection of all persons in the event of an emergency in accordance with NFPA 101. This was evidenced by the following:
During the review of the facility records with the Maintenance Supervisor, Facilities Director and Risk Manager:
1. Multiple versions of emergency plans were presented in emergency binders available to facility staff; during the review of available manuals it could not be determined which set of plans the facility was currently using during discussions with staff. The facility shall review and update emergency procedures for accuracy as it pertains to their facility and current processes.
2. Emergency plans available during the survey referred to outdated systems and procedures; there were three versions of verbal codes provided, these verbal codes were not consistent between the three versions. Additionally, there was a policy provided for the use of pager radios and had an outdated call tree without updated numbers; these numbers were not updated due to the system no longer being used based on discussion with facility staff.
The maintenance staff acknowledged the lack of proper paperwork for emergency procedures.

Based on record review during the survey, conducted May 3rd & 4th 2012, it was determined the facility failed to conduct fire drills in accordance with NFPA 101. This was evidenced by the following:
During the review of the facility records with the Maintenance Supervisor, Facilities Director and Risk Manager the second shift fire drills were not conducted at unexpected times and under varying conditions; of the twelve hour shift, fire drills were only conducted during a four hour window and three of the five documented drills were on the same day of the week.
The documentation provided showed the fire drills were conducted as follows; second shift (1500-0300): 06/16/11 @ 2000 (Thursday) - 08/18/11 @ 1925 (Thursday) - 10/03/11 @ 1800 (Monday) - 12/08/11 @ 1600 (Thursday) - 03/07/12 @ 1818 (Wednesday).
The maintenance staff acknowledged the above item.

Based on observation during the survey, conducted on May 3rd & 4th 2012, it was determined the facility failed to install and maintain the fire alarm system in accordance with NFPA 101. This was evidenced by the following:
During the walk through with the Maintenance Supervisor, Facilities Director and Risk Manager, corridor smoke detectors were not properly spaced in the following areas from corridor walls or exceeded the maximum spacing requirements.
1. Distance between smoke detectors by room 122 exceeded 30 '
2. TV room smoke detector is located too far from the wall
The maintenance staff acknowledged the above items.

Based on observation, record review and staff interview during the survey, conducted on May 3rd & 4th 2012, it was determined the facility failed to maintain the fire alarm system in accordance with NFPA 101. This was evidenced by the following:
During review of the facility records with the Maintenance Supervisor, Facilities Director and Risk Manager; the fire alarm system secondary power supply sealed lead-acid batteries were not load voltage tested semiannually, as required. The fire alarm system annual inspection report dated February 20, 2012 documented load voltage testing of the fire alarm control panel batteries. There was no documentation of a semi-annual load test being performed in accordance with NFPA 72, Section 7.3.2 subsection 6d.
The maintenance staff acknowledged the above items.

Based on observation and staff interview during the survey, conducted on May 3rd & 4th 2012, it was determined the facility failed to install the automatic fire sprinkler system in accordance with NFPA 101. This was evidenced by the following:
During the walk through with the Maintenance Supervisor, Facilities Director and Risk Manager:
1. The main electric room has two fire sprinkler heads spaced less than the required minimum distance between sprinklers of 6 feet.
2. The material storage and air compressor room has a 1" branch line supplying four sprinkler heads, documentation is required that will support the adequate water demand from the branch line in these locations.
3. The joining of pipe and fittings for the fire department connection and main drain located in the boiler room does not meet the requirements of NFPA 13 through the use of non-listed rubber type couplings.
4. The attached ambulance canopy did not have fire sprinkler protection.
5. The canopy at the employee entrance did not have fire sprinkler protection.
6. The canopy at the loading dock did not have fire sprinkler protection.
7. Sprinkler heads are located closer than 4 " from a wall or exceed the maximum listed spacing from walls; this was observed in the following locations: corridors adjacent to room 104 and 107, sun room adjacent to the Dining room, the dietary office, patient care supply room, the maintenance office, the CT scan control room, materials storage area, the garage/maintenance shop, the chapel, in the bathroom of patient room 126, and the janitor ' s closet by patient room 105.
8. The facility was not fully sprinklered throughout, this was observed in the following locations: corridor adjacent to copy room in front office area, an alcove in the ED administrative area, the vestibule from the ambulance entrance, the x-ray room closet, the IT storage room by a nurse station, the IT office, the bathroom of patient room 100 and above the false fire place in the small conference room.
The maintenance staff acknowledged the above items.

Based on observation during the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to provide supervisory devices for automatic sprinkler system components and valves in accordance with NFPA 101. This was evidenced by the following:
During the walk-through with the Maintenance Supervisor, Facilities Director and Risk Manager;
The control valve on antifreeze loop located in boiler room did not have a provision to monitor conditions of sprinkler system control valve.
The maintenance staff acknowledged the above item.

Based on observation, record review and staff interview during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 101. This was evidenced by the following:
1. During the review of facility records with the Maintenance Supervisor, Facilities Director and Risk Manager:
a. Annual fire sprinkler inspection report dated February 20, 2012 did not indicate any sampling or testing of the antifreeze solution for the loop located in the southwest corner of the boiler room.
b. Documentation was not provided to indicate that any five year internal inspections have been performed on system check valves.
2. During the walk-through of the facility with the Maintenance Supervisor, Facilities Director and Risk Manager:
a. Boiler room has a sprinkler branch line missing a hanger to support the pipe.
b. The spare sprinkler head cabinet did not have a minimum of two sprinkler heads of each type utilized in the facility including a sprinkler wrench for each type.
c. Sprinklers shall be replaced that are painted, corroded, damaged, loaded, or in the improper orientation; in the dining room, patient room 114 and the kitchen area sprinkler heads were loaded with debris and in the materials office there were painted sprinkler heads.
d. A sprinkler head in the drug screening room and small room off ED overflow were missing the escutcheon plate for the sprinkler head.
e. Sprinkler head is obstructed by HVAC duct work in the scope cleaning room.
f. A standard response sprinkler head in the copier room was within 1-foot of the ceiling diffuser; this head shall be of intermediate response.
g. In the Heart Risk Prevention room, patient room 113 and the PA ' s room the sprinkler head was pushed below the ceiling leaving a gap between the drywall and the sprinkler head.
h. One of the sprinkler heads in patient room 109 appeared to be without fluid in the frangible bulb.
The maintenance staff acknowledged the above items during the survey.

Based on observation during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to install and maintain portable fire extinguishers in accordance with NFPA 101. This was evidenced by the following:
During the walk-through with the Maintenance Supervisor, Facilities Director and Risk Manager:
1. Portable fire extinguisher located in the Maintenance shop was sitting on the floor.
2. Kitchen was not equipped with an A-B-C rated portable fire extinguisher in case of an emergency other than of a grease fire.
The maintenance staff acknowledged the above items.

Based on observation, record review and staff interview during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to provide a current smoking policy in accordance with NFPA 101. This was evidenced by the following:
During the review of the facility records with the Maintenance Supervisor, Facilities Director and Risk Manager; the Smoking policy did not correctly identify the current procedures that are in place for the facility's patients, staff and visitors.
The maintenance staff acknowledged the above item; a new policy was created and reviewed for compliance with current procedures prior to exiting the survey.

Based on observation and staff interview during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility did not provide commercial cooking equipment in accordance with NFPA 101. The following evidenced this:
During the walk-through with the Maintenance Supervisor, Facilities Director and Risk Manager:
1. Mesh type grease filters were present and are not tested, listed or acceptable for UL-300 commercial cooking systems.
2. Kitchen was equipped with a class "K" portable extinguisher but failed to maintain the required signage to indicate its use in case of an emergency.
3. Kitchen hood and ductwork appeared to be galvanized and did not conform to requirements of stainless or carbide steel composition, including seams, joints and penetrations of the hood and enclosures.
The maintenance staff acknowledged the above items during the survey.

Based on observation and staff interview during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to maintain egress corridors that were clear and unobstructed in accordance with NFPA 101. This was evidenced by the following:
During the walk-through with the Maintenance Supervisor, Facilities Director and Risk Manager:
1. The required 8 ft. wide egress corridor clear width was not maintained outside of the Lab and ED. The corridor was obstructed with furniture that included six chairs, coffee table, couch and a wall mounted drinking fountain that projected 14 inches from the corridor wall.
2. The facility contained "chart keepers" mounted onto the wall of the corridor. The "chart keepers" are mounted on the corridor wall outside various patient rooms at forty-four inches (44") off of the floor and when fully closed protrude into the corridor only three and a half inches (3 1/2"). When the doors to the "chart keepers" are opened, the door protrudes into the corridor eighteen inches (18") and does not have the means to automatically close and remain close after each use as required. The following are areas where the keepers were observed, room 101, 102, 103, 104, 105 and 107.
The maintenance staff acknowledged the above during the survey.

Based on observation and staff interview during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to install curtains that were flame resistant in accordance with NFPA 101. This was evidenced by the following:
During the walk-through with the Maintenance Supervisor, Facilities Director and Risk Manager; the curtains in patient room 116 did not have a tag to show the curtains were inherently fire retardant. Documentation was not provided during the survey to show the curtains had been treated with an aftermarket product.
The maintenance staff acknowledged the above during the survey.

Based on observation, record review and staff interview during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to maintain the medical gas system in accordance with NFPA 101. The following evidenced this:
1. During the review of facility records with the Maintenance Supervisor, Facilities Director and Risk Manager:
a. Annual medical gas reports dated April 06, 2010 and November 22, 2011 did not indicate all of the station outlets and associated equipment located inside the building for patient use were tested. Additionally, the testing reports did not include a valid signature by the person conducting the services at the time of inspection.
b. Annual medical gas report dated November 22, 2011 noted that the outside oxygen storage area had weeds throughout and should be removed to reduce the potential hazard of combustibles within the storage area. Dried plant growth was present during the site survey.
2. During the walk through with the Maintenance Supervisor, Facilities Director and Risk Manager:
a. Portable tanks stored within the oxygen storage area were not properly secured in racks or adequately fastened to prevent the cylinders from tipping over.
b. Various oxygen station outlets were not legibly identified for oxygen; this was observed in patient rooms 110, 112, 114, 115, 116, 117, 118 and the large conference room.
The maintenance staff acknowledged the above items.

Based on observation and staff interview during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to install the Type I essential electrical system in accordance with NFPA 101. The following evidenced this:
During the walk through of the facility with the Maintenance Supervisor, Facilities Director and Risk Manager; the emergency power off (EPO) for the generator was not able to be located during the survey.
The maintenance staff acknowledged the lack of an EPO during the survey.

Based on record review and staff interview during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to provide emergency procedures for laboratory personnel in accordance with NFPA 101. The following evidenced this:
During the review of the facility records with the Maintenance Supervisor, Facilities Director and Risk Manager, facility staff was not able to provide procedures for laboratory emergencies to include alarm actuation, evacuation, equipment shutdown procedures, provisions for control of emergencies that could occur in the laboratory to including specific detailed plans for control operations by an emergency control group within the organization or a public fire department.
The maintenance staff acknowledged the lack of documentation during the survey.

Based on record review and staff interview during the course of the survey conducted on May 3rd & 4th 2012, it was determined the facility failed to maintain emergency power systems in accordance with NFPA 101. This was evidenced by the following:
During the review of facility records with the Maintenance Supervisor, Facilities Director and Risk Manager:
1. Documentation provided for the monthly inspections and operation of the generator system did not acknowledge or indicated who had been performing the tests.
2. Documentation indicated the diesel emergency generator was operated weekly at a 26% load capacity. Generator shall operate at 30% of rated load capacity per month or an NFPA 110 annual load bank test must be performed.
3. Annual generator service report indicated the load bank test conducted did not meet the minimum NFPA 110 required load levels of 25% for 30 minutes, 50% for 30 minutes and 75% for one hour.
The maintenance staff acknowledged the above items during the survey.

Based on observation and staff interview during the course of the survey conducted on May 3rd & 4th, 2012, it was determined the facility failed to maintain electrical wiring and equipment in accordance with NFPA 101. The following evidenced this:
During the walk through of the facility with the Maintenance Supervisor, Facilities Director and Risk Manager:
1. Zip cords (flexible cable) were not being used on a temporary basis and as allowed by NFPA 70:
a. In the laboratory area an extension cord was being utilized as a substitute for the permanent wiring of the structure.
b. In the materials room an emergency light was " hard wired " using an altered extension cord.
c. The large conference room has an extension cord plugged into a surge suppressor, and then the extension cord proceeded to enter through a hole in the drywall covering a column and disappeared. It would appear the extension cord is used to supply power to a projector mounted to the ceiling grid approximately 8 feet away from the same column that the extension cord is run into. Also within this same drywall column is a station outlet for medical gas which appears to be a functioning outlet.
2. In the dictation room and the admin work room a power strip was installed as a substitute of permanent wiring of the facility.
3. In the IT office, the small conference room and the maintenance office there were power strips plugged into each other " piggy-backed " to extend the permanent wiring of the structure
4. The main electrical room and the administration electrical room were being used for storage of boxes and misc equipment.
The maintenance staff acknowledged the above items during the survey.