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Based on a recertification survey, tests to doors and observations made during the survey for life safety from fire with the facility's Physical Structure Director (employyee # 8), it was determined that some of the facility's doors protecting corridors on the fifth floor (#503, #506 and #513) do not close completely (do not latch) at patient's doors, Intra Venous (IV) fluid room, Pantry at the Intensive care Unit, ground floor soiled room as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.3.6.3

Findings include:

During the tour for life safety from fire, patient's sleeping room doors and doors were tested on 9/20/16 and 9/21/16 from 8:00 am until 4:00 pm and it was found that rooms #503, #508 and #515, IV fluid room, Pantry at the Intensive care Unit and ground floor soiled room did not latch, this can permit smoke, fire and noxious gases to enter the rooms in the event of a fire.

Based on a recertification survey, tests to doors and observations made during the survey for life safety from fire with the facility's Physical Structure Director (employee #8), it was determined that the smoke barrier doors of the kitchen are not arranged to automatically close failed to close flush when released as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.2.1.8.2.

Findings include:

1. The smoke barrier doors on the ground floor that separates the kitchen from the hallway were observed on 9/21/16 at 8:35 am and provided evidence that they are left opened and they do not have hold open devices connected to the fire alarm panel, this can permit smoke, fire and noxious gases to enter the hallway which is a means of egress from the floors above.

Based on a recertification, observations made during the survey for life safety from fire with the facility's Physical Structure Director (employee # 8 ), it was determined that the facility failed to provide documentation of testing performed on emergency lighting (battery operated lamps) which provides light for a period of 90 minutes, enabling those inside to move about safely in an emergency for the stairways and no evidence was found of the annual 90 minute tests as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.9.

Findings include:

Documentation about tests to emergency lighting (lamps) reviewed on 9/22/16 at 3:30 pm provided evidence that the facility is performing monthly tests for 30 seconds. However, no evidence was found that the facility is testing the emergency lamps annually for 90 minutes.

Based on a recertifcation survey, observations made during the survey for life safety from fire with the facility's Physical Structure Director (employee # 8), it was determined that the facility failed to ensure that the emergency room and other wards have written plans for staff to follow with respect to their duties in the event of an emergency as required by the 2000 edition of the Life Safety Code of the NFPA Section 18.7.1.1.

Findings include:

No evidence was found on 9/21/16 at 1:00 pm that emergency room personnel and ward personnel have a plan or assignments with specific tasks in the event of an emergency related to extinguisher use, circuit breaker shut off and oxygen valve shut off. All emergency personnel must be instructed related to their assignments and periodically tested for its implementation and the assignment must be posted for review by staff.

Based on a recertification survey, the review of written documents related to conducted fire drills during the survey for life safety from fire it was determined that the facility failed to ensure that sufficient fire drills are conducted under varying conditions as evidenced by only 11 fire drills performed out of 12, as required by LSC 2000 19.7.1.2.

Findings include:

Written documents about conducted fire drills for the off-site express emergency room were reviewed on 9/22/16 at 1:30 pm and it was found that the facility failed to perform at least one fire drill during a twelve month period, at least one quarterly on each shift. The facility has three shifts and provided evidence of fourteen fire drills during the past thirty-six months. The facility performed nine fire drills during the 7:00 am until 3:00 pm shifts, five during the 3:00 pm until 11:00 pm shifts and one during the 11:00 pm until 7:00 am shifts. The facility failed to comply with this regulation due to the lack of eleven fire drills during the third shifts.

Based on a recertification survey, observations made during the survey for life safety from fire with the facility's Physical Structure Director (employee # 8), it was determined that the facility failed to ensure that smoke detectors are available in required areas such as Medical record storage the facility's fire alarm does not automatically notify an approved central station in accordance with the applicable requirements of NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include:

1. During the physical environment tour from 9/20/16 through 9/23/16 from 8:00 am until 4:00 pm the following areas were found in need of smoke detectors connected to the fire alarm system:

a. The Medical record storage
b. These smoke detector along with new battery operated smoke detectors must be included in the monthly inspection and all smoke detector must be identified by area.

2. The fire alarm system lacks annunciation to an approved central station as reviewed on 9/21/16 at 3:30 pm. The fire alarm system must be arranged to transmit an alarm automatically via a central station to alert the municipal fire department and fire brigade.

Based on a recertification survey, observations made during the survey for life safety from fire with the facility's Physical Structure Director (employee #8), it was determined that the facility failed to ensure that at a portable fire extinguishers is available in the medical record storage as required by the 2000 edition of the Life Safety Code of the NFPA Section 9.7.4.1 and NFPA 10.

Findings include:

The medical record storage was visited on 9/23/16 at 8:25 am and it was found that this area contains a large amount of file and wooden pallets. There is a smoke detector but it is not connected to the alarm panel also it is not included on the monthly tests; the area only have one fire extinguisher of 5 lbs. The placement of the fire extinguisher should be place near the entrance of every room in order to facilitate its use.

Based on a recertification survey, observations made during the survey for life safety from fire with the facility's Physical Structure Director (employee #8), Director of Operational Affairs and safety officer (employee # 4), it was determined that the facility failed to monitor the means of egress near the x-ray department and fifth floor and fourth floor to ensure that it is maintained free from all obstructions in accordance with the 2000 edition of the Life Safety Code of the NFPA Section 7.1.10.1.

Findings include:

On 9/20/16 at 10:45 am a patient was observed in the hallway in front of the X-ray department in a stretcher. The patient was connected to an I.V solution and left in front of a set of seats which reduced the width of this exit passage to less than three feet. "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".

Based on a recertification survey, observations made during the survey for life safety from fire with the facility's Physical Structure Director (employee #8), it was determined that the facility failed to ensure that dirty linen is stored in an appropriate manner as required by the 200 edition of the Life Safety Code of the NFPA Section 19.7.5.5.

Findings include:

During the observational tour of the entire facility from 9/20/16 through 9/22/16 from 8:00 am until 4:00 pm, it was determined that personnel are using closets to place dirty linen, however they are not protected as hazardous areas. All floors and the emergency room were found with full plastic bags of dirty linen in hampers.
The facility's Physical Structure Director (employee #8) stated during an interview on 9/20/16 at 10:30 pm that these closets are used as a holding area until personnel make their rounds and remove them from the closet.
These closets have smoke detectors connected to the alarm panel and extractors; however the construction of these closets must be verified to ensure one hour fire rating (with 3/4 hour fire-rated doors) with positive latching. Also, collection containers cannot exceed 32 gallons within any 64 square foot area. This room is not 64 square feet and exceeded the 32 gallon capacity.

Based on a recertification survey, observations during the survey for Life safety from fire with the facility's Physical Structure Director (employee # 8), it was found that this facility does not comply with other Life Safety Code requirements not in CMS-2786-U.

Findings include:

1. The truck loading area was observed on 9/21/08 at 9:00 am and provided evidence that 2 big propane gas tank are located in this area. The cylinders are placed directly on the cement floor and should be placed on wood or another material that will prevent them from rusting and the area should be protected from unauthorized access. Cylinders must be protected from unauthorized access, moving, tipping or thief according to the National Fire Protection Association (NFPA) 99 section 4-3.5.2.2 (Storage of cylinders and containers). The gas propane cylinders are located at the bottom of a hill and the end of a driveway where trunks back up (in reverse) and unload supplies to the hospital. Trunks were found within twenty feet of the propane gas. According with NFPA 99 section 4-3.5.2.1 (Gases in cylinders and Liquefied Gases in containers) oxygen shall be maintained to prevent contact with oils, greases, organic lubricants, rubber or other material of organic nature. The facility must determine an acceptable area to store and protect these propane cylinders in the event that the brakes of the trucks fail when backing into the area and the area must have appropriate signage.

2. The operating rooms were visited on 9/22/16 from 1:00 pm until 2:00 pm and provided evidence that operating suite #A, #B and #C had multi-plugs and electrical cables directly on the floor.

3. No floor plans were found in the Emergency Room adult area and pediatric area and the Radiology department on 9/20/16 from 9:00 am until 5:00 pm.

4. Fire extinguisher documentation was reviewed on 9/22/16 from 3:30 pm and provided evidence of a monthly check list, but did not include what is performed to test them.

5. No evidence was found on 9/23/16 at 1:00 pm that the facility is periodically testing the smoke barrier doors held open by hold open devices to ensure that they close properly when released

6. Observations made on 9/23/16 at 9:00 am of the surgery department provided evidence that three small cylinders of oxygen were on the floor next to the recovery room. The cylinders were not fastened to the wall or in stands to prevent them from falling. Oxygen cylinders must be secured in order to prevent them from falling and possible explosion.

7. The diesel tank used to store and provide diesel to the essential electrical system (EES) was found out open and 6 cars were park near the diesel tank as observed on 9/22/16 at 10:30 am. The diesel tank is located in an area that makes it accessible to non-authorized persons if the gates remain open according to observation from 9/20/16 to 9/23/16.

8. Review of documentation and observations of the sprinkler system on 09/22/16 and 09/23/16 from 8:30 am until 3:30 pm the following was determined related with NFPA 13 for the hospital and off-site emergency room:

a. No evidence was provided that the facility has spare sprinklers, a sprinkler wrench or a cabinet to place them in.

b. No evidence was found of valve identification signs for the control valve, drain valve or inspector test valve.

c. No evidence was provided of installation documentation.

9. Two large propane gas tank located at the receiving area of the facility was visited on 8/21/16 at 9:10 am with the facility's physical plant director (employee #8) and provided evidence that it is not prepared to turn off in the event of an earthquake. The movement from an earthquake can cause metal tubing to crack which may leak gas and can cause an explosion. Seismic shut off devices which automatically turns off the gas at the source is required. These two tanks are not properly labeled according to what the commission public service ordered by the Industry Regulation for LPG, Natural Gas and other hazardous products conducted by pipes.

10. Television sets and radios brought by residents or their relatives are allowed at this facility as observed on 12/5/06 at 8:30 a.m. A total of four televisions and three radios were observed in resident's sleeping rooms without being inspected by the facility's safety officer (rooms #503, #515 B and #517). (NFPA-99) (7.6.2.1.10).

Based on a recertification survey, observations and documents reviewed during the survey for life safety from fire with the facility's Physical Structure Director (employee #8), it was determined that the facility failed to test electrical receptacles that are supplied by the essential electrical system at least twice a year in accordance with NFPA 99 Section 7-6.2.1.2.

Findings include:

Written evidence was reviewed on 9/22/16 at 3:45 pm about preventive maintenance to the receptacles indicates that they are testing the receptacles supplied by the generator once a year. However, receptacles that are supplied by the essential electrical system (generator) supply power to critical care areas and equipment (cardiac monitors, life support equipment, Intensive Care Unit equipment and wet locations). Equipment or wiring faults can cause abnormal temperature increases, these abnormal temperatures may cause fire and explosions. Critical care areas, wet locations and areas where critical care equipment are plugged into the essential electrical receptacles are required to be tested in intervals not exceeding six months because even brief interruptions of power can cause malfunctions of some equipment and appliances.

Based on a recertification survey, tests to doors and observations made during the survey for life safety from fire with the facility's Physical Structure Director (employyee # 8), it was determined that some of the facility's doors protecting corridors on the fifth floor (#503, #506 and #513) do not close completely (do not latch) at patient's doors, Intra Venous (IV) fluid room, Pantry at the Intensive care Unit, ground floor soiled room as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.3.6.3

Findings include:

During the tour for life safety from fire, patient's sleeping room doors and doors were tested on 9/20/16 and 9/21/16 from 8:00 am until 4:00 pm and it was found that rooms #503, #508 and #515, IV fluid room, Pantry at the Intensive care Unit and ground floor soiled room did not latch, this can permit smoke, fire and noxious gases to enter the rooms in the event of a fire.

Based on a recertification survey, tests to doors and observations made during the survey for life safety from fire with the facility's Physical Structure Director (employee #8), it was determined that the smoke barrier doors of the kitchen are not arranged to automatically close failed to close flush when released as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.2.1.8.2.

Findings include:

1. The smoke barrier doors on the ground floor that separates the kitchen from the hallway were observed on 9/21/16 at 8:35 am and provided evidence that they are left opened and they do not have hold open devices connected to the fire alarm panel, this can permit smoke, fire and noxious gases to enter the hallway which is a means of egress from the floors above.

Based on a recertification, observations made during the survey for life safety from fire with the facility's Physical Structure Director (employee # 8 ), it was determined that the facility failed to provide documentation of testing performed on emergency lighting (battery operated lamps) which provides light for a period of 90 minutes, enabling those inside to move about safely in an emergency for the stairways and no evidence was found of the annual 90 minute tests as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.9.

Findings include:

Documentation about tests to emergency lighting (lamps) reviewed on 9/22/16 at 3:30 pm provided evidence that the facility is performing monthly tests for 30 seconds. However, no evidence was found that the facility is testing the emergency lamps annually for 90 minutes.

Based on a recertifcation survey, observations made during the survey for life safety from fire with the facility's Physical Structure Director (employee # 8), it was determined that the facility failed to ensure that the emergency room and other wards have written plans for staff to follow with respect to their duties in the event of an emergency as required by the 2000 edition of the Life Safety Code of the NFPA Section 18.7.1.1.

Findings include:

No evidence was found on 9/21/16 at 1:00 pm that emergency room personnel and ward personnel have a plan or assignments with specific tasks in the event of an emergency related to extinguisher use, circuit breaker shut off and oxygen valve shut off. All emergency personnel must be instructed related to their assignments and periodically tested for its implementation and the assignment must be posted for review by staff.

Based on a recertification survey, the review of written documents related to conducted fire drills during the survey for life safety from fire it was determined that the facility failed to ensure that sufficient fire drills are conducted under varying conditions as evidenced by only 11 fire drills performed out of 12, as required by LSC 2000 19.7.1.2.

Findings include:

Written documents about conducted fire drills for the off-site express emergency room were reviewed on 9/22/16 at 1:30 pm and it was found that the facility failed to perform at least one fire drill during a twelve month period, at least one quarterly on each shift. The facility has three shifts and provided evidence of fourteen fire drills during the past thirty-six months. The facility performed nine fire drills during the 7:00 am until 3:00 pm shifts, five during the 3:00 pm until 11:00 pm shifts and one during the 11:00 pm until 7:00 am shifts. The facility failed to comply with this regulation due to the lack of eleven fire drills during the third shifts.

Based on a recertification survey, observations made during the survey for life safety from fire with the facility's Physical Structure Director (employee # 8), it was determined that the facility failed to ensure that smoke detectors are available in required areas such as Medical record storage the facility's fire alarm does not automatically notify an approved central station in accordance with the applicable requirements of NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include:

1. During the physical environment tour from 9/20/16 through 9/23/16 from 8:00 am until 4:00 pm the following areas were found in need of smoke detectors connected to the fire alarm system:

a. The Medical record storage
b. These smoke detector along with new battery operated smoke detectors must be included in the monthly inspection and all smoke detector must be identified by area.

2. The fire alarm system lacks annunciation to an approved central station as reviewed on 9/21/16 at 3:30 pm. The fire alarm system must be arranged to transmit an alarm automatically via a central station to alert the municipal fire department and fire brigade.

Based on a recertification survey, observations made during the survey for life safety from fire with the facility's Physical Structure Director (employee #8), it was determined that the facility failed to ensure that at a portable fire extinguishers is available in the medical record storage as required by the 2000 edition of the Life Safety Code of the NFPA Section 9.7.4.1 and NFPA 10.

Findings include:

The medical record storage was visited on 9/23/16 at 8:25 am and it was found that this area contains a large amount of file and wooden pallets. There is a smoke detector but it is not connected to the alarm panel also it is not included on the monthly tests; the area only have one fire extinguisher of 5 lbs. The placement of the fire extinguisher should be place near the entrance of every room in order to facilitate its use.

Based on a recertification survey, observations made during the survey for life safety from fire with the facility's Physical Structure Director (employee #8), Director of Operational Affairs and safety officer (employee # 4), it was determined that the facility failed to monitor the means of egress near the x-ray department and fifth floor and fourth floor to ensure that it is maintained free from all obstructions in accordance with the 2000 edition of the Life Safety Code of the NFPA Section 7.1.10.1.

Findings include:

On 9/20/16 at 10:45 am a patient was observed in the hallway in front of the X-ray department in a stretcher. The patient was connected to an I.V solution and left in front of a set of seats which reduced the width of this exit passage to less than three feet. "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".

Based on a recertification survey, observations made during the survey for life safety from fire with the facility's Physical Structure Director (employee #8), it was determined that the facility failed to ensure that dirty linen is stored in an appropriate manner as required by the 200 edition of the Life Safety Code of the NFPA Section 19.7.5.5.

Findings include:

During the observational tour of the entire facility from 9/20/16 through 9/22/16 from 8:00 am until 4:00 pm, it was determined that personnel are using closets to place dirty linen, however they are not protected as hazardous areas. All floors and the emergency room were found with full plastic bags of dirty linen in hampers.
The facility's Physical Structure Director (employee #8) stated during an interview on 9/20/16 at 10:30 pm that these closets are used as a holding area until personnel make their rounds and remove them from the closet.
These closets have smoke detectors connected to the alarm panel and extractors; however the construction of these closets must be verified to ensure one hour fire rating (with 3/4 hour fire-rated doors) with positive latching. Also, collection containers cannot exceed 32 gallons within any 64 square foot area. This room is not 64 square feet and exceeded the 32 gallon capacity.

Based on a recertification survey, observations during the survey for Life safety from fire with the facility's Physical Structure Director (employee # 8), it was found that this facility does not comply with other Life Safety Code requirements not in CMS-2786-U.

Findings include:

1. The truck loading area was observed on 9/21/08 at 9:00 am and provided evidence that 2 big propane gas tank are located in this area. The cylinders are placed directly on the cement floor and should be placed on wood or another material that will prevent them from rusting and the area should be protected from unauthorized access. Cylinders must be protected from unauthorized access, moving, tipping or thief according to the National Fire Protection Association (NFPA) 99 section 4-3.5.2.2 (Storage of cylinders and containers). The gas propane cylinders are located at the bottom of a hill and the end of a driveway where trunks back up (in reverse) and unload supplies to the hospital. Trunks were found within twenty feet of the propane gas. According with NFPA 99 section 4-3.5.2.1 (Gases in cylinders and Liquefied Gases in containers) oxygen shall be maintained to prevent contact with oils, greases, organic lubricants, rubber or other material of organic nature. The facility must determine an acceptable area to store and protect these propane cylinders in the event that the brakes of the trucks fail when backing into the area and the area must have appropriate signage.

2. The operating rooms were visited on 9/22/16 from 1:00 pm until 2:00 pm and provided evidence that operating suite #A, #B and #C had multi-plugs and electrical cables directly on the floor.

3. No floor plans were found in the Emergency Room adult area and pediatric area and the Radiology department on 9/20/16 from 9:00 am until 5:00 pm.

4. Fire extinguisher documentation was reviewed on 9/22/16 from 3:30 pm and provided evidence of a monthly check list, but did not include what is performed to test them.

5. No evidence was found on 9/23/16 at 1:00 pm that the facility is periodically testing the smoke barrier doors held open by hold open devices to ensure that they close properly when released

6. Observations made on 9/23/16 at 9:00 am of the surgery department provided evidence that three small cylinders of oxygen were on the floor next to the recovery room. The cylinders were not fastened to the wall or in stands to prevent them from falling. Oxygen cylinders must be secured in order to prevent them from falling and possible explosion.

7. The diesel tank used to store and provide diesel to the essential electrical system (EES) was found out open and 6 cars were park near the diesel tank as observed on 9/22/16 at 10:30 am. The diesel tank is located in an area that makes it accessible to non-authorized persons if the gates remain open according to observation from 9/20/16 to 9/23/16.

8. Review of documentation and observations of the sprinkler system on 09/22/16 and 09/23/16 from 8:30 am until 3:30 pm the following was determined related with NFPA 13 for the hospital and off-site emergency room:

a. No evidence was provided that the facility has spare sprinklers, a sprinkler wrench or a cabinet to place them in.

b. No evidence was found of valve identification signs for the control valve, drain valve or inspector test valve.

c. No evidence was provided of installation documentation.

9. Two large propane gas tank located at the receiving area of the facility was visited on 8/21/16 at 9:10 am with the facility's physical plant director (employee #8) and provided evidence that it is not prepared to turn off in the event of an earthquake. The movement from an earthquake can cause metal tubing to crack which may leak gas and can cause an explosion. Seismic shut off devices which automatically turns off the gas at the source is required. These two tanks are not properly labeled according to what the commission public service ordered by the Industry Regulation for LPG, Natural Gas and other hazardous products conducted by pipes.

10. Television sets and radios brought by residents or their relatives are allowed at this facility as observed on 12/5/06 at 8:30 a.m. A total of four televisions and three radios were observed in resident's sleeping rooms without being inspected by the facility's safety officer (rooms #503, #515 B and #517). (NFPA-99) (7.6.2.1.10).

Based on a recertification survey, observations and documents reviewed during the survey for life safety from fire with the facility's Physical Structure Director (employee #8), it was determined that the facility failed to test electrical receptacles that are supplied by the essential electrical system at least twice a year in accordance with NFPA 99 Section 7-6.2.1.2.

Findings include:

Written evidence was reviewed on 9/22/16 at 3:45 pm about preventive maintenance to the receptacles indicates that they are testing the receptacles supplied by the generator once a year. However, receptacles that are supplied by the essential electrical system (generator) supply power to critical care areas and equipment (cardiac monitors, life support equipment, Intensive Care Unit equipment and wet locations). Equipment or wiring faults can cause abnormal temperature increases, these abnormal temperatures may cause fire and explosions. Critical care areas, wet locations and areas where critical care equipment are plugged into the essential electrical receptacles are required to be tested in intervals not exceeding six months because even brief interruptions of power can cause malfunctions of some equipment and appliances.