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Based on observation it was determined the facility failed to provide a safe means of egress from the main kitchen to the dining room.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. Section 7.1.10.1." " 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." Section 7.1.10.2.1 "No furnishings, decorations, or other objects shall obstruct exits or their access thereto egress therefrom, or visibility thereof. "

Finding s include

On February 01, 2017 the surveyor, accompanied by the Manager of Environmental Services and Director of Human Resources Enviroment Services observed the main exit egress from the main kitchen had two food carts stored directly in front of the exit door leading to the dining room.

During the exit conference on February 01, 2017 the above findings were again acknowledged by the Manager of Environmental Services and Director of Human Resources, and Medical Staff Coordinator Human Resources Assistant.

Failure to provide a clear and unimpeded means of egress could cause harm to the patients and staff in a fire emergency.

Based on record review and interview with the Manager of Environmental Services and Director of Human Resources Enviroment Services it was determined two of twelve months in 2016 the facility did not test the battery backup light emergency light in the operating room, and there was no record of testing of the battery backup light in the basement. In addition: there was no record of the 90 minute 1/1/12 hour testing of both battery backup emergency lights.

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 February 01, 2017 the surveyor accompanied by the Manager of Environmental Services and Director of Human Resources, and Enviroment Services it was determined two of twelve months in 2016 the facility did not test the battery backup emergency lights in the operating room, and there was no record of testing of the battery backup emergency light in the basement. In addition: there was no record of the 90 minute 1/1/12 hour testing of both battery backup emergency lights.

During the exit conference on February 01, 2017, the above findings were again acknowledged by the Manager of Environmental Services and Director of Human Resources, and Medical Staff Coordinator Human Resources Assistant.

Failing to test the battery backup emergency lighting units in time of an emergency could cause harm to the patients in an emergency power outage.

Based on Record review and interview with the Manager of Environmental Services and Director of Human Resources Enviroment Services it was determined the facility did not have documented evidence that the kitchen hood system was cleaned semi-annually in accordance with NFPA 96.

NFPA 101 Life Safety Code, 2012 Edition, Chapter 19, Section 19.3.2.5, "Cooking Facilities." "Cooking facilities shall be protected in accordance with 9.2.3." Section 9.2.3, "Commercial Cooking Equipment" "Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.... Chapter 11, Section 11.2 Inspection and Testing, and Maintenance of Fire extinguishing Systems. Section 11.4 Inspection for grease buildup The entire exhaust system shall be inspected for grease buildup by properly trained, qualified; and certified persons acceptable to the authority having jurisdiction and in accordance with Table 11.4. Systems serving moderate -volume cooking operations Inspection frequency semi-annually."

Findings Include:

On February 01, 2017 the surveyor accompanied by the Manager of Environmental Services and Director of Human Resources Enviroment Services it was determined the Manager of Environmental Services was unable to provide documented evidence that the cooking hood and vents were inspected and cleaned in accordance with NFPA 96 semi-annually from July to December of 2016.

During the exit conference on February 01, 2017, the above findings were again acknowledged by the Manager of Environmental Services and Director of Human Resources, and Medical Staff Coordinator Human Resources Assistant.

Failing to inspect and clean the kitchen hood and vents semi-annually will allow a build-up of grease and provide fuel for a fire. A fire in the kitchen may cause harm to patients and staff.

Based on observation it was determined the facility failed to provide protective guards on light bulbs in three locations in there basement of the hospital. .

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 February 01, 2017 the surveyor accompanied by the Manager of Environmental Services and Director of Human Resources and Enviroment Services observed the following rooms or areas had no protective covers on the exposed light bulbs .

1. Utility storeroom basement
2. In house laundry
3. Auxiliary storeroom.

During the exit conference on February 01, 2017, the above findings were again acknowledged by the Manager of Environmental Services and Director of Human Resources, and Medical Staff Coordinator Human Resources Assistant.

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 interview with the Manager of Environmental Services and Director of Human Resources Enviroment Services during review of the fire protection records it was determined the facility did not have documented evidence that the operating room had isolated electrical testing done in 2016.

NFPA 101 Life Safety Code, 2012, NFPA 99 Health Care Facilities Chapter 6 Section 6.3.3.3 Isolated Power systems. Section 6.3.4.1 Maintenance and Testing of electrical Systems. Section 6.3.4.1.4 The LIM circuit shall be tested at intervals of not more than one month by actuating the LIM test switch see (6.3.2.6.3.6,) which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4"

Findings include:

During review of the fire protection records it was determined the facility did not have documented evidence that the operating room had isolated electrical testing done in 2016
No records were available for review during the survey.

During the exit conference on February 01, 2017, the above findings were again acknowledged by the Manager of Environmental Services and Director of Human Resources, and Medical Staff Coordinator Human Resources Assistant.

Failing to test the isolated electrical panel units in time of an emergency could cause harm to the patients in an emergency power outage.