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Based on facility tour observations and staff interview the facility failed to ensure smoke barriers were maintained without penetrations. This had the potential to affect all of those utilizing these areas of the facility. The patient census at the beginning of the survey was 33.

Findings include:

Facility tour took place on 11/19/13 with staff members B2 and C3. During tour in the area between Room 60 and a clean supply room on the first floor, observations were made of a conduit with blue and white wires with open space around the wires.

Observation on 11/19/13 of the east fire barrier in the health center revealed an unsealed sleeve with three flex conduits and wires passing through. This was verified by staff B2 and C3 at 4:39 PM on 11/19/13.






21521

On 11/19/13 at 1:48 P.M. observation was made of the drop down ceiling above the fire wall separating the medical surgical unit from a medical office building. A one inch conduit was observed to have an open lumen.On 11/19/13 at 1:48 P.M. Staff A1 confirmed the observation.

On 11/20/13 at 3:30 P.M. observation above the drop down ceiling of the 2 hour fire wall between the heart center and surgery area revealed three one inch pipes with annular spaces. On 11/20/13 at 3:30 P.M. in an interview Staff A1 confirmed the observation.

Based on observation and interview, the facility failed to ensure stairways between floors were enclosed with construction having a fire resistance rating of at least one hour. This has the potential to affect all patients and visitors in the facility. The census of the facility was 33 patients.

Findings:

On 11/19/13 at 3:58 P.M. observation of the door to a stairwell opposite the kitchen and lead up to the roof, revealed the door's rating could not be determined, and the door's self closer did not close the door completely. On 11/19/13 at 3:58 P.M. Staff A1 confirmed the observation.

Based on observations on tour and staff interview the facility failed to ensure all exit accesses were marked with visible signs in order to provide all occupants a readily available and safe access to exit discharges in the event of an emergency. This had the potential to affect all of those utilizing these areas of the facility. The patient census at the beginning of the survey was 33.

Findings include:

Facility tour took place on 11/19/13 with staff members B2 and C3. During tour in the obstetrics area in the east/ west corridor adjacent to the nurses' station observation was made of no exit signage directing occupant flow to the south double doors.

In the north/ south corridor on the west end of the obstetrics department observation was made of no exit signage directing occupant flow to the stairs, near obstetrics triage 1.

This was verified by staff B2 and C3 during tour on 11/19/13 at 4:27 PM.




21521

On 11/19/13 at 2:22 P.M. a fire evacuation plan posted on the eastern wing of the medical surgical department was reviewed. The review revealed a path of egress leading across a common area, down the western wing of the medical surgical department and out. Observation of this path of egress did not reveal an exit sign marking the path of egress noted in the evacuation plan.

On 11/19/13 at 2:22 P.M. Staff A1 confirmed the observation.

On 11/19/13 at 2:35 P.M. a fire evacuation plan posted on the western wing of the medical surgical department was reviewed. The review revealed a path of egress leading to a common area, then down a corridor that lead to the main entrance. Observation of this path of egress did not reveal an exit sign marking the path of egress noted in the evacuation plan.

On 11/19/13 at 2:35 P.M. Staff A1 confirmed the observation.

On 11/19/13 at 4:18 P.M. observation was made of the physical therapy treatment area. Observation within the treatment area revealed one exit; however, an exit sign was not observed.

On 11/19/13 at 4:18 P.M. Staff A1 confirmed the observation.

Based on observation and interview, the facility failed to maintain the construction rating of each barrier in each smoke compartment. This has the potential to affect all patients and visitors using the facility. The facility's census was 33 patients.

Findings:

On 11/19/13 at 2:06 P.M. observation was made of the drop down ceiling above the smoke barrier doors in the eastern most wing of the medical surgical unit. A one-inch conduit with a grey wire was observed to have an open lumen. On 11/19/13 at 2:06 P.M. Staff A1 confirmed the observation.

On 11/19/13 at 4:28 P.M. observation was made of the two hour fire doors north of the kitchen and across the main corridor. Review of the schematic confirmed the doors were to be two hour rated. The doors' rating could not be ascertained by observation. On 11/19/13 at 4:28 P.M. Staff A1 confirmed the observation.

On 11/20/13 at 9:06 A.M. observation above the drop down ceiling of the two hour fire rated wall in the corridor leading to the emergency department and near the elevator revealed two one inch conduits with their lumens open to air. On 11/20/13 at 9:06 A.M. Staff A1 confirmed the observation.

On 11/19/13 at 2:13 P.M. observation was made of storage room greater than 50 square feet in the eastern wing of the medical surgical unit. Review of the schematic on 11/19/13 revealed the north wall to have a two hour rating. Observation of the wall above the drop down ceiling at 2:13 P.M. revealed two one inch conduits with annular spaces. On 11/19/13 at 2:13 P.M. Staff A1 confirmed the observation.

On 11/19/13 at 2:26 P.M. observation was made above the drop down ceiling of the smoke barrier in the western wing of the medical surgical unit. Observation was made of a two inch conduit with a lumen open to air. On 11/19/13 at 2:26 P.M. Staff A1 confirmed the observation.

On 11/19/13 at 3:28 P.M. observation was made above the drop down ceiling of the two hour rated south wall that in part surrounded the kitchen. Observation was made of a conduit that traveled through the two hour wall and lead to a junction box with an open hole. On 11/19/13 at 3:28 P.M. Staff A1 confirmed the observation.

On 11/19/13 at 4:03 P.M. observation was made above the drop down ceiling of the two hour protective construction on the north side of the kitchen. Observation was made of a plumbing line that had a square annular space around it. On 11/19/13 at 4:03 P.M. Staff A1 confirmed the observation.

Based on observation and interview, the facility failed to maintain a one hour construction rating or an approved automatic fire extinguishing system to protect a hazardous area. This had the potential to affect all patients and visitors in the facility. The facility's census was 33 patients.

Findings:

On 11/19/13 at 2:13 P.M. observation was made of storage room greater than 50 square feet in eastern wing of the medical surgical unit. Within the room soiled lined bags were observed on a shelf, and a 450 cubic centimeter metallic bin for holding additional soiled linen was observed. Above the drop down ceiling that is above the door, two heating, ventilation and cooling conduits and two one inch conduits were all observed to have open annular spaces. On 11/19/13 at 2:13 P.M. Staff A1 confirmed the observation.

On 11/19/13 at 3:23 P.M. observation was made of the gift shop. Review of the schematic of the gift shop area revealed two areas surrounded by 2 hour protective construction. Observation revealed one to be an office area. That area's door was observed propped open by a kickstop and a self-closure. After the kickstop was de-activated, the door still did not close because of decorations hanging off the door.On 11/19/13 at 3:23 P.M. Staff A1 confirmed the observation.

On 11/19/13 at 3:23 P.M. observation was made of the gift shop. Review of the schematic of the gift shop area revealed two areas surrounded by 2 hour protective construction. Observation revealed one to be a storage area. That area's door was observed propped open by a kickstop and a self-closure. After the kickstop was de-activated, the door still did not close because of decorations hanging off the door.On 11/19/13 at 3:23 P.M. Staff A1 confirmed the observation.

On 11/19/13 at 4:08 P.M. observation was made of the door that lead to a mechanical space across from the north side of the kitchen. Review of the schematic revealed the space was surrounded by two hour fire protective construction. Observation of the door did not reveal what its rating was. On 11/19/13 at 4:08 P.M. Staff A1 confirmed the observation.

Based on observations on tour and staff interview the facility failed to ensure stairways were clear of possible obstruction. This had the potential to affect all of those utilizing these areas of the facility. The patient census at the beginning of the survey was 33.

Findings include:

Facility tour took place on 11/19/13 with staff members B2 and C3. Observations were made in a stairwell near the Mack Ivor entry at 4:00 PM on 11/19/13 of a metal cabinet and a plastic watering can on the top landing of the staircase. The finding was confirmed with staff B2 and C3.

Observations within a stairwell near the WOW/ Health Coaching office showed an exit stair landing with a metal cabinet labeled "education" and a plastic game wheel. The observation was confirmed with staff B2 and C3 at 5:00 PM on 11/20/13.

Based on observations on tour and staff interview the facility failed to ensure adequate illumination was provided at exterior exit discharges. This had the potential to affect all of those utilizing these areas of the facility. The patient census at the beginning of the survey was 33.

Findings include:

Tour of the hospital's exterior was conducted on 11/19/13 with staff members B2 and C3. During tour on the exterior of the hospital, observations were made of three exit discharges which lacked sufficient illumination in the following locations: Morey Center exit discharge, the cafe' exit discharge, and at the lab exit discharge at 1:52 PM. These findings were confirmed with staff B2 and C3.

Based on record review and staff interview the facility failed to ensure documentation of the fire alarm signal transmission when the pull station was activated. This had the potential to affect all of those utilizing these areas of the facility. The patient census at the beginning of the survey was 33.

Findings include:

On 11/20/13 at 4:30 PM fire drill documentation review revealed there was no recorded time of fire department receipt of signal. An interview with staff B2 at 4:45 pm confirmed the lack of verification of the transmission of the signal.

Based on observations on tour, record review, and staff interview the facility failed to ensure smoke detectors were not located too near airflow devices and were sensitivity tested as required. This had the potential to affect all of those utilizing these areas of the facility. The patient census at the beginning of the survey was 33.

Findings include:

Facility tour took place on 11/19/13 and 11/20/13 with staff members B2 and C3. During tour observations were made of smoke detectors located near airflow devices in the following locations:
1. Miracle L:ife Center in the west corridor
2. two smoke detectors within the basement corridor outside of mechanical room 2 and the information systems door.

On 11/20/13 during documentation review there was no documentation for the sensitivity testing of the detectors verified by staff B2 at 4:16 PM.

Based on observations on tour and staff interview the facility failed to ensure sprinkler heads were maintained in reliable operating condition. This had the potential to affect all of those utilizing these areas of the facility. The patient census at the beginning of the survey was 33.

Findings include:

Facility tour took place on 11/19/13 with staff members B2 and C3. During tour of the north south corridor across from ACC 16, heading toward the new obstetrics unit, observation was made of two sprinkler heads with bent deflectors that would not provide complete coverage if activiated. This observation was confirmed with staff B2 and C3 at 4:13 PM.





21521

On 11/19/13 at 3:38 P.M. a storage closet across from the kitchen was observed to have a box and artificial plants directly underneath a sprinkler head. On 11/19/13 at 3:38 P.M. Staff A1 confirmed the observation.

Based on observations and staff interview the facility failed to ensure that fire extinguishers were not mounted greater than five feet from the floor and were accessible without obstructions. This had the potential to affect all of those utilizing these areas of the facility. The patient census at the beginning of the survey was 33.

Findings include:

Facility tour took place on 11/20/13 with staff members B2 and C3. In the first floor medical gas room observation was made on 11/20/13 at 8:23 AM of a fire extinguisher obstructed by a two wheel cart and a medical gas stand. This observation was confirmed with staff B2 and C3.

During tour in the lower level at 9:56 AM two fire extinguishers were observed in the corridor, one near the coding office and one across from the employee health services office, mounted more than five feet from the floor. These observations were confirmed with staff B2 and C3.

Based on observation and interview, the facility failed to ensure each portable fire extinguisher is readily accessible in accordance with NFPA 101 20.3.5.2 and 9.7.4.1, and therefore NFPA 10. This has the potential to affect all patients and visitors to the facility. The facility's census at the time of survey was 33 patients.

Findings:

On 11/20/13 at 2:00 P.M. a fire extinguisher was observed in a locked cabinet. In an interview at the same time, Staff R2 was asked to access the fire extinguisher. Staff R2 looked through her keys, but was unable to locate one. Staff A1 then demonstrated the key was unnecessary, and access could be gained if enough force was applied to the door. (The door's locking mechanism remained undamaged.)

Based on observation and interview, the facility failed to ensure patient care areas were free of portable space heating devices. This has the potential to affect all patients and visitors in the facility. The census of the facility was 33 patients.

Findings:

On 11/19/13 at 2:53 P.M. in the volunteer services office, an office which shares a smoke compartment containing sleeping patients, a portable space heater was observed.On 11/19/13 at 2:53 P.M. Staff A1 confirmed the observation.

On 11/19/13 at 2:58 P.M. in the case management office, an office which shares space within a smoke compartment containing sleeping patients, a portable space heater was observed. Staff A1 confirmed the observation at 2:58 P.M.

Based on observations and staff interview the facility failed to ensure an exit access was readily accessible. This had the potential to affect all of those utilizing these areas of the facility. The patient census at the beginning of the survey was 33.

Findings include:

During facility tour took place on 11/19/13 at 7:55 AM with staff members B2 and C3 observation was made of a wheeled copier/fax/printer in the corridor in the intensive care unit (ICU) in the opening of a double doorway, next to a nurses' station. The presence of that equipment in that location reduced the egress capacity of the corridor to less than six feet of clearance. Release of the double doors showed the equipment obstructed the doors' ability to close. The reduced width of the corridor was confirmed by staff B2.

Based on observation and interview, the facility failed to ensure each medical gas storage and administration area was protected in accordance with NFPA 99, Chapter 4.

Findings:

On 11/20/13 at 10:22 A.M. in an interview, Staff P0 indicated he/she would turn off all medical gas shut off valves, including those in the corridor for the operating rooms, rather than the ones just for the post anesthesia care unit.

At 10:25 A.M. a nerve block/invasive procedure cart was observed in front of the post anesthesia care unit shut off valves.On 11/20/13 at 10:25 A.M. in an interview, Staff A1 confirmed the observation.

Based on record review and staff interview on 11/20/13 the facility failed to ensure single station smoke detectors had been tested according to National Fire Protection Association 72 7-2. This had the potential to affect all occupants of the building. The census was under 10 during the survey.
Findings include:
On 11/20/13 tour of the building showed there were three single station smoke detectors present.
During record review on 11/20/13 at 11:43 AM staff B2 said the single station smoke detectors had not been tested weekly according to manufacturer instructions provided by staff B2. Page three of the instructions revealed " test this unit every week to make sure it is working properly. "

Based on observation and interview, the facility failed to ensure compliance with NFPA 101, 9.7.4, manual extinguishing equipment, and (therefore), NFPA 10 1-6, general requirements. This has the potential to affect all patients, staff and visitors to the building.

Findings:

On 11/20/13 at 11:34 A.M. fire extinguisher was observed near laboratory specimens, in a corner, adjacent to the centrifuge. It could not be determined if the fire extinguisher had been checked monthly. On 11/20/13 at 11:34 A.M. in an interview, Staff A1 confirmed the observation. At 2:43 P.M. in an interview, Staff B2 stated the fire extinguisher had not been checked because they were unaware it was there and that the extinguisher wasn't theirs.

*NFPA 101, 9.7.5 and therefore NFPA 25, 2-2, inspection.

Findings:

On 11/20/13 at 2:30 P.M. a review of the building ' s sprinkler inspection documentation was completed. The review did not reveal any quarterly inspections.On 11/20/13 at 2:50 P.M. in an interview Staff B2 confirmed the sprinkler inspections were only done yearly.

*NFPA 101, 9.6.5, emergency control, and (therefore) NFPA 72, 7-2 test methods.

Findings:

On 11/20/13 at 2:30 P.M. a review of the building ' s alarm inspection documentation was completed. Review of the documentation did not reveal the length of time it took the initiating device signal to reach the supervising station. On 11/20/13 at 2:50 P.M. in an interview Staff A1 confirmed the length of time was not documented.


*NFPA 101, 9.6, fire detection, alarm, and communication system, and (therefore) NFPA 72, 7-3, inspection and testing frequency, for management of smoke detectors.

Findings:

On 11/20/13 at 2:30 P.M. a review of the building's alarm inspection documentation was completed. Review of the documentation did not reveal any smoke detector sensitivity testing. On 11/21/13 at 1:30 P.M. in an interview, Staff C3 confirmed sensitivity testing had not been performed.

Based on record review and staff interview the facility failed to ensure the generators were exercised under load as required, and failed to record water jacket temperature prior to starting the generators. This had the potential to affect all of those utilizing the facility. The patient census at the beginning of the survey was 33.

Findings include:

Review of the facility's records for generator maintenance on 11/20/13 revealed the facility had four generators. Of the four generators had not been exercised under load as required. Documentation for generator #3 revealed there were two months, 10/13 and 12/12, that a load test was incomplete. Documentation for generator #2 revealed there was one month, 11/12, that a load test was incomplete.
Review of the facility's records for generator maintenance on 11/20/13 revealed there was no record of the water jacket temperature for the two outdoor generators. The lack of documentation was confirmed with staff B2.

Based on facility tour observations and staff interview the facility failed to ensure smoke barriers were maintained without penetrations. This had the potential to affect all of those utilizing these areas of the facility. The patient census at the beginning of the survey was 33.

Findings include:

Facility tour took place on 11/19/13 with staff members B2 and C3. During tour in the area between Room 60 and a clean supply room on the first floor, observations were made of a conduit with blue and white wires with open space around the wires.

Observation on 11/19/13 of the east fire barrier in the health center revealed an unsealed sleeve with three flex conduits and wires passing through. This was verified by staff B2 and C3 at 4:39 PM on 11/19/13.






21521

On 11/19/13 at 1:48 P.M. observation was made of the drop down ceiling above the fire wall separating the medical surgical unit from a medical office building. A one inch conduit was observed to have an open lumen.On 11/19/13 at 1:48 P.M. Staff A1 confirmed the observation.

On 11/20/13 at 3:30 P.M. observation above the drop down ceiling of the 2 hour fire wall between the heart center and surgery area revealed three one inch pipes with annular spaces. On 11/20/13 at 3:30 P.M. in an interview Staff A1 confirmed the observation.

Based on observation and interview, the facility failed to ensure stairways between floors were enclosed with construction having a fire resistance rating of at least one hour. This has the potential to affect all patients and visitors in the facility. The census of the facility was 33 patients.

Findings:

On 11/19/13 at 3:58 P.M. observation of the door to a stairwell opposite the kitchen and lead up to the roof, revealed the door's rating could not be determined, and the door's self closer did not close the door completely. On 11/19/13 at 3:58 P.M. Staff A1 confirmed the observation.

Based on observations on tour and staff interview the facility failed to ensure all exit accesses were marked with visible signs in order to provide all occupants a readily available and safe access to exit discharges in the event of an emergency. This had the potential to affect all of those utilizing these areas of the facility. The patient census at the beginning of the survey was 33.

Findings include:

Facility tour took place on 11/19/13 with staff members B2 and C3. During tour in the obstetrics area in the east/ west corridor adjacent to the nurses' station observation was made of no exit signage directing occupant flow to the south double doors.

In the north/ south corridor on the west end of the obstetrics department observation was made of no exit signage directing occupant flow to the stairs, near obstetrics triage 1.

This was verified by staff B2 and C3 during tour on 11/19/13 at 4:27 PM.




21521

On 11/19/13 at 2:22 P.M. a fire evacuation plan posted on the eastern wing of the medical surgical department was reviewed. The review revealed a path of egress leading across a common area, down the western wing of the medical surgical department and out. Observation of this path of egress did not reveal an exit sign marking the path of egress noted in the evacuation plan.

On 11/19/13 at 2:22 P.M. Staff A1 confirmed the observation.

On 11/19/13 at 2:35 P.M. a fire evacuation plan posted on the western wing of the medical surgical department was reviewed. The review revealed a path of egress leading to a common area, then down a corridor that lead to the main entrance. Observation of this path of egress did not reveal an exit sign marking the path of egress noted in the evacuation plan.

On 11/19/13 at 2:35 P.M. Staff A1 confirmed the observation.

On 11/19/13 at 4:18 P.M. observation was made of the physical therapy treatment area. Observation within the treatment area revealed one exit; however, an exit sign was not observed.

On 11/19/13 at 4:18 P.M. Staff A1 confirmed the observation.

Based on observation and interview, the facility failed to maintain the construction rating of each barrier in each smoke compartment. This has the potential to affect all patients and visitors using the facility. The facility's census was 33 patients.

Findings:

On 11/19/13 at 2:06 P.M. observation was made of the drop down ceiling above the smoke barrier doors in the eastern most wing of the medical surgical unit. A one-inch conduit with a grey wire was observed to have an open lumen. On 11/19/13 at 2:06 P.M. Staff A1 confirmed the observation.

On 11/19/13 at 4:28 P.M. observation was made of the two hour fire doors north of the kitchen and across the main corridor. Review of the schematic confirmed the doors were to be two hour rated. The doors' rating could not be ascertained by observation. On 11/19/13 at 4:28 P.M. Staff A1 confirmed the observation.

On 11/20/13 at 9:06 A.M. observation above the drop down ceiling of the two hour fire rated wall in the corridor leading to the emergency department and near the elevator revealed two one inch conduits with their lumens open to air. On 11/20/13 at 9:06 A.M. Staff A1 confirmed the observation.

On 11/19/13 at 2:13 P.M. observation was made of storage room greater than 50 square feet in the eastern wing of the medical surgical unit. Review of the schematic on 11/19/13 revealed the north wall to have a two hour rating. Observation of the wall above the drop down ceiling at 2:13 P.M. revealed two one inch conduits with annular spaces. On 11/19/13 at 2:13 P.M. Staff A1 confirmed the observation.

On 11/19/13 at 2:26 P.M. observation was made above the drop down ceiling of the smoke barrier in the western wing of the medical surgical unit. Observation was made of a two inch conduit with a lumen open to air. On 11/19/13 at 2:26 P.M. Staff A1 confirmed the observation.

On 11/19/13 at 3:28 P.M. observation was made above the drop down ceiling of the two hour rated south wall that in part surrounded the kitchen. Observation was made of a conduit that traveled through the two hour wall and lead to a junction box with an open hole. On 11/19/13 at 3:28 P.M. Staff A1 confirmed the observation.

On 11/19/13 at 4:03 P.M. observation was made above the drop down ceiling of the two hour protective construction on the north side of the kitchen. Observation was made of a plumbing line that had a square annular space around it. On 11/19/13 at 4:03 P.M. Staff A1 confirmed the observation.

Based on observation and interview, the facility failed to maintain a one hour construction rating or an approved automatic fire extinguishing system to protect a hazardous area. This had the potential to affect all patients and visitors in the facility. The facility's census was 33 patients.

Findings:

On 11/19/13 at 2:13 P.M. observation was made of storage room greater than 50 square feet in eastern wing of the medical surgical unit. Within the room soiled lined bags were observed on a shelf, and a 450 cubic centimeter metallic bin for holding additional soiled linen was observed. Above the drop down ceiling that is above the door, two heating, ventilation and cooling conduits and two one inch conduits were all observed to have open annular spaces. On 11/19/13 at 2:13 P.M. Staff A1 confirmed the observation.

On 11/19/13 at 3:23 P.M. observation was made of the gift shop. Review of the schematic of the gift shop area revealed two areas surrounded by 2 hour protective construction. Observation revealed one to be an office area. That area's door was observed propped open by a kickstop and a self-closure. After the kickstop was de-activated, the door still did not close because of decorations hanging off the door.On 11/19/13 at 3:23 P.M. Staff A1 confirmed the observation.

On 11/19/13 at 3:23 P.M. observation was made of the gift shop. Review of the schematic of the gift shop area revealed two areas surrounded by 2 hour protective construction. Observation revealed one to be a storage area. That area's door was observed propped open by a kickstop and a self-closure. After the kickstop was de-activated, the door still did not close because of decorations hanging off the door.On 11/19/13 at 3:23 P.M. Staff A1 confirmed the observation.

On 11/19/13 at 4:08 P.M. observation was made of the door that lead to a mechanical space across from the north side of the kitchen. Review of the schematic revealed the space was surrounded by two hour fire protective construction. Observation of the door did not reveal what its rating was. On 11/19/13 at 4:08 P.M. Staff A1 confirmed the observation.

Based on observations on tour and staff interview the facility failed to ensure stairways were clear of possible obstruction. This had the potential to affect all of those utilizing these areas of the facility. The patient census at the beginning of the survey was 33.

Findings include:

Facility tour took place on 11/19/13 with staff members B2 and C3. Observations were made in a stairwell near the Mack Ivor entry at 4:00 PM on 11/19/13 of a metal cabinet and a plastic watering can on the top landing of the staircase. The finding was confirmed with staff B2 and C3.

Observations within a stairwell near the WOW/ Health Coaching office showed an exit stair landing with a metal cabinet labeled "education" and a plastic game wheel. The observation was confirmed with staff B2 and C3 at 5:00 PM on 11/20/13.

Based on observations on tour and staff interview the facility failed to ensure adequate illumination was provided at exterior exit discharges. This had the potential to affect all of those utilizing these areas of the facility. The patient census at the beginning of the survey was 33.

Findings include:

Tour of the hospital's exterior was conducted on 11/19/13 with staff members B2 and C3. During tour on the exterior of the hospital, observations were made of three exit discharges which lacked sufficient illumination in the following locations: Morey Center exit discharge, the cafe' exit discharge, and at the lab exit discharge at 1:52 PM. These findings were confirmed with staff B2 and C3.

Based on record review and staff interview the facility failed to ensure documentation of the fire alarm signal transmission when the pull station was activated. This had the potential to affect all of those utilizing these areas of the facility. The patient census at the beginning of the survey was 33.

Findings include:

On 11/20/13 at 4:30 PM fire drill documentation review revealed there was no recorded time of fire department receipt of signal. An interview with staff B2 at 4:45 pm confirmed the lack of verification of the transmission of the signal.

Based on observations on tour, record review, and staff interview the facility failed to ensure smoke detectors were not located too near airflow devices and were sensitivity tested as required. This had the potential to affect all of those utilizing these areas of the facility. The patient census at the beginning of the survey was 33.

Findings include:

Facility tour took place on 11/19/13 and 11/20/13 with staff members B2 and C3. During tour observations were made of smoke detectors located near airflow devices in the following locations:
1. Miracle L:ife Center in the west corridor
2. two smoke detectors within the basement corridor outside of mechanical room 2 and the information systems door.

On 11/20/13 during documentation review there was no documentation for the sensitivity testing of the detectors verified by staff B2 at 4:16 PM.

Based on observations on tour and staff interview the facility failed to ensure sprinkler heads were maintained in reliable operating condition. This had the potential to affect all of those utilizing these areas of the facility. The patient census at the beginning of the survey was 33.

Findings include:

Facility tour took place on 11/19/13 with staff members B2 and C3. During tour of the north south corridor across from ACC 16, heading toward the new obstetrics unit, observation was made of two sprinkler heads with bent deflectors that would not provide complete coverage if activiated. This observation was confirmed with staff B2 and C3 at 4:13 PM.





21521

On 11/19/13 at 3:38 P.M. a storage closet across from the kitchen was observed to have a box and artificial plants directly underneath a sprinkler head. On 11/19/13 at 3:38 P.M. Staff A1 confirmed the observation.

Based on observations and staff interview the facility failed to ensure that fire extinguishers were not mounted greater than five feet from the floor and were accessible without obstructions. This had the potential to affect all of those utilizing these areas of the facility. The patient census at the beginning of the survey was 33.

Findings include:

Facility tour took place on 11/20/13 with staff members B2 and C3. In the first floor medical gas room observation was made on 11/20/13 at 8:23 AM of a fire extinguisher obstructed by a two wheel cart and a medical gas stand. This observation was confirmed with staff B2 and C3.

During tour in the lower level at 9:56 AM two fire extinguishers were observed in the corridor, one near the coding office and one across from the employee health services office, mounted more than five feet from the floor. These observations were confirmed with staff B2 and C3.

Based on observation and interview, the facility failed to ensure each portable fire extinguisher is readily accessible in accordance with NFPA 101 20.3.5.2 and 9.7.4.1, and therefore NFPA 10. This has the potential to affect all patients and visitors to the facility. The facility's census at the time of survey was 33 patients.

Findings:

On 11/20/13 at 2:00 P.M. a fire extinguisher was observed in a locked cabinet. In an interview at the same time, Staff R2 was asked to access the fire extinguisher. Staff R2 looked through her keys, but was unable to locate one. Staff A1 then demonstrated the key was unnecessary, and access could be gained if enough force was applied to the door. (The door's locking mechanism remained undamaged.)

Based on observation and interview, the facility failed to ensure patient care areas were free of portable space heating devices. This has the potential to affect all patients and visitors in the facility. The census of the facility was 33 patients.

Findings:

On 11/19/13 at 2:53 P.M. in the volunteer services office, an office which shares a smoke compartment containing sleeping patients, a portable space heater was observed.On 11/19/13 at 2:53 P.M. Staff A1 confirmed the observation.

On 11/19/13 at 2:58 P.M. in the case management office, an office which shares space within a smoke compartment containing sleeping patients, a portable space heater was observed. Staff A1 confirmed the observation at 2:58 P.M.

Based on observations and staff interview the facility failed to ensure an exit access was readily accessible. This had the potential to affect all of those utilizing these areas of the facility. The patient census at the beginning of the survey was 33.

Findings include:

During facility tour took place on 11/19/13 at 7:55 AM with staff members B2 and C3 observation was made of a wheeled copier/fax/printer in the corridor in the intensive care unit (ICU) in the opening of a double doorway, next to a nurses' station. The presence of that equipment in that location reduced the egress capacity of the corridor to less than six feet of clearance. Release of the double doors showed the equipment obstructed the doors' ability to close. The reduced width of the corridor was confirmed by staff B2.

Based on observation and interview, the facility failed to ensure each medical gas storage and administration area was protected in accordance with NFPA 99, Chapter 4.

Findings:

On 11/20/13 at 10:22 A.M. in an interview, Staff P0 indicated he/she would turn off all medical gas shut off valves, including those in the corridor for the operating rooms, rather than the ones just for the post anesthesia care unit.

At 10:25 A.M. a nerve block/invasive procedure cart was observed in front of the post anesthesia care unit shut off valves.On 11/20/13 at 10:25 A.M. in an interview, Staff A1 confirmed the observation.

Based on record review and staff interview on 11/20/13 the facility failed to ensure single station smoke detectors had been tested according to National Fire Protection Association 72 7-2. This had the potential to affect all occupants of the building. The census was under 10 during the survey.
Findings include:
On 11/20/13 tour of the building showed there were three single station smoke detectors present.
During record review on 11/20/13 at 11:43 AM staff B2 said the single station smoke detectors had not been tested weekly according to manufacturer instructions provided by staff B2. Page three of the instructions revealed " test this unit every week to make sure it is working properly. "

Based on observation and interview, the facility failed to ensure compliance with NFPA 101, 9.7.4, manual extinguishing equipment, and (therefore), NFPA 10 1-6, general requirements. This has the potential to affect all patients, staff and visitors to the building.

Findings:

On 11/20/13 at 11:34 A.M. fire extinguisher was observed near laboratory specimens, in a corner, adjacent to the centrifuge. It could not be determined if the fire extinguisher had been checked monthly. On 11/20/13 at 11:34 A.M. in an interview, Staff A1 confirmed the observation. At 2:43 P.M. in an interview, Staff B2 stated the fire extinguisher had not been checked because they were unaware it was there and that the extinguisher wasn't theirs.

*NFPA 101, 9.7.5 and therefore NFPA 25, 2-2, inspection.

Findings:

On 11/20/13 at 2:30 P.M. a review of the building ' s sprinkler inspection documentation was completed. The review did not reveal any quarterly inspections.On 11/20/13 at 2:50 P.M. in an interview Staff B2 confirmed the sprinkler inspections were only done yearly.

*NFPA 101, 9.6.5, emergency control, and (therefore) NFPA 72, 7-2 test methods.

Findings:

On 11/20/13 at 2:30 P.M. a review of the building ' s alarm inspection documentation was completed. Review of the documentation did not reveal the length of time it took the initiating device signal to reach the supervising station. On 11/20/13 at 2:50 P.M. in an interview Staff A1 confirmed the length of time was not documented.


*NFPA 101, 9.6, fire detection, alarm, and communication system, and (therefore) NFPA 72, 7-3, inspection and testing frequency, for management of smoke detectors.

Findings:

On 11/20/13 at 2:30 P.M. a review of the building's alarm inspection documentation was completed. Review of the documentation did not reveal any smoke detector sensitivity testing. On 11/21/13 at 1:30 P.M. in an interview, Staff C3 confirmed sensitivity testing had not been performed.

Based on record review and staff interview the facility failed to ensure the generators were exercised under load as required, and failed to record water jacket temperature prior to starting the generators. This had the potential to affect all of those utilizing the facility. The patient census at the beginning of the survey was 33.

Findings include:

Review of the facility's records for generator maintenance on 11/20/13 revealed the facility had four generators. Of the four generators had not been exercised under load as required. Documentation for generator #3 revealed there were two months, 10/13 and 12/12, that a load test was incomplete. Documentation for generator #2 revealed there was one month, 11/12, that a load test was incomplete.
Review of the facility's records for generator maintenance on 11/20/13 revealed there was no record of the water jacket temperature for the two outdoor generators. The lack of documentation was confirmed with staff B2.