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The facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 19. 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 19. 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

On October 06, 2010 the surveyor, accompanied by the Director of Maintenance, observed the following corridor doors would not tightly close when tested, had impediments door wedges etc: holding the doors open or were not smoke resistant.

1. Corridor doors to the Main Emergency Treatment room these doors do not positively latch and have a gap between the double doors of approximately 1/2 inch when closed.
2. OB room for Emergency Department
3. Two Gurney's were blocking the corridor door in the Rapid Treatment room
4. Room #97 Cat Scanner room
5. Double doors to Radiology
6. Kitchen dry food storage room impediment in use door wedge
7. Rooms 402 and 407
8. Storage closet by the Clinic Nurses station
9. Rooms four and six in the Clinic.
10. Main laboratory breakroom, office corridor door
11. Laundry room corridor door had tape on the door latching mechanism and the door did not positively latch.
12. X ray room number one in the Emergency Department.

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

The facility failed to maintain the self closing/automatic-closing doors in the smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Sections, 19.3.7.6 "Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 18.2.2.2.6. ( See Chapter 19 for additional requirements) Chapter 8, Section 8.3.4."Doors" Section 8.3.4.3, "Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1. Section 7.2.1.8.1 (1) "Upon release of the hold-open mechanism, the door becomes self-closing."

On October 06, 2010 the surveyor, accompanied by the Director of Maintenance observed the smoke barrier doors did not close all the way when tested. These door are rated smoke barrier doors indicated by the rating on the doors.

1. Smoke barrier doors adjacent to the Acute Care Nurses Station
2. Smoke barrier doors by room 401
3. Smoke barrier doors by the Main Chapel

Failure to properly adjust or repair the smoke doors could cause harm to the residents. Non closing smoke doors will allow smoke to enter smoke zones not directly effected by the fire, which could cause harm to the patients.

The facility failed to provide a self-closing or an automatic-closing door in a hazardous area.

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.

On October 06, 2010 the surveyor accompanied by the Director of Maintenance observed the door to room five for the Business Office was missing a self-closing device on the door. The room when measured by the Director of Maintenance was approximately 12 x 10 total square feet and had boxes of business documents in the room..

Failing to install self-closing hardware on a smoke/fire resistance door could cause harm to the residents residents in time of a fire.

The facility failed to maintain the sprinkler heads.

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

On October 06, 2010 the surveyor, accompanied by the Director of Maintenance observed the sprinkler heads throughout the facility. The following locations had either lint accumulation on the sprinklers, paint, stucco or were corroded apparent by the green/blue/white color on the sprinklers.

1. Patient Financial Office
2. Basement of the hospital
3. Adjacent tot the Director of Nursing office in the corridor
4. Radiology storage room
5. Radiology bathroom
6. Billing office and Billing Department
7. Bathroom next to outpatient lab
8. Room #9 North Wing,
9. Room #5 Business storage room
10. Painted sprinklers in the corridor between rooms seven and nine.
11. Adjacent to the Human Resources Office in the corridor.
12. Marketing Office corroded sprinkler
13. Room # 12
14. Laundry room /hot water heater room in laundry
15. Main Housekeeping lint and paint on sprinklers
16. IT computer services room.
17. Main kitchen office and food prep area of kitchen to include the freezer and refrigerator had corroded sprinklers.
18. Main dining room
19 Archived storage room
20 Room 3204
21. Waiting room for Specialty Clinic
22. The bathroom across from the Arizona Ambulance Crew Quarters which was being used for storage this room was missing a sprinkler in one of the two rooms it was not protected.

Failing to maintain sprinkler heads and keep the fusible links clean could allow a fire to burn longer before the sprinkler head will activate. This could cause harm to the patients.

The facility allowed the use of extension cords.

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.

On October 06, 2010 the surveyor, accompanied by Director of Maintenance observed the following locations had extension cord (s) in use connected to appliances.

1. Mammogram Room
2. Room # 12 Medical records file storage room.
3. Billing Department

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


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)

On October 06, 2010 the surveyor, accompanied by the Director of Maintenance observed storage a medical crash cart stored in front of the electrical panel located in surgery operating room.

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.