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Based on observation the facility failed to provide a self-closing or an automatic-closing devices in a hazardous area or was not smoke resistant.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.2.1, "Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

Findings Include:

On February 15, 2013 the surveyor, accompanied by the Facilities Director, Risk Manager, and Maintenance staff observed the following hazardous areas did not have an automatic or self closing device on the doors or the door did not close when tested three of three of three times when tested.

1. Hot water heater room in Santa Rita
2. Electrical room by Administration
3. Medical Records storage room
4, Rincon Equipment storage room
5. Rated door which opens dining room to the kitchen
6. Rincon laundry room corridor door there was a hole under the door latch of 1/2 inch circular

During the exit conference on February 15, 2013 the above findings were again acknowledged by the Facilities Director, Risk Manager, Maintenance staff and per a conference phone call with the CEO during the exit survey.

Failing to install self-closing or automatic closing hardware on a smoke/fire resistance doors could cause harm to patients in time of a fire.

Based on Record Review and observation the facility failed to conduct the required fire drills.

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."

Findings include:

On February 15, 2013 the surveyor, accompanied by the Facilities Director, reviewed the facility's fire drill records. The surveyor noted there were no fire drill report for the first quarter first shift of 2012. There was no documentation provided to the surveyor while on site to indicate the fire drill was completed.

During the exit conference on February 15, 2013 the above findings were again acknowledged by the Facilities Director, Risk Manager, Maintenance staff and per a conference phone call with the CEO during the exit survey.

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

Based on Observation the facility failed to clean the kitchen exhaust hood system filters.

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." , Chapter 8, Section 8-3.1, " 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".

Findings include:

On February 15, 2013 the surveyor, accompanied by the Facilities Director, Risk Manager, Maintenance staff and Kitchen Manager observed the kitchen exhaust system hood filters five of five had an excessive amount of grease buildup throughout the filters.

During the exit conference on February 15, 2013 the above findings were again acknowledged by the Facilities Director, Risk Manager, Maintenance staff and per a conference phone call with the CEO during the exit survey.

Failing to keep the entire kitchen exhaust hood system clean from grease could cause a fire, which could cause damage to the kitchen and cause harm to the patients.

Based on record Review the facility failed to document the required testing of the emergency generator.

NFPA 101 Life Safety Code, 2000, Chapter 19, 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."

Findings include:

On February 15, 2013 the surveyor, accompanied by the Facilities Director reviewed the generator test records. The facility did not document the number of seconds (10 seconds or less) from normal power to emergency power for 10 of 12 months in 2012. The two months done was by Simenson Generator.

During the exit conference on February 15, 2013 the above findings were again acknowledged by the Facilities Director, Risk Manager, Maintenance staff and per a conference phone call with the CEO during the exit survey.

Failure to document the transfer time from normal power to emergency power could result in harm to patients during lighting system failures.

Based on Observation the facility failed to allow access to the electrical equipment/panel.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1., Section 9.1.2 "Electrical wiring and equipment shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, ARTICLE 110, SECTION 110-26 Spaces About Electrical Equipment. "Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons." Table 110-26(a) Working Space Minimum of three (3) feet in all directions.

"( NO STORAGE ALLOWED IN THE WORKING SPACE) "

Findings include:

On February 15, 2013 the surveyor, accompanied by the Facilities Director, Risk Manager, and Maintenance staff observed three Bio-hazard barrels stored directly in front of the facility Main electrical panels.

During the exit conference on February 15, 2013 the above findings were again acknowledged by the Facilities Director, Risk Manager, Maintenance staff and per a conference phone call with the CEO during the exit survey.

Blocking of access to electrical panels or equipment may delay personnel from controlling an emergency situation. Patients could be harmed if a fire should start because of a delay.

Based on Observation the facility allowed the use of a multiple outlet adapter, (power strip.)

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 15, 2013 the surveyor, accompanied by the Facilities Director, Risk Manager, and Maintenance staff observed the use of a multiple outlet adapter a microwave plugged into a power strip and not directly plugged into a receptacle wall outlet in the Medical Records Office.

During the exit conference on February 15, 2013 the above findings were again acknowledged by the Facilities Director, Risk Manager, Maintenance staff and per a conference phone call with the CEO during the exit survey.

The use of multiple outlet adapters could create an overload of the electrical system and cause a fire or an electrical hazard. A fire could cause harm to the patients.

Based on observation the facility failed to provide a guard on the light bulb located in the facility Main electrical room.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1, Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, Article 110, Section 110-27 (b) Prevent Physical Damage. " In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage

Findings Include:

On February 15, 2013 the surveyor, accompanied by the Facilities Director, Risk Manager, and Maintenance staff observed the light bulb in the facility main electrical room was not protected from physical damage.

During the exit conference on February 15, 2013 the above findings were again acknowledged by the Facilities Director, Risk Manager, Maintenance staff and per a conference phone call with the CEO during the exit survey.

Failure to keep light guards on the light could cause accidental damage or possibly a fire, which could cause harm to the patients.

Based on observation the facility failed to provide a self-closing or an automatic-closing devices in a hazardous area or was not smoke resistant.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.2.1, "Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

Findings Include:

On February 15, 2013 the surveyor, accompanied by the Facilities Director, Risk Manager, and Maintenance staff observed the following hazardous areas did not have an automatic or self closing device on the doors or the door did not close when tested three of three of three times when tested.

1. Hot water heater room in Santa Rita
2. Electrical room by Administration
3. Medical Records storage room
4, Rincon Equipment storage room
5. Rated door which opens dining room to the kitchen
6. Rincon laundry room corridor door there was a hole under the door latch of 1/2 inch circular

During the exit conference on February 15, 2013 the above findings were again acknowledged by the Facilities Director, Risk Manager, Maintenance staff and per a conference phone call with the CEO during the exit survey.

Failing to install self-closing or automatic closing hardware on a smoke/fire resistance doors could cause harm to patients in time of a fire.

Based on Record Review and observation the facility failed to conduct the required fire drills.

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."

Findings include:

On February 15, 2013 the surveyor, accompanied by the Facilities Director, reviewed the facility's fire drill records. The surveyor noted there were no fire drill report for the first quarter first shift of 2012. There was no documentation provided to the surveyor while on site to indicate the fire drill was completed.

During the exit conference on February 15, 2013 the above findings were again acknowledged by the Facilities Director, Risk Manager, Maintenance staff and per a conference phone call with the CEO during the exit survey.

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

Based on Observation the facility failed to clean the kitchen exhaust hood system filters.

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." , Chapter 8, Section 8-3.1, " 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".

Findings include:

On February 15, 2013 the surveyor, accompanied by the Facilities Director, Risk Manager, Maintenance staff and Kitchen Manager observed the kitchen exhaust system hood filters five of five had an excessive amount of grease buildup throughout the filters.

During the exit conference on February 15, 2013 the above findings were again acknowledged by the Facilities Director, Risk Manager, Maintenance staff and per a conference phone call with the CEO during the exit survey.

Failing to keep the entire kitchen exhaust hood system clean from grease could cause a fire, which could cause damage to the kitchen and cause harm to the patients.

Based on record Review the facility failed to document the required testing of the emergency generator.

NFPA 101 Life Safety Code, 2000, Chapter 19, 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."

Findings include:

On February 15, 2013 the surveyor, accompanied by the Facilities Director reviewed the generator test records. The facility did not document the number of seconds (10 seconds or less) from normal power to emergency power for 10 of 12 months in 2012. The two months done was by Simenson Generator.

During the exit conference on February 15, 2013 the above findings were again acknowledged by the Facilities Director, Risk Manager, Maintenance staff and per a conference phone call with the CEO during the exit survey.

Failure to document the transfer time from normal power to emergency power could result in harm to patients during lighting system failures.

Based on Observation the facility failed to allow access to the electrical equipment/panel.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1., Section 9.1.2 "Electrical wiring and equipment shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, ARTICLE 110, SECTION 110-26 Spaces About Electrical Equipment. "Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons." Table 110-26(a) Working Space Minimum of three (3) feet in all directions.

"( NO STORAGE ALLOWED IN THE WORKING SPACE) "

Findings include:

On February 15, 2013 the surveyor, accompanied by the Facilities Director, Risk Manager, and Maintenance staff observed three Bio-hazard barrels stored directly in front of the facility Main electrical panels.

During the exit conference on February 15, 2013 the above findings were again acknowledged by the Facilities Director, Risk Manager, Maintenance staff and per a conference phone call with the CEO during the exit survey.

Blocking of access to electrical panels or equipment may delay personnel from controlling an emergency situation. Patients could be harmed if a fire should start because of a delay.

Based on Observation the facility allowed the use of a multiple outlet adapter, (power strip.)

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 15, 2013 the surveyor, accompanied by the Facilities Director, Risk Manager, and Maintenance staff observed the use of a multiple outlet adapter a microwave plugged into a power strip and not directly plugged into a receptacle wall outlet in the Medical Records Office.

During the exit conference on February 15, 2013 the above findings were again acknowledged by the Facilities Director, Risk Manager, Maintenance staff and per a conference phone call with the CEO during the exit survey.

The use of multiple outlet adapters could create an overload of the electrical system and cause a fire or an electrical hazard. A fire could cause harm to the patients.

Based on observation the facility failed to provide a guard on the light bulb located in the facility Main electrical room.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1, Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, Article 110, Section 110-27 (b) Prevent Physical Damage. " In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage

Findings Include:

On February 15, 2013 the surveyor, accompanied by the Facilities Director, Risk Manager, and Maintenance staff observed the light bulb in the facility main electrical room was not protected from physical damage.

During the exit conference on February 15, 2013 the above findings were again acknowledged by the Facilities Director, Risk Manager, Maintenance staff and per a conference phone call with the CEO during the exit survey.

Failure to keep light guards on the light could cause accidental damage or possibly a fire, which could cause harm to the patients.