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

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

Findings Include:

On February 11, 2014, the surveyors, accompanied by the Chief Financial Officer, Peoples Choice, Director of Maintenance and staff members, observed the following areas do not meet the building construction and are not smoke proof:

1. Room 3204, hole in corridor wall measuring 34 1/2 inch by 33 inches, to include 2 1/2 inch hole in the door, lock removed;
2. Rooms 3206, 3207, and 3208, hole in interior wall approximately 15 inches by 3 inches (med gases);
3. Gift Shop, hole in wall under counter; and
4. Laundry, and vacant room, dry wall removed from corridor interior wall and ceiling measuring approximately 45 feet by 8 feet to include doors casing are not smoke tight.

On February 11, 2014 the above findings were again acknowledged by the Chief Executive Officer/ Chief Financial Officer.

The facility failed to cover walls and ceilings with fire resistive/smoke resistive building material. Failing to contain smoke or heat from a fire will cause harm to the patients.

Based on observation the facility failed to maintain the smoke/fire resistive rating of corridor walls.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.1, "Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5 (See also 19.2.5.9) (See all Exceptions) Section 19.3.6.2 "Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour." (See all Exceptions}.

Findings Include:

On February 11, 2014, the surveyors, accompanied by the Chief Financial Officer, Peoples Choice, Director of Maintenance and staff members, observed penetrations in the corridor walls located in the following areas:

1. Housekeeping, two open conduits in the corridor walls across from room 3206;
2. Corridor walls by room 112, two holes;
3. Corridor penetrations by triage and Clinic; and
4. Nurses lounge, penetrations in corridor wall.

On February 11, 2014 the above findings were again acknowledged by the Chief Executive Officer/ Chief Financial Officer.

Corridor walls must remain smoke tight/fire resistive to prevent smoke and heat from entering resident rooms. Smoke/heat will cause harm to the patients.

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

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

Findings Include:

On February 11, 2014, the surveyors, accompanied by the Chief Financial Officer, Peoples Choice, Director of Maintenance and staff members, observed the following corridor doors would not tightly close when tested.

1. Nurses Lounge, Door closing device removed;
2. Physical Therapy across from gym, door wedged open with an impediment;
3. Chapel, Door closing device removed;
4. Financial counseling office, door closing device removed;
5. Room 133, door tested three of three times and will not positively latch;
6. Room 130, door tested three of three times and will not positively latch; and
7. Patient linen closet, no door closing device.

On February 11, 2014 the above findings were again acknowledged by the Chief Executive Officer/ Chief Financial Officer.

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

Based on observation 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 19.2.2.2.6. ( 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."

Findings include:

On February 11, 2014, the surveyors, accompanied by the Chief Financial Officer, Peoples Choice, Director of Maintenance and staff members, tested the U.L. listed double rated smoke doors by the Lab corridor.( UL tag defaced) When closed the doors would not tightly close or latch.

On February 11, 2014 the above findings were again acknowledged by the Chief Executive Officer/ Chief Financial Officer.

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

Based on observation the facility did not maintain the integrity, smoke resistance, of doors in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.2.1 requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls and doors must be able to resist the passage of smoke. NFPA 80 "Fire Doors and Fire Windows" Chapter 2, Section 2-3.1.7 "The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. +/- 1/16 in for steel doors and shall not exceed 1/8 in. for wood doors.

Findings include:

On February 11, 2014, the surveyors, accompanied by the Chief Financial Officer, Peoples Choice, Director of Maintenance and staff members, observed the following hazardous area doors:

1. Storage of Combustibles and flammables in closet by room 3204, no door closing device;
2. Clinic, soiled utility room door tested three of three times, will not positively latch;
3. Old Clinic Lobby, three hour rated door, no closing device;
4. Triage and clinic corridor rated door, removed ( UL equal to Old Clinic Lobby door);
5. Kitchen, rated door to corridor, tested three of three times will not positively latch;
6. Housekeeping by room 306, chemicals stored in room, no door closing device;
7. ED janitor closet, combustibles/flammables, and dirty linen, no door closing device;
8. Double doors to ER, wedged open;
9. Double rated doors to Radiology, tested three of three times will not positively latch;
10. Gift shop, approximately 130 sq ft no door closing device;
11. Radiology storage, 2 doors no closing devices; and
12. IT offices/storage, no door closing devices.

On February 11, 2014 the above findings were again acknowledged by the Chief Executive Officer/ Chief Financial Officer.

Failing to prevent heat and smoke from spreading into the exit corridor will cause harm to patients.

Based on observation the facility failed to maintain the battery operated emergency lighting.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.2.9.1 " Emergency lighting shall be provided in accordance with Section 7.9."Section 7.9.2.4 "Battery-operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition."

Findings Include:

On February 11, 2014, the surveyors, accompanied by the Chief financial Officer, Peoples Choice, Director of Maintenance and staff members, tested the following emergency lighting units. The lighting units would not light during the test.

1. CT trailer, emergency light, failed;
2. ER, emergency light # 9, failed;
3. OR one and two, emergency lights, failed; and
4. OR, emergency light # 8, failed.

On February 11, 2014 the above findings were again acknowledged by the Chief Executive Officer/ Chief Financial Officer

Failure to maintain emergency lighting units in proper operating condition will cause harm to the patients during a power outage.

Based on observation and Fire Drill Record review 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 11, 2014, the surveyors, accompanied by the Chief Financial Officer, Peoples Choice, Director of Maintenance and staff members, reviewed the facility's fire drill records. The surveyors reviewed the Fire Drill log which indicated fire drills were conducted the same day for each shift, each quarter and not varied. The Fire Drill record indicated as little as the date of the drill and one employee participating in the drill and not the the entire facilities personnel (nurses, interns, maintenance, and administrative staff) The facilities written fire plan has the required elements of a basic response required of staff involved with a fire emergency, however the Fire Drill Record does not contain the elements indicating a fire scenario and steps to remove occupants, transmission of fire alarm confinement of effected area, relocation of patients.

On February 11, 2014 the above findings were again acknowledged by the Chief Executive Officer/ Chief Financial Officer.

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

Based on observation and record review the facility failed to have qualified personnel conducting the annual fire alarm system tests and maintenance.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.4.1, "Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6." Section 9.6.1.4 "A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72 National Fire Alarm Code. NFPA 72 Chapter 7 "Inspection Testing, and Maintenance" Section 7-1.2.2 "Service personnel shall be qualified and experienced in the inspection, testing, and maintenance of fire alarm systems. Examples of qualified personnel shall be permitted to include, but not be limited to, individuals with the following qualifications:
(1) Factory trained and certified.
(2) National Institute for Certification in Engineering Technologies fire alarm certified.
(3) International Municipal Signal Association fire alarm certified.
(4) Certified by a state or local authority.
(5) Trained and qualified personnel employed by an organization listed by a national testing laboratory. for the servicing of fire alarm systems.

Findings include:

On February 11, 2014, the surveyors, accompanied by the Chief Financial Officer, Peoples Choice, Director of Maintenance and staff members, observed the monthly and annual fire alarm maintenance reports. The Fire Alarm System annual inspection was completed on January 29, 2014. During the facilities inspection the surveyor observed the Fire Alarm Panel to be in "TROUBLE". At this time the staff stated the Fire Alarm maintenance company will be at the facility on February 14, 2014 to make the required repairs.

On February 11, 2014 the above findings were again acknowledged by the Chief Executive Officer/ Chief Financial Officer.

Failure to maintain the fire alarm system utilizing qualified personnel will result in harm to the patients.

Based on observation the facility failed to provide sprinkler protection through out the facility.

NFPA 101 Life Safety Code,2000,Chapter 19, Section 19.3.5.1, " Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.1.1 "Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler systems."
NFPA 13, Chapter 1, Section 1-6 "Level of Protection " 1-6.1 "A building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas."

Findings include:

On February 11, 2014, the surveyors, accompanied by the Chief Financial Officer, Peoples Choice, Director of Maintenance and staff members, observed the Old Clinic hall way from waiting area to clinic, has no sprinkler protection.

On February 11, 2014 the above findings were again acknowledged by the Chief Executive Officer/ Chief Financial Officer.

Failing to provide sprinkler protection throughout the facility will allow a fire to grow rapidly and cause more sprinkler heads to fuse than necessary. Smoke produced by a fire in a non sprinkled area will cause harm to the patients.

Based on observation and record review the facility did not inspect, test and maintain the automatic sprinkler system in accordance with the requirements of the Life Safety Code. The facility failed to maintain the sprinkler heads and assure that all parts of the sprinkler system were in accordance with the UL Listing.


NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.5.1. "Buildings containing health care facilities shall be protected throughout by an 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, Water Based Extinguishment Systems, requires monthly, quarterly and annual testing of automatic sprinkler systems.
Testing, and Maintenance of Water-Based Fire Protection systems. NFPA 25, Section 2-2.1.1 "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign material , paint, and physical damage and shall be installed in the proper orientation..." NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, Chapter 3, Section 3-2.7.2, "Escutcheon Plates used with a recessed or flushed sprinkler shall be part of a listed sprinkler assembly."

Findings include:

On February 11, 2014, the surveyors, accompanied by the Chief Financial Officer, Peoples Choice, Director of Maintenance and staff members, reviewed the records which indicated that the automatic sprinkler system was not inspected or tested monthly, quarterly or annually. The following findings are:

1. The sprinkler quarterly inspector test did not indicate the amount of time it takes for the local alarm to sound on the third and fourth quarter of 2013;
2. Conference room, one of two sprinklers, with spackle;
3. Room 3206, bathroom, one of one sprinkler with paint;
4. Room 3209, bathroom, one of one sprinkler with paint;
5. Room 108, bathroom, one of one sprinkler with paint;
6. Room 401, bathroom, one of one sprinkler with paint;
7. Room 303, closet sprinkler covered with paint;
8. PT utility room, sprinkler with paint;
9. Fast Track, two of three sprinklers gaps and not smoke tight;
10. ED, one of four sprinklers, with paint;
11. Door 120, two of two sprinklers in room no escutcheon plates;
12. Nurse Flight room, one escutcheon plate missing;
13. IT offices/storage, one of five escutcheon plates, not smoke tight; and
14. Server room, one of two sprinklers with paint.

On February 11, 2014 the above findings were again acknowledged by the Chief Executive Officer/ Chief Financial Officer.

Failure to inspect, test, and maintain the sprinkler system could result in harm to the patients through the spread of smoke and fire.
Failing to maintain sprinkler heads and keep the fusible link clean could allow a fire to burn longer before the sprinkler head will activate. Failing to maintain sprinkler heads, missing escutcheon plates, which are part of the UL Listing of the sprinkler assembly, could allow heat and smoke to effect other areas of the building. This could cause harm to the patients.

Based on observation the facility failed to mount a fire extinguishers below the maximum height.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.5.6, "Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1. Section 9.7.4.1, "Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed in accordance with NFPA 10 Standard for the Installation of Portable Fire Extinguishers." NFPA 10,Chapter 1,Section 1-6.10. "Fire extinguishers having a gross weight not exceeding 40 lbs. shall be installed so that the top of the fire extinguisher is not more than 5 ft. above the floor. Fire extinguishers having a gross weight greater that 40 lbs. shall be so installed that the top of the fire extinguisher is not more than 3 ½ ft. above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 inches."

Findings Include:

On February 11, 2014, the surveyors, accompanied by the Chief Financial Officer, Peoples Choice, Director of Maintenance and staff members, observed the following wall mounted fire extinguisher. The top of the extinguishers are mounted more than sixty inches above the floor:

1. Patient linen closet, extinguisher measured sixty one inches;
2. OR, extinguisher greater than sixty inches; and
3. Pharmacy, measured sixty four and one half inches.

On February 11, 2014 the above findings were again acknowledged by the Chief Executive Officer/ Chief Financial Officer.

Failing to mount fire extinguishers at the correct height will cause removal problems and may cause injuries to Patients and Staff.

Based on observation the facility failed to provide noncombustible ashtrays of safe design; and the facility failed to provide self-closing metal containers in all designated smoking areas.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.7.4. "Smoking regulations shall be adopted and shall include not less than the following provisions:
(3) "Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted."
(4) "Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted."

Findings include:

On February 11, 2014, the surveyors, accompanied by the Chief Financial Officer, Peoples Choice, Director of Maintenance and staff members, observed the designated smoking area. No ashtrays of safe design were provided in the area. The smoking area does not have self-closing metal containers, which ashtrays can be emptied into.

On February 11, 2014 the above findings were again acknowledged by the Chief Executive Officer/ Chief Financial Officer.

Failure to provide metal containers for the disposal of cigarette butts could result in a fire which could cause harm to patients.

Based on Record review and Observation the kitchen hood was not cleaned or inspected in accordance with NFPA 96.

NFPA 101 Life Safety Code, 2000 Edition, Chapter 19, Section 19.3.2.6, "Cooking Facilities." "Cooking facilities shall be protected in accordance with 9.2.3." Section 9.2.3, "Commercial Cooking Equipment" "Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.... Chapter 8, Section 8-3 "Cleaning" "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. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person (s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1." Table 8-3.1, Exhaust System Inspection Schedule "Type or Volume of Cooking Frequency" "Systems serving moderate-volume cooking operations." Frequency is Semiannually"
Section 8-3.1.1 "Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified, and certified company or person (s) acceptable to the authority having jurisdiction in accordance with Section 8-3."
Section 8-3.1.2 "When a vent cleaning service is used, a certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company. It shall also indicate areas not cleaned."

Findings Include:

On February 11, 2014, the surveyors, accompanied by the Chief Financial Officer, Peoples Choice, Director of Maintenance and staff members, observed the kitchen hood cleaning label. The label was not readable. The facility was unable to provide documented evidence that the cooking hood and vents were inspected and cleaned in accordance with NFPA 96.

On February 11, 2014 the above findings were again acknowledged by the Chief Executive Officer/ Chief Financial Officer.

Failing to inspect and clean the kitchen hood and vents will allow a build-up of grease and provide fuel for a fire. A fire in the kitchen may cause harm to patients and staff.

Based on observation the facility allowed the use of a portable space heater.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.7.8" Portable space heating shall be prohibited in all health care occupancies."
Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212 Degrees F.

Findings include:

On February 11, 2014, the surveyors, accompanied by the Chief Financial Officer, Peoples Choice, Director of Maintenance and staff members, observed portable space heaters in the following areas:

1. Physical Therapy, space heater no tip off or temperature rating;
2. Room 119, space heater no tip off, no temperature rating, and plugged into a power strip; and
3. Room 140, space heater no tip off, no temperature rating, and plugged into an extension cord.

On February 11, 2014 the above findings were again acknowledged by the Chief Executive Officer/ Chief Financial Officer.

Allowing the use of portable space heaters, close to combustibles, will cause a fire which will cause harm to the patients.

Based on Observation the facility failed to separate empty and full medical gas cylinders and provide a sign for medical gas cylinder and keep the oxygen bottles free of combustible materials.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.2.4. "Medical gas storage and administration areas shall be protected in Accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99, Chapter 4, Section 4-3.5.2.2 (a) (2) "If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

NFPA 101 Life Safety Code 2000, or Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99 Standard for Health Care Facilities"NFPA 99, Chapter 8, Section 8-3.1.11 "Storage Requirements" Section 8-3.1.11.2 "Storage of nonflammable gases less than 3000 cubic. feet.." (a) "Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. (c) "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by: (c) (2) A minimum distance of 5 ft. if the entire storage location is protected by an automatic sprinkler system..."

Findings Include:

On February 11, 2014, the surveyors, accompanied by the Chief Financial Officer, Peoples Choice, Director of Maintenance and staff members, observed the Patient linen closet has one E- O2 bottle stored with combustibles and flammables. The Respiratory Therapy storage room has two full E O2 bottles and on empty E- O2 bottle not marked, FULL/EMPTY or segregated and within five feet of combustibles and an electrical light switch and outlets.

On February 11, 2014 the above findings were again acknowledged by the Chief Executive Officer/ Chief Financial Officer.

Leaking oxygen could penetrate combustible materials and create an extreme fire hazard, which could cause harm to the patients. In an emergency, patients could be harmed if an empty medical gas cylinder was mistakenly taken from the storage area.

Based on observation the facility removed the emergency shower/eye wash.

NFPA 99, Health Care Facilities, Chapter 10, Section 10-6 "Emergency Shower." "Where the eyes or body of any person can be exposed to injurious corrosive materials, suitable fixed facilities for quick drenching of flushing of the eyes and body shall be provided within the work area for immediate emergency use....

Findings include:

On February 11, 2014, the surveyors, accompanied by the Chief Financial Officer, Peoples Choice, Director of Maintenance and staff members, observed the emergency eye wash and shower station. The emergency shower had been removed from the Laboratory

On February 11, 2014 the above findings were again acknowledged by the Chief Executive Officer/ Chief Financial Officer.

Failing to provide an emergency shower within the work place will cause harm to Staff if a spill should occur.

Based on record review and observation 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 11, 2014, the surveyors, accompanied by the Chief Financial Officer, Peoples Choice, Director of Maintenance and staff members reviewed the generator test records. No documentation of monthly transfer tests (10 seconds or less) from normal power to emergency power was documented for: May, July, August, September, October, November and December 2013.

On February 11, 2014 the above findings were again acknowledged by the Chief Executive Officer/ Chief Financial Officer.

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

Based on observation the facility failed to provide protection from electrical shock; failed to provide a guard on the light bulb; failed to provide receptacle face plates; and allowed the use of a multiple outlet adapters, power strips and did not use the wall outlet receptacles for appliances.

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 110-12 (a) Unused Openings. "Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment."
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.
NEC, 1999, Article 410, Section 410-56 (e) Position of Receptacle Faces. "3. After installation, receptacle faces shall be flush with or project from faceplate of insulating material and shall project a minimum of 0.015 in. From metal faceplate. Faceplate shall be installed so as to completely cover the opening and seat against the mounting surface."
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 11, 2014, the surveyors, accompanied by the Chief Financial Officer, Peoples Choice, Director of Maintenance and staff members observed the following:

1. Smoke barrier by room 3209, J-Box no cover;
2. Room 3204, light no cover;
3. Clinic storage across from room 112, no light cover;
4. Panel 2PW, exposed energized electrical at bottom of circuit panel;
5. Smoke barrier by Triage and Clinic, J-Box no cover;
6. North door by Chapel, J-Box no cover;
7. Acute break room, refrigerator plugged into a power strip;
8. Physical Therapy, light no cover;
9. Pt. utility room, light no cover;
10. Pt. med room, no light cover;
11. Respiratory Therapy oxygen storage, outlet cover broken;
12. Basement, eight light units, no covers;
13. Room 122, and 123 no light covers;
14. Medical records, nine of nine lights, no covers;
15. Housekeeping, microwave plugged into a power strip; and
16. Radiology Storage, sixteen lights no covers.

On February 11, 2014 the above findings were again acknowledged by the Chief Executive Officer/ Chief Financial Officer.

Failing to protect energized electrical equipment or wiring can cause a shock or fire. A fire could cause harm to the patient.
Failure to keep light guards on the light could cause accidental damage or possibly a fire, which could cause harm to the patients.
Failing to repair broken receptacles and face plates may contribute to starting a fire by allowing the electrical wiring to short when an electrical appliance is plugged in or removed from the receptacle. A fire in the facility may cause harm to the patients.
The use of multiple outlet adapters could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.