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Based on observation it was determined 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 November 2nd and 3rd 2015 surveyor, accompanied by the Plant Operations Manager observed the following doors:

1. OB Room 116, the door was tested three of three times and would not positively latch.
2. OR 1, door was tested three of three times and would not positively latch.
3. The Medical Assistant office door in ED has a closing device and was impeded by a door wedge and would not close.

During the exit conference on November 3, 2015, the above findings were again acknowledged by the CEO, CFO, CNO, Assistant Administrator and the Plant Operations Manager.

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

Based on observation it was determined the facility failed to maintain doors or automatic closing devices in hazardous areas.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.2.2.2.6. "Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure ( not in 19 except boiler rooms, heater rooms and mechanical equipment rooms) shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility..."
Chapter 7, Section 7.2.1.8.1 " A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2..." (See (1) through (5) )

On November 2nd and 3rd 2015 surveyor, accompanied by the Plant Operations Manager observed the following hazardous area doors:

1. OR Housekeeping storage room C-45. The door was tested three of three times and would not positively latch.
2. B 103 Housekeeping storage room containing chemicals does not have a door closing device.
3. Kitchen chemicals storage room has double doors with no door closing device.

During the exit conference on November 3, 2015, the above findings were again acknowledged by the CEO, CFO, CNO, Assistant Administrator and the Plant Operations Manager.

In a fire doors that are not closed or will not close automatically will allow smoke and heat to
spread throughout the facility which will cause harm to the residents/patients.

Based on document review and staff interview it was determined 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 November 2, 2015 surveyor, accompanied by the Plant Operations Manager reviewed the Fire Drill Documentation from October 24, 2014 thru July 29, 2015. The second shift Fire Drill documentation for first, second, third and forth quarters did not include a coded announcement or the use of audible alarms. The fire drill documentation did not include the evacuation of immediate area, isolation of the fire, preparation of the floors for evacuation or the extinguishment of the fire.

During the exit conference on November 3, 2015, the above findings were again acknowledged by the CEO, CFO, CNO, Assistant Administrator and the Plant Operations Manager.

Failure to train and drill the staff on fire procedures will result in harm to the residents/patients.

Based on observation it was determined the facility failed to assure that all parts of the facility were provided sprinkler system coverage.

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." Chapter 9, Section 9.7.1.1, " Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems." Chapter 5, Section 5-5.6, " The clearance between the deflector and the top of storage shall be 18 in. or greater."

Findings include:

On November 2nd and 3rd, 2015 the surveyor, accompanied by the Plant Operations Manager observed storage less than 18 inches of the sprinkler deflector in the ED storage closet.

During the exit conference on November 3, 2015, the above findings were again acknowledged by the CEO, CFO, CNO, Assistant Administrator and the Plant Operations Manager.

The blocking of sprinkler water from getting to the seat of a fire could result in injury to
residents/patients.

Based on observation and staff interview it was determined the facility failed to clean the kitchen exhaust hood system, filters and grease drip tray.

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 November 3, 2015 the surveyor, accompanied by the Plant Operations Manager and the Dietary Manager observed the kitchen filters above the grill and the cook top. Eight of twelve filters have a coating of excessive grease buildup.

The staff member interviewed stated the filters are cleaned one time a week.

During the exit conference on November 3, 2015, the above findings were again acknowledged by the CEO, CFO, CNO, Assistant Administrator and the Plant Operations Manager.

Failing to keep the entire kitchen exhaust hood system clean from grease could cause a delay in the fire suppression system to activate which could cause more damage to the kitchen and could cause harm to the residents.

Based on observation and testing it was determined 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 November 3, 2015 the surveyor, accompanied by the Plant Operations Manager observed a portable space heater in the Clinical Information office. The office was not occupied and the space heater did not have a tip off switch. The floor covering was carpet.

During the exit conference on November 3, 2015, the above findings were again acknowledged by the CEO, CFO, CNO, Assistant Administrator and the Plant Operations Manager.

The use of portable space heaters close to combustibles will cause a fire which could cause harm to the residents/patients.

Based on policy review it was determined the facility failed to have a written copy of Emergency procedures.

NFPA 101, Life Safety Code, 2000 edition, Chapter 19, Section 19.3.2.2 "Laboratories." "Laboratories employing quantities of flammable, combustible, or hazardous materials that are considered as a severe hazard shall be protected in accordance with NFPA 99, Standard for Health Care Facilities."

NFPA 99, Chapter 10, Section 10-2.1.3, "Emergency Procedures" Section 10-2.1.3.1 "Procedures for laboratory emergencies shall be developed. Such procedures shall include...Equipment Shutdown Procedures...10-2.1.3.2 Emergency procedures shall be established for controlling chemical spills...."

Findings Include:

On November 2, 2015, the surveyor accompanied by the Plant Operations Manager and the Laboratory Supervisor asked to review the emergency procedures for the laboratory. No written procedures or on-line procedures were found. The surveyor requested the chemical spill kit. The spill kit could not be located.

During the exit conference on November 3, 2015, the above findings were again acknowledged by the CEO, CFO, CNO, Assistant Administrator and the Plant Operations Manager.

Failing to have emergency procedures and an emergency spill kit during and emergency could injure staff and damage laboratory equipment

Based on observation it was determined the facility removed the Emergency shower from the last survey on May 11, 2011.

NFPA 101, Life Safety Code, 2000 edition, Chapter 19, Section 19.3.2.2 "Laboratories." "Laboratories employing quantities of flammable, combustible, or hazardous materials that are considered as a severe hazard shall be protected in accordance with NFPA 99, Standard for Health Care Facilities."
Chapter 10-6 Emergency Shower. Where the eyes or body of any person can be exposed to injurious materials, suitable fixed facilities for quick drenching or flushing of the eyes and body shall be provided within the work area for immediate emergency use. Fixed eye baths shall be designed and installed to avoid injurious water pressure...."

Findings Include:

On November 2, 2015, the surveyor accompanied by the Plant Operations Manager and the Laboratory Supervisor observed that the Emergency Shower was removed.

During the exit conference on November 3, 2015, the above findings were again acknowledged by the CEO, CFO, CNO, Assistant Administrator and the Plant Operations Manager.

Failing to have emergency shower in the time of exposure to hazardous chemicals could injure staff.

Based on observation the facility failed to maintain the batteries 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 3-6.4.1.1 (b) 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. 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...."

Findings include:

On November 3, 2015 the surveyor, accompanied by the Plant Operations Manager observed the two batteries have corrosion on four of four battery terminals.

During the exit conference on November 3, 2015, the above findings were again acknowledged by the CEO, CFO, CNO, Assistant Administrator and the Plant Operations Manager.

Failure to inspect the emergency generator for fluid levels and general condition could result in harm to patients and staff during lighting system failures.

Based on observation it was determined the facility allowed the use of a multiple outlet adapter, power strips and did not use the wall outlet receptacles for appliances.

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 November 3, 2015 the surveyor, accompanied by the Plant Operations Manager observed refrigerators, microwave and toaster ovens plugged into multi-outlet power strips and not directly plugged in to the wall outlet receptacles in the following rooms:

1. OR microwave plugged into a power strip.
2. Pharmacy has a hanging power strip with a microwave, refrigerator and a toaster oven plugged in.
3. Employee education office has a refrigerator plugged into a power strip.
4. Quality office has a refrigerator plugged into a power strip.

During the exit conference on November 3, 2015, the above findings were again acknowledged by the CEO, CFO, CNO, Assistant Administrator and the Plant Operations Manager.

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.

Based on observation it was determined 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 November 2nd and 3rd 2015 surveyor, accompanied by the Plant Operations Manager observed the following doors:

1. OB Room 116, the door was tested three of three times and would not positively latch.
2. OR 1, door was tested three of three times and would not positively latch.
3. The Medical Assistant office door in ED has a closing device and was impeded by a door wedge and would not close.

During the exit conference on November 3, 2015, the above findings were again acknowledged by the CEO, CFO, CNO, Assistant Administrator and the Plant Operations Manager.

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

Based on observation it was determined the facility failed to maintain doors or automatic closing devices in hazardous areas.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.2.2.2.6. "Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure ( not in 19 except boiler rooms, heater rooms and mechanical equipment rooms) shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility..."
Chapter 7, Section 7.2.1.8.1 " A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2..." (See (1) through (5) )

On November 2nd and 3rd 2015 surveyor, accompanied by the Plant Operations Manager observed the following hazardous area doors:

1. OR Housekeeping storage room C-45. The door was tested three of three times and would not positively latch.
2. B 103 Housekeeping storage room containing chemicals does not have a door closing device.
3. Kitchen chemicals storage room has double doors with no door closing device.

During the exit conference on November 3, 2015, the above findings were again acknowledged by the CEO, CFO, CNO, Assistant Administrator and the Plant Operations Manager.

In a fire doors that are not closed or will not close automatically will allow smoke and heat to
spread throughout the facility which will cause harm to the residents/patients.

Based on document review and staff interview it was determined 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 November 2, 2015 surveyor, accompanied by the Plant Operations Manager reviewed the Fire Drill Documentation from October 24, 2014 thru July 29, 2015. The second shift Fire Drill documentation for first, second, third and forth quarters did not include a coded announcement or the use of audible alarms. The fire drill documentation did not include the evacuation of immediate area, isolation of the fire, preparation of the floors for evacuation or the extinguishment of the fire.

During the exit conference on November 3, 2015, the above findings were again acknowledged by the CEO, CFO, CNO, Assistant Administrator and the Plant Operations Manager.

Failure to train and drill the staff on fire procedures will result in harm to the residents/patients.

Based on observation it was determined the facility failed to assure that all parts of the facility were provided sprinkler system coverage.

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." Chapter 9, Section 9.7.1.1, " Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems." Chapter 5, Section 5-5.6, " The clearance between the deflector and the top of storage shall be 18 in. or greater."

Findings include:

On November 2nd and 3rd, 2015 the surveyor, accompanied by the Plant Operations Manager observed storage less than 18 inches of the sprinkler deflector in the ED storage closet.

During the exit conference on November 3, 2015, the above findings were again acknowledged by the CEO, CFO, CNO, Assistant Administrator and the Plant Operations Manager.

The blocking of sprinkler water from getting to the seat of a fire could result in injury to
residents/patients.

Based on observation and staff interview it was determined the facility failed to clean the kitchen exhaust hood system, filters and grease drip tray.

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 November 3, 2015 the surveyor, accompanied by the Plant Operations Manager and the Dietary Manager observed the kitchen filters above the grill and the cook top. Eight of twelve filters have a coating of excessive grease buildup.

The staff member interviewed stated the filters are cleaned one time a week.

During the exit conference on November 3, 2015, the above findings were again acknowledged by the CEO, CFO, CNO, Assistant Administrator and the Plant Operations Manager.

Failing to keep the entire kitchen exhaust hood system clean from grease could cause a delay in the fire suppression system to activate which could cause more damage to the kitchen and could cause harm to the residents.

Based on observation and testing it was determined 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 November 3, 2015 the surveyor, accompanied by the Plant Operations Manager observed a portable space heater in the Clinical Information office. The office was not occupied and the space heater did not have a tip off switch. The floor covering was carpet.

During the exit conference on November 3, 2015, the above findings were again acknowledged by the CEO, CFO, CNO, Assistant Administrator and the Plant Operations Manager.

The use of portable space heaters close to combustibles will cause a fire which could cause harm to the residents/patients.

Based on observation it was determined the facility removed the Emergency shower from the last survey on May 11, 2011.

NFPA 101, Life Safety Code, 2000 edition, Chapter 19, Section 19.3.2.2 "Laboratories." "Laboratories employing quantities of flammable, combustible, or hazardous materials that are considered as a severe hazard shall be protected in accordance with NFPA 99, Standard for Health Care Facilities."
Chapter 10-6 Emergency Shower. Where the eyes or body of any person can be exposed to injurious materials, suitable fixed facilities for quick drenching or flushing of the eyes and body shall be provided within the work area for immediate emergency use. Fixed eye baths shall be designed and installed to avoid injurious water pressure...."

Findings Include:

On November 2, 2015, the surveyor accompanied by the Plant Operations Manager and the Laboratory Supervisor observed that the Emergency Shower was removed.

During the exit conference on November 3, 2015, the above findings were again acknowledged by the CEO, CFO, CNO, Assistant Administrator and the Plant Operations Manager.

Failing to have emergency shower in the time of exposure to hazardous chemicals could injure staff.

Based on observation the facility failed to maintain the batteries 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 3-6.4.1.1 (b) 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. 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...."

Findings include:

On November 3, 2015 the surveyor, accompanied by the Plant Operations Manager observed the two batteries have corrosion on four of four battery terminals.

During the exit conference on November 3, 2015, the above findings were again acknowledged by the CEO, CFO, CNO, Assistant Administrator and the Plant Operations Manager.

Failure to inspect the emergency generator for fluid levels and general condition could result in harm to patients and staff during lighting system failures.

Based on observation it was determined the facility allowed the use of a multiple outlet adapter, power strips and did not use the wall outlet receptacles for appliances.

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 November 3, 2015 the surveyor, accompanied by the Plant Operations Manager observed refrigerators, microwave and toaster ovens plugged into multi-outlet power strips and not directly plugged in to the wall outlet receptacles in the following rooms:

1. OR microwave plugged into a power strip.
2. Pharmacy has a hanging power strip with a microwave, refrigerator and a toaster oven plugged in.
3. Employee education office has a refrigerator plugged into a power strip.
4. Quality office has a refrigerator plugged into a power strip.

During the exit conference on November 3, 2015, the above findings were again acknowledged by the CEO, CFO, CNO, Assistant Administrator and the Plant Operations Manager.

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.