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Through observation during the survey, Sept. 6 and 7, 2016, it was determined that the facility failed to maintain the hazardous areas.


During the walk-through of the facility with the Maintenance Director:
1) The HIM file storage room door was not equipped with a door closure.\
2) The CLinic Soiled Utility door was wedged open
3) The Laundry Clean Linen pick up door was wedged open
4) Pharmacy door wedged open
5) B Electrical closet penetrations not sealed
6) D Electrical closet penetrations not sealed
7) OR Suite Soiled Utility door wedged open
8) D East Electrical closet penetrtions not sealed
9) IT Server room penetration not sealed

These deficiencies could effect nine of thirty smoke compartments.

Through observation and testing during the survey, Sept. 6 and 7, 2016, it was determined that the facility failed to maintain all components of the fire alarm system in accordance with NFPA 72.


During review of the fire alarm records, with the Maintenance Director, the annual fire alarm test was out of date, the last test was completed 5/28/15.


This deficiency could effect the entire facility.

It was determined by observation during the course of the survey, September 6 and 7, 2016, the facility failed to install and maintain the automatic fire sprinkler system in accordance with NFPA 13, Installation of Sprinkler Systems and NFPA 25, Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. This was evidenced by the following:

1) Kitchen Dry Storage, storage within 18" of sprinkler heads.
2) Clean Linen closet in Kitchen doesn't have sprinker coverage.


These deficiencies could effect one of thirty smoke compartments.

Through observation during the survey,September 6 and 7, 2016, it was determined the facility failed to test the automatic sprinkler system per NFPA 25.
 

During document review and a walk through of the facility, with the Maintenance Director, documentation was not available for quarterly sprinkler testing.


This deficiency could effect the entire facility.

Through record review during the survey, September 6 and 7, 2016, it was determined the facility failed to inspect and professionally clean the kitchen exhaust system on a semi-annual basis.
 
During the review of the facility records, with the Maintenance Director, documentation was not available to confirm that the facility had a kitchen-hood-exhaust-system inspection and cleaning schedule as required by NFPA 96, (Chapter 8, Section 8-3). The hood is currently being cleaned on an annual basis.



This deficiency could effect one of thirty smoke compartments

Through observation during the survey, September 6 and 7, 2016, it was determined the facility had portable space heating devices and the elements were not listed as not to exceed 212F.
 
During a walk through of the facility with the Maintenance Director;
1) HIM office heaters being used
2) Patient Financial, heaters being used

These deficiencies could effect two of thirty smoke compartments

Through observation during the survey, September 6 and 7, 2016, it was determined that the facility failed to maintain the egress corridors free of all obstructions or impediments to full instant use in the case of fire or other emergency.
 

During the walk through of the facility, with the Maintenance Director;
1) ER Med gas shut off was obstructed by rolling carts
2) ER fire extinguisher was obstructed by rolling carts
Both items corrected during the survey


These deficiencies could effect one of thirty smoke compartments

Through record review during the survey, September 6 and 7, 2016, it was determined that the facility failed to maintain the generator emergency function per NFPA 110, 6-4.1.
 

During the review of the facility record and observation, with the Maintenance Director, documentation was not available for weekly generator inspections.


This deficiency could effect the entire facility.

Through observation during the survey, September 6 and 7, 2016, it was determined that the facility failed to install and maintain the electrical system in accordance with NFPA 70.
 

During the walk through of the facility, with the Maintenance Director;
1) Maintenance area,open electrical j-box at light fixture.
2) HIM office extension cord in use
3) CNO office extension cord feeding refrigerator
4) IT room, multiplug adapter in use and daisy chained power strip - IT room corrected during the survey


These deficiencies could effect four of thirty smoke compartments.

Through observation during the survey, Sept. 6 and 7, 2016, it was determined that the facility failed to maintain the hazardous areas.


During the walk-through of the facility with the Maintenance Director:
1) The HIM file storage room door was not equipped with a door closure.\
2) The CLinic Soiled Utility door was wedged open
3) The Laundry Clean Linen pick up door was wedged open
4) Pharmacy door wedged open
5) B Electrical closet penetrations not sealed
6) D Electrical closet penetrations not sealed
7) OR Suite Soiled Utility door wedged open
8) D East Electrical closet penetrtions not sealed
9) IT Server room penetration not sealed

These deficiencies could effect nine of thirty smoke compartments.

Through observation and testing during the survey, Sept. 6 and 7, 2016, it was determined that the facility failed to maintain all components of the fire alarm system in accordance with NFPA 72.


During review of the fire alarm records, with the Maintenance Director, the annual fire alarm test was out of date, the last test was completed 5/28/15.


This deficiency could effect the entire facility.

It was determined by observation during the course of the survey, September 6 and 7, 2016, the facility failed to install and maintain the automatic fire sprinkler system in accordance with NFPA 13, Installation of Sprinkler Systems and NFPA 25, Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. This was evidenced by the following:

1) Kitchen Dry Storage, storage within 18" of sprinkler heads.
2) Clean Linen closet in Kitchen doesn't have sprinker coverage.


These deficiencies could effect one of thirty smoke compartments.

Through observation during the survey,September 6 and 7, 2016, it was determined the facility failed to test the automatic sprinkler system per NFPA 25.
 

During document review and a walk through of the facility, with the Maintenance Director, documentation was not available for quarterly sprinkler testing.


This deficiency could effect the entire facility.

Through record review during the survey, September 6 and 7, 2016, it was determined the facility failed to inspect and professionally clean the kitchen exhaust system on a semi-annual basis.
 
During the review of the facility records, with the Maintenance Director, documentation was not available to confirm that the facility had a kitchen-hood-exhaust-system inspection and cleaning schedule as required by NFPA 96, (Chapter 8, Section 8-3). The hood is currently being cleaned on an annual basis.



This deficiency could effect one of thirty smoke compartments

Through observation during the survey, September 6 and 7, 2016, it was determined the facility had portable space heating devices and the elements were not listed as not to exceed 212F.
 
During a walk through of the facility with the Maintenance Director;
1) HIM office heaters being used
2) Patient Financial, heaters being used

These deficiencies could effect two of thirty smoke compartments

Through observation during the survey, September 6 and 7, 2016, it was determined that the facility failed to maintain the egress corridors free of all obstructions or impediments to full instant use in the case of fire or other emergency.
 

During the walk through of the facility, with the Maintenance Director;
1) ER Med gas shut off was obstructed by rolling carts
2) ER fire extinguisher was obstructed by rolling carts
Both items corrected during the survey


These deficiencies could effect one of thirty smoke compartments

Through record review during the survey, September 6 and 7, 2016, it was determined that the facility failed to maintain the generator emergency function per NFPA 110, 6-4.1.
 

During the review of the facility record and observation, with the Maintenance Director, documentation was not available for weekly generator inspections.


This deficiency could effect the entire facility.

Through observation during the survey, September 6 and 7, 2016, it was determined that the facility failed to install and maintain the electrical system in accordance with NFPA 70.
 

During the walk through of the facility, with the Maintenance Director;
1) Maintenance area,open electrical j-box at light fixture.
2) HIM office extension cord in use
3) CNO office extension cord feeding refrigerator
4) IT room, multiplug adapter in use and daisy chained power strip - IT room corrected during the survey


These deficiencies could effect four of thirty smoke compartments.