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Based on Observation and Record Review with the Lead Maintenance Tech and Support Services Manager the facility failed to test and document the Monthly thirty second test for one of three battery back up emergency lighting units located on the second floor, Business office.

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" " A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction."

Findings include:

On November 20, 2013 the surveyor accompanied by the Lead Maintenance Tech and Support Services Manager reviewed the battery backup emergency lighting documentation. The documentation did not include the September 2013 Monthly 30 second test for the three battery backup emergency lights in the Business office corridor.

During the exit conference on November 20, 2013 the above findings were again acknowledged by the Chief Executive Officer, Support Services Manager and Lead Maintenance Tech.

Failing to test document the emergency lighting units could cause harm to the staff and patients.

Based on Observation, Record Review and Interview with the Lead Maintenance Tech and Support Services Manager 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 20, 2013 the surveyor, accompanied by Lead Maintenance Tech and Support Services Manager reviewed the facility's fire drill records. The facility Lead Maintenance Tech advised the surveyor while reviewing the fire drills that they were conducting two twelve hour shifts for the hospital 7AM to 7 PM.

The surveyor was advised by the Lead Maintenance Tech while reviewing the fire drills for 2013 there was no fire drill documentation for the first quarter second shift. No documentation was shown or found during the survey to indicate the fire drill was completed.

The fire drill for the third quarter of 2013, second shift was annotated as a verbal fire drill. The documentation did not indicate the time of the fire drill or that the actual fire procedures were performed per the Life Safely Code.

"The Lead Maintenance Tech advised the surveyor during the review of the documentation and interview of the fire drill documentation he had only asked the staff member at the front desk what to do in case of a fire and no fire drill procedures was actually performed."

During the exit conference on November 20, 2013 the above findings were again acknowledged by the Chief Executive Officer, Support Services Manager and Lead Maintenance Tech.

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

Based on Observation with the Lead Maintenance Tech 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 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..." 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 November 20, 2013 the surveyor, accompanied by the Lead Maintenance Tech observed the following findings:

1. Nuclear Medicine Room one of one sprinklers had paint/texture on the sprinkler frame and the sprinkler was hanging down from the ceiling leaving a gap between the sprinkler and ceiling of approximately 1/2 inch.
2. The Business office Men's room one of one sprinklers was hanging down from the ceiling leaving a gap of approximately 1/2 inch between the ceiling and the sprinkler.
4. The Cat Scan room and Mammogram room one of one sprinklers was missing the Escutcheon plate for the sprinkler assembly.

During the exit conference on November 20, 2013 the above findings were again acknowledged by the Chief Executive Officer, Support Services Manager and Lead Maintenance Tech.

Failing to maintain sprinkler heads and replace 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 with the Lead Maintenance Tech the facility failed to secure one of one E type oxygen cylinders, one of one H tank helium cylinders and failed to maintain the five foot clearance from 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 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..."

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 8, Section 8-3.1.11.2 (3) (h) Cylinder or container restraint shall meet 4-3.5.2.1(b) (27)." Section 4-3.5.2.1(b)(27) "Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart."

Findings include:

On November 20, 2013 the surveyor, accompanied by the Lead Maintenance Tech observed the Physical Therapy Office had an H tank helium cylinder unsecured not in a stand or cart. The Acute Care Medical Supplies storage room had one E-type oxygen cylinder being stored within five feet of combustibles in the medical supplies storage room containing plastics and cardboard boxes and one of one E type oxygen cylinders was not secured in a stand or cart.

During the exit conference on November 20, 2013 the above findings were again acknowledged by the Chief Executive Officer, Support Services Manager and Lead Maintenance Tech.

Leaking oxygen will penetrate combustible material and create an extreme fire hazard, which could cause harm to the patients. Failing to secure compressed gas cylinders, which could be knocked over, will cause harm to residents and staff.

Based on Observation with the Lead Maintenance Tech the facility allowed the use of a multiple outlet adapters and an extension cord 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 20, 2013 the surveyors, accompanied by the Lead Maintenance Tech, observed the use of multiple outlet adapters in use for appliances, refrigerator, microwaves and an extension cord was observed in use in the following locations in the facility.

1. Business Office
2. Human Services Office
3. Infusion Room
4. Outpatient waiting room, extension cord.

During the exit conference on November 20, 2013 the above findings were again acknowledged by the Chief Executive Officer, Support Services Manager and Lead Maintenance Tech.

The use of multiple outlet adapters/extension cord 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 with the Lead Maintenance Tech the facility failed to allow access to electrical equipment/panels.

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)"

Findings include:

On November 20, 2013 the surveyor, accompanied by the Lead Maintenance Tech, observed the electrical panels in the Pharmacy and I/S main computer room had storage of trash buckets, a laptop computer and metal carts etc; placed directly in front of the two or three electrical panels in the rooms.

During the exit conference on November 20, 2013 the above findings were again acknowledged by the Chief Executive Officer, Support Services Manager and Lead Maintenance Tech.

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 Observation and Record Review with the Lead Maintenance Tech and Support Services Manager the facility failed to test and document the Monthly thirty second test for one of three battery back up emergency lighting units located on the second floor, Business office.

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" " A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction."

Findings include:

On November 20, 2013 the surveyor accompanied by the Lead Maintenance Tech and Support Services Manager reviewed the battery backup emergency lighting documentation. The documentation did not include the September 2013 Monthly 30 second test for the three battery backup emergency lights in the Business office corridor.

During the exit conference on November 20, 2013 the above findings were again acknowledged by the Chief Executive Officer, Support Services Manager and Lead Maintenance Tech.

Failing to test document the emergency lighting units could cause harm to the staff and patients.

Based on Observation, Record Review and Interview with the Lead Maintenance Tech and Support Services Manager 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 20, 2013 the surveyor, accompanied by Lead Maintenance Tech and Support Services Manager reviewed the facility's fire drill records. The facility Lead Maintenance Tech advised the surveyor while reviewing the fire drills that they were conducting two twelve hour shifts for the hospital 7AM to 7 PM.

The surveyor was advised by the Lead Maintenance Tech while reviewing the fire drills for 2013 there was no fire drill documentation for the first quarter second shift. No documentation was shown or found during the survey to indicate the fire drill was completed.

The fire drill for the third quarter of 2013, second shift was annotated as a verbal fire drill. The documentation did not indicate the time of the fire drill or that the actual fire procedures were performed per the Life Safely Code.

"The Lead Maintenance Tech advised the surveyor during the review of the documentation and interview of the fire drill documentation he had only asked the staff member at the front desk what to do in case of a fire and no fire drill procedures was actually performed."

During the exit conference on November 20, 2013 the above findings were again acknowledged by the Chief Executive Officer, Support Services Manager and Lead Maintenance Tech.

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

Based on Observation with the Lead Maintenance Tech 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 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..." 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 November 20, 2013 the surveyor, accompanied by the Lead Maintenance Tech observed the following findings:

1. Nuclear Medicine Room one of one sprinklers had paint/texture on the sprinkler frame and the sprinkler was hanging down from the ceiling leaving a gap between the sprinkler and ceiling of approximately 1/2 inch.
2. The Business office Men's room one of one sprinklers was hanging down from the ceiling leaving a gap of approximately 1/2 inch between the ceiling and the sprinkler.
4. The Cat Scan room and Mammogram room one of one sprinklers was missing the Escutcheon plate for the sprinkler assembly.

During the exit conference on November 20, 2013 the above findings were again acknowledged by the Chief Executive Officer, Support Services Manager and Lead Maintenance Tech.

Failing to maintain sprinkler heads and replace 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 with the Lead Maintenance Tech the facility failed to secure one of one E type oxygen cylinders, one of one H tank helium cylinders and failed to maintain the five foot clearance from 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 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..."

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 8, Section 8-3.1.11.2 (3) (h) Cylinder or container restraint shall meet 4-3.5.2.1(b) (27)." Section 4-3.5.2.1(b)(27) "Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart."

Findings include:

On November 20, 2013 the surveyor, accompanied by the Lead Maintenance Tech observed the Physical Therapy Office had an H tank helium cylinder unsecured not in a stand or cart. The Acute Care Medical Supplies storage room had one E-type oxygen cylinder being stored within five feet of combustibles in the medical supplies storage room containing plastics and cardboard boxes and one of one E type oxygen cylinders was not secured in a stand or cart.

During the exit conference on November 20, 2013 the above findings were again acknowledged by the Chief Executive Officer, Support Services Manager and Lead Maintenance Tech.

Leaking oxygen will penetrate combustible material and create an extreme fire hazard, which could cause harm to the patients. Failing to secure compressed gas cylinders, which could be knocked over, will cause harm to residents and staff.

Based on Observation with the Lead Maintenance Tech the facility allowed the use of a multiple outlet adapters and an extension cord 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 20, 2013 the surveyors, accompanied by the Lead Maintenance Tech, observed the use of multiple outlet adapters in use for appliances, refrigerator, microwaves and an extension cord was observed in use in the following locations in the facility.

1. Business Office
2. Human Services Office
3. Infusion Room
4. Outpatient waiting room, extension cord.

During the exit conference on November 20, 2013 the above findings were again acknowledged by the Chief Executive Officer, Support Services Manager and Lead Maintenance Tech.

The use of multiple outlet adapters/extension cord 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 with the Lead Maintenance Tech the facility failed to allow access to electrical equipment/panels.

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)"

Findings include:

On November 20, 2013 the surveyor, accompanied by the Lead Maintenance Tech, observed the electrical panels in the Pharmacy and I/S main computer room had storage of trash buckets, a laptop computer and metal carts etc; placed directly in front of the two or three electrical panels in the rooms.

During the exit conference on November 20, 2013 the above findings were again acknowledged by the Chief Executive Officer, Support Services Manager and Lead Maintenance Tech.

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.