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Based on record review and interview with the Chief Operating Officer it was determined there was no records, documentation available on site for review of testing of the battery backup emergency lights for the 1/1/2 hour 90 minute test of the hospital battery back up emergency lighting units.

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 7.9.3 " Periodic Testing of Emergency Lighting Equipment" " Section 7.9.3.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows: (1) Functional Testing shall be conducted monthly with a mininum of 3 weeks and a maximum of 5 weeks between tests., for not less than 30 seconds except as otherwise permitted by 7.9.3.1.1.(2) The Test interval shall be permitted to be extended beyond 30 days with the approval of authority having jurisdiction.(3) Functional testing shall be conducted annually for a minimum of 1/1/2 hours if the emergency lighting system is battery powered. (4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1 (1) and (3). (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings include:

On December 20, 2016 after reviewing the documentation for the battery backup emergency lights for the hospital there was no recorded written 90 minute 1/1/2 hour tests conducted from September of 2015 to September of 2016.

During the exit conference on December 20, 2016 the above findings were again acknowledged by the Chief Operating Officer and Support Services Manager

Failing to test and document battery backup emergency lighting units for the hospital could cause harm to the patients in an emergency power outage.

Based on observation it was determined the facility failed to maintain one illuminated exit sign in the nurses storeroom.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.2.10, Section 19.2.10.1 " Means of egress shall have signs in accordance with Section 7.10."Section 7.10.5.1, "Every sign required by 7.10.1.2 or 7.10.1.5 or 7.10.8.1 other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode...."

Findings include:

On December 20, 2016 the surveyor, accompanied by the Maintenance Technicians observed the exit sign in the nurses storeroom. Both light bulbs were burnt out in the exit light at the time of observation.

During the exit conference on December 20, 2016 the above findings were again acknowledged by the Chief Operating Officer and Support Services Manager.

Failing to maintain the illuminated exit sign could cause harm to the residents in time of a fire or emergency.

Based on observation it was determined the facility failed to maintain an ABC fire extinguisher from being blocked and readily accessible in the physical therapy area of the hospital.

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, inspected, and maintained in accordance with NFPA 10, Standard for portable Fire Extinguishers." NFPA 10, Chapter 7, Section 7.2.2 Periodic inspections or electronic monitoring of fire extinguishers shall include a check of at least the following items:

(2) No obstruction to access or visibility."

Findings include:

On December 20, 2016 the surveyor accompanied by the Maintenance Technicians, observed the ABC fire extinguisher located in the Physical Therapy exit access corridor area of the hospital was being blocked by the parallel bars/equipment.

During the exit conference on December 20, 2016 the above findings were again acknowledged by the Chief Operating Officer and the Support Services Manager.

Failing to have the ABC fire extinguisher readily available for an emergency could result in harm to the patients.

Based on observation it was determined the facility failed to maintain several corridor doors within the main hospital.

NFPA 101, Life Safety Code, 2012 Edition, Chapter 19, Section 19.3.6.3.5. "Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction. (1) The device used shall be capable of keeping the door fully closed if a force of 5lbs is applied at the latch edge of the door. Section 19.3.6.3.10 Doors shall not be held open by devices other than those that release when the door is pushed or pulled.
Section A.19.3.6.3.10 Doors should not be blocked open by furniture, door stops, chocks, tie backs drop down or plunger-type devices or other devices that necessitate manual unlatching or releasing action to close...."

Findings Include:

On December 20, 2016 the surveyor accompanied by the Maintenance Technicians observed the following rated corridor doors would not close and latch, had impediments holding the corridor doors open which are on door closures or the doors were not smoke resistant.

1. 1/1/2 half hour doors located by the doctors sleep rooms.
2. Kitchen dry food storage room
3. Mechanical room metal smoke seal torn
4. Three hour doors between the main hospital and General Services
5. Emergency Department Counseling room.
6. Emergency Department Clean linen room
7. Emergency Department Soiled Utilities

During the exit conference on December 20, 2016 the above findings were again acknowledged by the Chief Operating Officer and the Support Services Manager.

Failing to maintain corridor doors from latching, being propped open from heat or smoke could cause harm to the resident and staff in time of a fire.

Based on observation it was determined the facility failed to fill penetrations in two of two smoke barriers in entire main hospital.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of at least ½ hour." Chapter 8, Section 8.5.6.2 Penetrations for cables cable trays, conduits, pipes, tubes, vents wires and similar items to accommodate electrical, plumbing and communications systems that pass through a wall, floor or /ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof /ceiling of a smoke barrier assembly shall be protected by a system or material capable of restricting the transfer of smoke.

Findings include:

On December 20, 2016 the surveyor, accompanied by the Maintenance Technicians observed unsealed penetrations, holes where blue wires went through both sides of two smoke barriers located by the Atrium and the Obstetrics locations of the hospital.

During the exit conference on December 20, 2016 the above findings were again acknowledged by the Chief Operating Officer and Support Services Manager.

Failing to the penetrations, holes in the smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility which could cause harm to the patients in time of a fire.

Based on observation it was determined the facility failed to provide a protective guard on light bulbs located in the Central Sterile room.

NFPA 101 Life Safety Code, 2012, 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, 2011 Edition, "National Electrical Code." NEC, 2011, Article 110, 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...."

Findings include:

On December 20, 2016 the surveyor, accompanied by the Maintenance Technicians observed exposed light bulbs with no protective guards on the light bulbs in the following locations:

1. Central Sterile.

During the exit conference on December 20, 2016 the above findings were again acknowledged by the Chief Operating Officer and the Support Services Manager.

Failure to keep light guards on the light bulbs could cause accidental damage or possibly a fire, which could cause harm to the patients.

Based on observation it was determined the facility did not allow access to electrical panels in the obstetrics storage room.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.5.1.1 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, 2011 Edition, "National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction." NEC, 2011 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)"

Findings include:

On December 20, 2016 the surveyor accompanied by the Maintenance Technicians observed a vacuum pump and cart blocking the electrical panel in the obstetrics storage room.

During the exit conference on December 20, 2016 the above findings were again acknowledged by the Chief Operating Officer and Support Services Manager.

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.

Based on interview with the Chief Operation Officer it was determined the facility did not provide a patient smoking policy for the hospital for the surveyor to review during the survey.

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:

Smoking Regulations:

Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 19.7.4 (3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
18.7.4, 19.7.4"

Findings include:

On December 20, 2016 the surveyor asked for the hospital smoking policy for patients. The surveyor was advised there was no written policy available for review.

During the exit conference on December 20, 2016 the above findings were again acknowledged by the Chief Operating Officer and the Suport Services Manager.

Failure to have a patient smoking policy for review could result in harm to the patients if the patients have to be supervised while smoking.

Based on observation it was determined the facility 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, 2012. 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, " 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , "All Patient Care Areas," Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) 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 December 20, 2016 the surveyor, accompanied by the Maintenance Technicians observed a microwave plugged into a power strip in the Nursing Administration area, and not directly plugged into the receptacle wall outlets.

In addition: two power strips were connected together as one; these were being daisy chained from the wall receptacle outlet which was then connected to the bed in the operating room.

In addition: two receptacle cover plates were observed to be cracked/broken in the nurses storeroom.

During the exit conference on December 20, 2016 the above findings were again acknowledged by the Chief Operating Officer and Support Services Manager.

The use of multiple outlet adapters or daisy chaining power strips together 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 the five feet clear for combustibles for oxygen cylinders and mark the oxygen cylinders empty or full.

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 2012 Edition Chapter 11 Cylinder and Container storage Requirements.

Section 11.3.2 Storage for nonflammable gases greater than 8.5. m (300 cubic ft) but less than 3000 cubic feet, at STP shall comply with requirements in 11.3.2.1 through 11.3.2.3 . Section 11.3.2.3 Mininum distance of 1.5 m (5ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of sprinkler systems. Section 11.6.5. Special Precautions Section 11.6.5.3 Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner.

Findings include:

On December 20, 2016 the surveyor accompanied by the Maintenance Technicians observed full and empty oxygen cylinders stored in the Respiratory Equipment room had respiratory equipment etc: within the 5 feet of the oxygen cylinders; and the emergency department oxygen storage room had full and empty oxygen cylinders not marked. There were no posted sign indicating empty or full oxygen cylinders.

During the exit conference on December 20, 2016 the above findings were again acknowledged by the Chief Operating Officer and Support Services Manager.

Failing to secure compressed medical gas cylinders could cause harm to the patients and staff.