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Based on observation it was determined the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On May 27, 2015 surveyor, accompanied by the Director of Maintenance, and staff observed the following doors:

1. Medical storage room door has holes around door handle, not smoke tight.
2. CEO office door closing device disconnected.
3. Second floor clean linen door is not smoke tight and will not positively latch after testing three of three times.
4. Rehab gym has two of two sets of doors that will not positively latch.
5. First and Second floor double doors to the elevator will not close and positively latch when tested three of three times.

During the exit conference on May 27, 2015 the above findings were again acknowledged by the Director of Business Development, Chief Clinical Officer, DQRM/IP and the Director of Maintenance.

In time of a fire failing to protect patients from heat and smoke could cause harm to the patients.

Based on observation it was determined the facility failed to maintain the self closing/automatic-closing doors in the smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Sections, 19.3.7.6 "Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 18.2.2.2.6..."
( See Chapter 19 for additional requirements) Chapter 8, Section 8.3.4."Doors" Section 8.3.4.3: "Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1...."

Findings include:

On May 27, 2015 surveyor, accompanied by the Director of Maintenance, and staff observed the Smoke Barrier double doors in the East wing. The door hinges were missing screws and the astragal was torn and not smoke tight.

During the exit conference on May 27, 2015 the above findings were again acknowledged by the Director of Business Development, Chief Clinical Officer, DQRM/IP and the Director of Maintenance.

Failure to properly adjust or repair the smoke doors will cause harm to residents. Non closing smoke doors will allow smoke to enter smoke zones not directly effected by the fire.

Based on observation it was determined the facility failed to maintain doors or automatic closing devices in corridor doors.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.2.2.2.6. "Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure ( not in 19 except boiler rooms, heater rooms and mechanical equipment rooms) shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility. "
Chapter 7, Section 7.2.1.8.1 " A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2." (See (1) through (5) ).

Findings include:

On May 27, 2015 surveyor, accompanied by the Director of Maintenance, and staff observed the following hazardous areas:

1. Kitchen extra storage room of combustibles, the door has been removed.
2. Kitchen dry food storage room has a one gallon container of lemon juice holding the door with a closing device open.
3. Admin copier, shredder and combustible storage room door has been removed.
4. Second floor shower room door held open with a port pottie.

During the exit conference on May 27, 2015 the above findings were again acknowledged by the Director of Business Development, Chief Clinical Officer, DQRM/IP and the Director of Maintenance.

In a fire doors that are not closed or will not close automatically will allow smoke and heat to
spread throughout the facility which will cause harm to the residents/patients.

Based on observation, staff interview and policy review it was determined the facility did not keep exits readily accessible at all times.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.2.1 and Section 19.2.3.3 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 18.2.3.3 "Aisles, corridors and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft (Existing built to 8 feet must be maintained 8 feet clear) in clear and unobstructed width". Chapter 7 Section 7.5.1.1" Exits shall be so located and exit access shall be arranged so that exits are readily accessible at all times." Section 7.5.1.2 "Where exits are not immediately accessible from an open floor area, continuous passageways, aisles, or corridors leading directly to every exit and shall be maintained and shall be arranged to provide access for each occupant to not less than two exits by separate ways of travel."

Findings include:

On May 27, 2015 surveyor, accompanied by the Director of Maintenance, and staff observed the ICU exit corridors were reduced from eight feet to six feet seven inches when measured by a shredder and a large trash can.

During the exit conference on May 27, 2015 the above findings were again acknowledged by the Director of Business Development, Chief Clinical Officer, DQRM/IP and the Director of Maintenance.

Failure to keep the exit corridors and exit access clear could hinder the evacuation during an emergency and will cause harm to patients.

Based on record review it was determined the facility failed to complete sensitivity testing on the facilities smoke detectors.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.1.1.1.1, "The requirements of this chapter apply to existing buildings or portions thereof currently occupied as health care. Existing health care facilities shall comply with the provisions of this chapter" Chapter 19, Section 19.3.4.1 "General" "Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.", Chapter 9, Section 9.6.1.4. A fire alarm system required for life safety shall be installed, tested and maintained in accordance with the applicable requirements of NFPA 70. National Electrical code, and NFPA 72, National fire Alarm Code. NFPA 101, Chapter 4, Section 4.6.12.3, " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 72 National Fire Alarm Code, Chapter 7 Inspection Testing, and Maintenance/Paragraph 7-3.2 "Testing shall be performed in accordance with the schedules in this chapter or more frequently where required by authority having jurisdiction. Section 7-3.2.1 "Detectors sensitivity shall be checked within 1 year after installation and every alternate year thereafter. Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced."

Findings include:

On May 27, 2015 surveyor, accompanied by the Director of Maintenance, reviewed the fire alarm inspection documentation. The documentation did not indicate the U.L. sensitivity of the smoke detectors or if the smoke detectors passed the required sensitivity range.

During the exit conference on May 27, 2015 the above findings were again acknowledged by the Director of Business Development, Chief Clinical Officer, DQRM/IP and the Director of Maintenance.

Failure to test and maintain the fire alarm systems smoke detectors could result in harm to the patients.

Based on record review it was determined the facility did not inspect, test and maintain the automatic sprinkler system in accordance with the requirements of the Life Safety Code.

NFPA 101 Life Safety Code, 2000, Chapter 19 Section 19.3.5.1, "Buildings containing health care facilities shall be protected throughout by an 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, Water Based Extinguishment Systems, requires monthly, quarterly and annual testing of automatic sprinkler systems.

Findings Include:

On May 27, 2015 surveyor, accompanied by the Director of Maintenance, reviewed the automatic sprinkler system records. The documents stated the water pressure gages are out of date and have not been changed, the internal valve inspection has not been completed and the sprinklers that have paint and damage have not been replaced.

During the exit conference on May 27, 2015 the above findings were again acknowledged by the Director of Business Development, Chief Clinical Officer, DQRM/IP and the Director of Maintenance.

Failure to inspect, test, and maintain the sprinkler system could result in harm to the patients and staff through the spread of smoke and fire.

Based on observation, it was determined the facility failed to provide a medical gas cylinder storage room free of combustible materials and separated storage of full/empty O2 bottles.

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, "Health Care Facilities", Chapter 4, Section 4-5.1.1.2 "Storage Requirements (Location, Construction, Arrangement.) Section 4-5.1.1.2 (b) 5 "Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials." Section 4-5.1.1.2 (b) 7 "Combustible materials, such as paper, cardboard, plastics, and fabrics shall not be stored or kept near supply system cylinders or manifolds containing oxygen..."

NFPA 101 Life Safety Code 2000, Chapter 19, Section "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care facilities, NFPA 99 Chapter 4 Section 4-3.5.2.2 (a)(2) " If stored within the same enclosure, empty and full cylinder shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

Findings include:

On May 27, 2015 surveyor, accompanied by the Director of Maintenance, and staff observed the Dialysis room has one full E-O2 bottle stored with three empty E-O2 bottles in the storage rack marked full and stored next to combustibles.

During the exit conference on May 27, 2015 the above findings were again acknowledged by the Director of Business Development, Chief Clinical Officer, DQRM/IP and the Director of Maintenance.

Leaking oxygen will penetrate combustible material and create an extreme fire hazard, which will cause harm to the residents.

The facility failed to separate empty and full oxygen cylinders

Based on observation it was determined the facility failed to provide a guard on the light bulb located in the supply closet, allowed the use of a multiple outlet adapter, power strips and did not use the wall outlet receptacles for appliances, and did not repair 110 outlets.

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 installed shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, 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.

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 May 27, 2015 surveyor, accompanied by the Director of Maintenance, and staff observed the main riser room does not have a guard on the light. The Pharmacy has a microwave plugged into a power strip, the CEO office has an extension cord plugged into a coffee machine, and a 110 GFI receptacle is broken.

During the exit conference on May 27, 2015 the above findings were again acknowledged by the Director of Business Development, Chief Clinical Officer, DQRM/IP and the Director of Maintenance.

Failure to keep light guards on the light could cause accidental damage or possibly a fire, which could cause harm to the patients.
The use of multiple outlet adapters 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.