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Based on observation and staff interview, it was determined that the facility failed to protect hazardous areas with one hour fire rated construction.

Findings were:

During a tour of the facility with staff M on 12/07/2010 at 9:30 a.m. observation revealed the one hour wall to the lobby did not have a 3/4 hour fire rated door, the service window was not of one hour construction, and there were electrical penetrations in the one hour wall.

These findings were confirmed by staff M at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to provide emergency lighting of at least one and one half hour duration.

Findings were:

During a tour of the facility with staff M on 12/08/2010 at 12:45 p.m., it was observed that the facility failed to provide exterior emergency lighting from the 3 exits to the public way.

During a review of facility records with staff M on 12/08/2010 at 1:00 p.m., it was observed that the facility failed to annually test the emergency lighting batteries for 90 minutes.

These findings were confirmed by staff M at the exit interview.

Based on observation and staff interview, it was determined that the facility failed to provide emergency lighting of at least one and one half hour duration.

Findings were:

During a tour of the facility with staff M on 12/08/2010 from 9:00 a.m. to 1:00 p.m., observation revealed the facility failed to provide exterior emergency lighting from the exit to the public way at the 400 hall exit, the Speciality Center exit, the outpatient exit, and the exit from respiratory.

These locations were confirmed by staff M at the exit interview.

Based on observation and staff interview, it was determined that the facility personnel in charge of fire drills failed to properly document the events.

Findings were:

During a review of facility records with staff M on 12/08/2010 at 1:00 p.m., observation revealed that the documentation of fire drills did not contain all the required information in a manner easily recognized by a outside observer. Such items as time of drill, location of alarm, shift drill was taking place, how drill was started, and if outside agencies were involved were some of the items hard to find in the documentation.

These findings were confirmed by staff M at the time of discovery.

Based on observation and staff interview, it was determined that the 2 fire sprinkler systems in the facility were not being maintained in accordance with NFPA 25, the Standard for Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

Findings were:

During a tour of the facility with staff M on 12/08/2010 from 9:00 a.m. to 1:00 p.m., observation revealed that the 2 fire sprinkler systems were yellow tagged by a licensed fire sprinkler company. The fire sprinkler system in the lab was yellow tagged due to paint being on 2 of the sprinkler heads. The fire sprinkler system located in material management was yellow tagged due to 3 upright sprinkler heads installed where pendent sprinkler heads were required.

These findings were confirmed by staff M at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to test the fire sprinkler system in accordance with NFPA 25.

Findings were:

During a review of facility records with staff M on 12/08/2010 at 1:00 p.m., observation revealed that the facility failed to test and document the testing of the fire sprinkler system alarm devices on a quarterly basis as required by NFPA 25.

This finding was confirmed by staff M at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to maintain the fire extinguishers in accordance with NFPA 10.

Findings were:

During a tour of the facility with staff M on 12/08/2010 at 11:15 a.m., observation revealed that a use placard was not posted at the K class fire extinguisher in the kitchen.

This finding was confirmed by staff M at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to properly ventilate the equipment.

Findings were:

During a tour of the facility with staff M on 12/08/2010 at 11:30 a.m., observation revealed that the clothes dryer in the laundry room was ventilated to the outside with plastic exhaust duct.

This finding was confirmed by staff M at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to maintain the cooking facilities in accordance with NFPA 96.

Findings were:

During a tour of the facility with Staff M on 12/08/2010 at 11:00 a.m., observation revealed that the exhaust fan outlet for the NFPA 96 commercial hood was a downblast fan.

This finding was confirmed by staff M at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to maintain the medical gas storage in accordance with NFPA 99, Standards for Health Care Facilities.

Findings were:

During a tour of the facility with staff M on 12/08/2010 at 11:15 a.m., it was observed that the facility's emergency oxygen reserve manifold was located at the bulk storage tank and that there was not an Emergency Oxygen Supply Connection (EOSC) on the outside of the facility.

This finding was confirmed by the staff at the exit interview.

Based on observation and staff interview, it was determined that not all electrical wiring was in compliance with NFPA 70, The National Electrical Code.

Findings were:

During a tour of the facility with staff M on 12/08/2010 from 9:00 a.m. to 1:00 p.m., it was observed that surge protectors in the business office and the speciality center were being used as fixed wiring and were not mounted off the floor to protect from physical damage.

These findings were confirmed by staff M at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to protect hazardous areas with one hour fire rated construction.

Findings were:

During a tour of the facility with staff M on 12/07/2010 at 9:30 a.m. observation revealed the one hour wall to the lobby did not have a 3/4 hour fire rated door, the service window was not of one hour construction, and there were electrical penetrations in the one hour wall.

These findings were confirmed by staff M at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to provide emergency lighting of at least one and one half hour duration.

Findings were:

During a tour of the facility with staff M on 12/08/2010 at 12:45 p.m., it was observed that the facility failed to provide exterior emergency lighting from the 3 exits to the public way.

During a review of facility records with staff M on 12/08/2010 at 1:00 p.m., it was observed that the facility failed to annually test the emergency lighting batteries for 90 minutes.

These findings were confirmed by staff M at the exit interview.

Based on observation and staff interview, it was determined that the facility failed to provide emergency lighting of at least one and one half hour duration.

Findings were:

During a tour of the facility with staff M on 12/08/2010 from 9:00 a.m. to 1:00 p.m., observation revealed the facility failed to provide exterior emergency lighting from the exit to the public way at the 400 hall exit, the Speciality Center exit, the outpatient exit, and the exit from respiratory.

These locations were confirmed by staff M at the exit interview.

Based on observation and staff interview, it was determined that the facility personnel in charge of fire drills failed to properly document the events.

Findings were:

During a review of facility records with staff M on 12/08/2010 at 1:00 p.m., observation revealed that the documentation of fire drills did not contain all the required information in a manner easily recognized by a outside observer. Such items as time of drill, location of alarm, shift drill was taking place, how drill was started, and if outside agencies were involved were some of the items hard to find in the documentation.

These findings were confirmed by staff M at the time of discovery.

Based on observation and staff interview, it was determined that the 2 fire sprinkler systems in the facility were not being maintained in accordance with NFPA 25, the Standard for Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

Findings were:

During a tour of the facility with staff M on 12/08/2010 from 9:00 a.m. to 1:00 p.m., observation revealed that the 2 fire sprinkler systems were yellow tagged by a licensed fire sprinkler company. The fire sprinkler system in the lab was yellow tagged due to paint being on 2 of the sprinkler heads. The fire sprinkler system located in material management was yellow tagged due to 3 upright sprinkler heads installed where pendent sprinkler heads were required.

These findings were confirmed by staff M at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to test the fire sprinkler system in accordance with NFPA 25.

Findings were:

During a review of facility records with staff M on 12/08/2010 at 1:00 p.m., observation revealed that the facility failed to test and document the testing of the fire sprinkler system alarm devices on a quarterly basis as required by NFPA 25.

This finding was confirmed by staff M at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to maintain the fire extinguishers in accordance with NFPA 10.

Findings were:

During a tour of the facility with staff M on 12/08/2010 at 11:15 a.m., observation revealed that a use placard was not posted at the K class fire extinguisher in the kitchen.

This finding was confirmed by staff M at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to properly ventilate the equipment.

Findings were:

During a tour of the facility with staff M on 12/08/2010 at 11:30 a.m., observation revealed that the clothes dryer in the laundry room was ventilated to the outside with plastic exhaust duct.

This finding was confirmed by staff M at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to maintain the cooking facilities in accordance with NFPA 96.

Findings were:

During a tour of the facility with Staff M on 12/08/2010 at 11:00 a.m., observation revealed that the exhaust fan outlet for the NFPA 96 commercial hood was a downblast fan.

This finding was confirmed by staff M at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to maintain the medical gas storage in accordance with NFPA 99, Standards for Health Care Facilities.

Findings were:

During a tour of the facility with staff M on 12/08/2010 at 11:15 a.m., it was observed that the facility's emergency oxygen reserve manifold was located at the bulk storage tank and that there was not an Emergency Oxygen Supply Connection (EOSC) on the outside of the facility.

This finding was confirmed by the staff at the exit interview.

Based on observation and staff interview, it was determined that not all electrical wiring was in compliance with NFPA 70, The National Electrical Code.

Findings were:

During a tour of the facility with staff M on 12/08/2010 from 9:00 a.m. to 1:00 p.m., it was observed that surge protectors in the business office and the speciality center were being used as fixed wiring and were not mounted off the floor to protect from physical damage.

These findings were confirmed by staff M at the time of discovery.