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It was determined by observation during a walk-through of the facility with the Maintenance Director on April 5, 2013 that the facility failed to maintain the Flagler Off Campus Location furnace room per requirements contained in the 2000 edition of NFPA 101, the Life Safety Code.

? The surveyor found several ceiling tiles missing in the Flagler Off Campus Location furnace room. This condition precludes heat from activating the sprinkler head within the furnace room. This deficiency was acknowledged by the Maintenance Director during the survey and has the potential to impact an indeterminate number of patients, employees and visitors.

NFPA 101, Section 8.4.1(2) requires this hazardous area be housed in a one-hour enclosure, OR protected with an automatic sprinkler.

It was determined by observation during a walk-through of the facility with the Maintenance Director on April 5, 2013 that the facility failed to maintain an exit corridor in the Main Hospital in accordance with the requirements contained in the 2000 edition of NFPA 101, the Life Safety Code.

Cardboard boxes, etcetera were left in the corridor at the rear exit of the hospital. This deficiency was acknowledged by the Maintenance Supervisor. This deficiency has the potential to impact an indeterminate number of employees and visitors.

Corridors are a component of the means of egress, which shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress there from, or visibility thereof shall be in accordance with 7.1.10.

NFPA 101, Section 7.1.10.1, which states, "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency."

It was determined by a review of the records with the Maintenance Director on April 5, 2013 that the facility failed to properly document the required number of the fire drills for the Limon and Flagler Off Campus Locations per requirements contained in the 2000 edition of NFPA 101, the Life Safety Code.

? The facility failed to produce documentation for quarterly fire drills for the Limon Off Campus Location. This deficiency was acknowledged by the Maintenance Director during the survey and has the potential to impact an indeterminate number of patients, employees and visitors.
? The facility failed to produce documentation for quarterly fire drills for the Flagler Off Campus Location. This deficiency was acknowledged by the Maintenance Director during the survey and has the potential to impact an indeterminate number of patients, employees and visitors.

NFPA 101, Section 20.7.1.2, states, in part, "...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."

It was determined by observation during a walk-through of the facility with the Maintenance Director on April 5, 2013 that the facility failed to maintain the portable fire extinguisher cabinets in the Limon Off Campus Location in accordance with the requirements contained in the 1998 edition of NFPA 10, the Standard for Portable Fire Extinguishers.

The portable fire extinguishers are housed in lockable cabinets to preclude tampering. Facility staff is aware of where the cabinet keys are located, and the keys are accessible to all staff.

? The locking mechanism for the fire extinguisher cabinets at the Limon Off Campus Location "drags" against the metal housing containing the portable fire extinguishers. This requires excessive force to unlock the cabinet door. This deficiency was acknowledged by the Maintenance Director during the survey and has the potential to impact an indeterminate number of patients, employees and visitors.

NFPA 10, Section 1-6.3 states, in part, "Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the even of fire. ..."

It was determined by observation during a walk-through of the facility with the Maintenance Director on April 5, 2013 that the facility failed to maintain the electrical system in the Flagler Off Campus Location in accordance NFPA 70, the National Electrical Code.

? The surveyor found an extension cord feeding a relocatable power strip as a replacement for permanent wiring in the Flagler Off Campus Location Employee Break Room. This deficiency was acknowledged by the Maintenance Director during the survey and has the potential to impact an indeterminate number of patients, employees and visitors.

Article 400-8 of the 1999 edition of the National Electrical Code states, in part:

Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
1. As a substitute for the fixed wiring of a structure ...