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Based on random observation during the survey walk-through, not all exit access corridors have interior finishes verified to be in accordance with 19.3.3. This deficiency could affect patients, staff and visitors in the Wellness Center and Physical Therapy, because the lack of protection for the surfaces could result in fire and smoke compromising the use of the closest exit access corridor.

Finding include:
A. The corridor adjacent to the Wellness Center and Physical Therapy has cork board paneling which could not be verified to have a minimum Class C finish rating to comply with 19.3.3.2 Exception.




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Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1 or otherwise protected in accordance with the exceptions. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, because the lack of smoke detectors could result in smoke compromising the use of the facility's exit access corridors.

Findings include:

A. An office/charting area, not staffed 24-hours, contains furnishings, multiple shelves, files etc and is stationed at the corridor intersection across from the D.O.N. office (shown on the facility life safety plan). This area contains a pass through sliding window which is open to the corridor. This area is not provided with smoke detection to comply with 19.3.6.1, Exceptions

B. A nurse station not staffed 24-hours, contains furnishings, multiple shelves, files etc and is stationed at the corridor intersection across from Waiting in the Rural Health Clinic. This area contains a pass through sliding window, and lacks a door, therefore this area which is open to the corridor is not provided with smoke detection to comply with 19.3.6.1, Exceptions.

C. A wooden set of steps used for rehabilitaion were observed in the exit access corridor adjacent to the Wellness Center, this corridor is being used for patient care which does not comply with 19.3.6.1.




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Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3.2 for a means to keep the door closed. These deficiencies could affect all patients, staff and visitors in the facility, because the lack of compartmentation could result in smoke compromising the use of the facility's exit access corridors.


Findings include:

A. The door to the Reception area was observed to not be resistant to the passage of smoke due to the lack of latching hardware.

B. The door to the Wellness Center was observed to not be resistant to the passage of smoke, due to the use of an unapproved hold open device.

C. The pair of cross corridor doors leading to the East corridor of the MedSurg wing both open in the same direction and were observed to not be resistant to the passage of smoke due to the lack of a coordinator.




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Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the building's exit access corridors.

Findings include:

A. The sprinklered Generator room did not have a labeled self-closing door to comply with 19.3.2.1(5), 8.4.1.2 and 8.2.4.3.5.

B. The un sprinklered Laundry room did not have a self-closing corridor door to comply with 19.3.2.1(5), 8.4.1.2 and 8.2.4.3.5.

C. The Central Supply Room corridor door was held open with a door wedge and was not self closing.

D. The entry door from Dining into the Kitchen was observed to have the fire rating label painted. Verification of the required fire rating for the door could not be done.

E. The Cast Room (as shown on the life safety floor plan) is being used for equipment storage. This room is not designated as a hazardous area on the life safety floor plan.




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Based on random observation during the survey walk-through, not all exit doors are arranged so that exits are readily accessible at all times to comply with 19.2.1 and Chapter 7. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. The deficiencies listed below were observed, relative to the discharge door located adjacent to the Reception desk. The door is equipped with a push bar and a thumbturn deadbolt retractor:

1. When locked, the door requires 2 operations for egress which does not comply with 7.2.1.5.4.

2. When extended, the deadbolt may prevent the door from latching to comply with 19.3.6.3.2.

B. The exterior egress path for the exit door west of the Wellness Center and adjacent to the basement stair was observed to not be in compliance with 7.1.6.3. due to the amount of combustible items stored in the egress path. These items include, a barbecue grille, wooden pallets, discarded generator batteries, old cabinets, outdoor furniture etc.

C. The exterior path of egress for the West wing Medsurg discharge door was observed to be less than 6 feet from combustible materials. Surveyor observed a wooden fence along with wood pallets, rubber tires and a garbage dumpster all located directly adjacent to the exterior egress path.




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Based on random observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies to comply with 8.2.3.2.4.2. These deficiencies could affect all patients, staff and visitors in the facility, because the lack of compartmentation could result in smoke compromising the use of the facility's exit access corridors.


Findings include:

A. The indicated 2-hour barrier separating the "staff only" wing housing the laundry, central supply, maintenance shop, cart room, clean linen and other rooms was observed to not be constructed as a continuous fire rated separation due to the following:

1. The type of installation at the barrier door sidelights to comply with a U.L. listed assembly for a 2-hour wall. The existing sidelight framing along with gypsum board placed on both sides of the glazed opening does not constitue a 2-hour fire rated barrier assembly.

2. The type of installation within the same barrier wall contains a large window (once was the nursery viewing window unit) that is framed in with gypsum board placed on both sides of the glazed opening, this does not constitue a 2-hour fire rated barrier assembly.


B. An indicated 2-hour fire barrier separating the building in half is located east west from Diatary, to the exterior wall at hazardous waste was observed to contain an unprotected steel beam as part of the barrier assembly. Location observed The North section of the wall across the corridor from Diatary.

C. The sprinklered Medical Records/Office corridor door located in the 2-hour barrier (refer to item B) contains a hardware latchset which is not listed to comply with 8.2.3.2.4.2 for a fire rated door assembly.



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Based on random observation during the survey walk through not all components of the fire alarm system are maintained to comply with NFPA 72, 1999. This deficiency could affect staff, visitors and patients in the Kitchen, Dining and East corridor by causing a delay in the activation of the fire alarm during a fire emergency.

Finding includes:

A. Dining Room (once part of Long Term Care) contains a single heat detector which was disconnected from the ceiilng.


26665


Based on random observation during the survey walk-through on January 30, 2012, not all portions of the facility's fire alarm system are installed in accordance with NFPA 72 1999.

Findings include:

B. During the walk-through of the corridor by laboratory a smoke detector was observed to be less than 3' from a supply diffuser and not in accordance with 2-3.5.1 for more than 3'.

This deficience could cause injury to patients or staff due to a delay in detection.




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Based on random observation and staff interview during the survey walk-through on January 30, 2012, not all portions of the facility's automatic sprinkler system are installed in accordance with NFPA 13 1999 and NFPA 101 2000.

Findings include:

A. During the survey walk-through of the Cat Scan Room and Medical Records areas were observed with 2 sprinkler heads in CT and 6 sprinkler heads in Medical Records all supplied by the same 1" copper pipe and not in accordance with 101 9.7.1.2 for up to 6 sprinkler heads on the domestic water system.

B. The sprinkler supply valve between the domestic water system and the sprinklers was observed to be a valve with no indicator to show what position the valve was in and not in accordance with 13 5-14.1.1.2.

C. The sprinkler piping observed above the ceiling in CT was observed to be reduced to 1/2" piping from the branch line and not 1" to the sprinkler head, thus not in accordance with 13 5-13.20.1.

D. The sprinkler piping observed above the ceiling in CT was observed without a sign to indicate what portion of the sprinkler system it controlled and not in accordance with 5-14.1.1.12.

E. The sprinkler valve observed above the ceiling in CT was observed without a supervisory circuit for monitoring the valve position in accordance with 13 5-14.1.1.3 (2).

These deficiencies could cause injury to patients and staff due to no warning and improper water flow to put out the fire.



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Based on random observation during the survey walk through it was observed that not all exits contain a manually operated fire alarm box to comply with 9.6.2.3. This deficiency could affect patients, staff and visitors in the area adjacent to the Wellness Center.

Finding includes:

A. The designated exit discharge door located close to the Wellness Center and basement stair was observed to lack a manually operated pull station.




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Based on random observation and staff interview during the survey walk-through on January 30, 2012, not all portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 25 1998 and NFPA 13 1999.

Findings include:

A. During the document review process records were not available for any quarterly testing of flow switches in accordance with NFPA 25 2-3.3. There was no documentation available for the annual sprinkler inspection which includes from the floor visual to comply with NFPA 25 2-2.1.1.

These deficiencies could cause injury to patients due to equipment failure.




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Based on random observation and staff interview during the survey walk-through on January 30, 2012, not all portions of the facility's commercial cooking equipment are installed and maintained in accordance with NFPA 96 1998.

Findings include:

A. During the survey of the Dietary Department the exhaust hood was observed with a hose connected to the drip tray and ran down to a 5 gallon bucket and not drained to an enclosed metal container with a capacity of less than 1 gallon in accordance with 3-2.6.

B. During an interview held at the hood location with the Director of Maintenance it was confirmed the electric supply to the fat fryer, the 6 burner stove and the griddle top did not automatically disconnect with the activation of the fire suppression system in accordance with 7-4.1.

C. During the survey of the Dietary Department the class "K" fire extinguisher was not provided with a placard explaining it's use only after the hood system had activated in accordance with 7- 2.1.1.

These deficiencies could cause injury to patients and staff during a fire condition.




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Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency to comply with 19.2.3.3. This deficiency could affect all patients in the facility, as well as any staff and visitors present, because the location of furniture could obstruct the required width of the means of egress and compromise the use of the facility's exit access corridors.

Findings include:

A. A waiting area with multiple chairs and other furnishings is stationed outside the Reception area and Lab which obstructs the 8'-0" corridor.





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Based on random observation and staff interview during the survey walk-through on January 30, 2012, not all portions of the facility's piped medical gas system are installed and maintained in accordance with NFPA 50 1996 and NFPA 99 1999.

Findings include:

A. The bulk oxygen supply location was observed with a vehicle parked less than 10' from the tank and not in accordance with 50 2-2.12.

B. The bulk supply location was observed to have a concrete pad approximately 3' in the direction of the vehicle axis and not 8' in accordance with 2-1.4.

C. During the survey of the basement area the medical vacuum system was observed with a manifolded exhaust pipe without check valves, a valve or other arrangement for isolating the running pump from the malfunctioning pump for maintenance in accordance with 99 4-3.2.1.9.

D. During the survey of the Emergency Room area a medical gas zone valve box labeled as Recovery Room was observed. During an interview held at that location with the Director of Maintenance, it was discovered the Recovery room had been changed to storage and the zone valve box was labeled incorrectly and not in accordance with 99 4-3.1.2.14 (b).

E. Trauma room 1 zone valve box was observed to be labeled as OR 1 and not in accordance with 99 4.3.1.2.14 (b).

F. Trauma room 1 was observed to only have a shut off valve for oxygen and not vacuum for anesthetizing locations in accordance with 99 4-3.1.2.3 (n).

These deficiencies could cause injury to patients and staff due to fire or explosion.




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Based on random observation during the survey walk-through on January 30, 2012, not all portions of the facility's emergency generator are installed in accordance with NFPA 110 1999.

Findings include:

A. During the survey of the generator location normal utility distribution electrical equipment was observed in the generator enclosure and not separated in accordance with 110 5-2.2

This deficiency could cause injury to patients and staff due to failure of both electrical systems.




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Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.




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Based on random observation during the survey walk-through on January 30, 2012, not all portions of the facility's Laboratory area are in compliance with NFPA 99 1999.

Findings include:

A. During the survey of the Laboratory an emergency eye wash was observed to be mounted on a faucet goose neck and not installed in accordance with 10-6.

This deficiency could cause injury to staff due to injurious water pressure.




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Based on random observation, document review and staff interview during the survey walk-through on January 30, 2012, not portions of the facility's emergency electrical system are test in accordance with NFPA 110 1999.

Findings include:

A. During the document review process records were not available for the monthly testing of the transfer switch in accordance with 6-4.5.

B. During the document review process records were not available for the annual transfer switch maintenance in accordance with 6-3.5.

C. During the document review process records for the amperage during monthly load testing showed less than 30% load with no load bank test in accordance with 6-4.2.

D. During the document review process records for the weekly generator inspection did show electrolyte level checking in accordance with 6-3.6 for verifying the battery meets the generator manufacture requirements.

These deficiencies could cause injury to patients due to equipment failure.




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Based on random observation and staff interview during the survey walk-through on January 30, 2012, not all portions of the facility's emergency electrical system are installed and maintained in accordance with NFPA 99 and 110 1999.

Findings include:

A. During the survey of the generator location an interview was held with the Director of Maintenance and it was discovered the monthly generator test was initiated by turning off the normal electrical main breaker and not in accordance with 110 4-2.4.10.

B. The transfer switch at the generator location was not provided with pilot lights to indicate switch position in accordance with 4-2.4.11.

C. During the survey of the facility various electrical panels were observed with normal and emergency electrical circuits fed from the same panel and not separated in accordance with 99 3-4.2.2.4 (a). Example location - panel EM located in the partial basement housing the water heaters contains breakers marked for equipment, medical gas and fire alarm.

These deficiencies could cause injury to patients and staff due to loss of electric circuits.




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Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised by the loss of a single transfer switch. Should the transfer switch fail upon return to normal power, the facility could be left with no power even though utility power is available.

Findings include:

A. All power serving the facility including the emergency department, patient rooms, the clinic, etc. is fed through a single transfer switch. This was confirmed during an interview held with the Director of Maintenance, who confirmed that everything is on emergency power. There are no normal power circuits which feed these areas without going through the transfer switch. This creates a single point of failure that could leave the facility completely out of power during critical care and does not meet the intent of NFPA-70, Section 517-30 through 35.



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Based on random observation during the survey walk-through, not all exit access corridors have interior finishes verified to be in accordance with 19.3.3. This deficiency could affect patients, staff and visitors in the Wellness Center and Physical Therapy, because the lack of protection for the surfaces could result in fire and smoke compromising the use of the closest exit access corridor.

Finding include:
A. The corridor adjacent to the Wellness Center and Physical Therapy has cork board paneling which could not be verified to have a minimum Class C finish rating to comply with 19.3.3.2 Exception.




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Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1 or otherwise protected in accordance with the exceptions. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, because the lack of smoke detectors could result in smoke compromising the use of the facility's exit access corridors.

Findings include:

A. An office/charting area, not staffed 24-hours, contains furnishings, multiple shelves, files etc and is stationed at the corridor intersection across from the D.O.N. office (shown on the facility life safety plan). This area contains a pass through sliding window which is open to the corridor. This area is not provided with smoke detection to comply with 19.3.6.1, Exceptions

B. A nurse station not staffed 24-hours, contains furnishings, multiple shelves, files etc and is stationed at the corridor intersection across from Waiting in the Rural Health Clinic. This area contains a pass through sliding window, and lacks a door, therefore this area which is open to the corridor is not provided with smoke detection to comply with 19.3.6.1, Exceptions.

C. A wooden set of steps used for rehabilitaion were observed in the exit access corridor adjacent to the Wellness Center, this corridor is being used for patient care which does not comply with 19.3.6.1.




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Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3.2 for a means to keep the door closed. These deficiencies could affect all patients, staff and visitors in the facility, because the lack of compartmentation could result in smoke compromising the use of the facility's exit access corridors.


Findings include:

A. The door to the Reception area was observed to not be resistant to the passage of smoke due to the lack of latching hardware.

B. The door to the Wellness Center was observed to not be resistant to the passage of smoke, due to the use of an unapproved hold open device.

C. The pair of cross corridor doors leading to the East corridor of the MedSurg wing both open in the same direction and were observed to not be resistant to the passage of smoke due to the lack of a coordinator.




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Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the building's exit access corridors.

Findings include:

A. The sprinklered Generator room did not have a labeled self-closing door to comply with 19.3.2.1(5), 8.4.1.2 and 8.2.4.3.5.

B. The un sprinklered Laundry room did not have a self-closing corridor door to comply with 19.3.2.1(5), 8.4.1.2 and 8.2.4.3.5.

C. The Central Supply Room corridor door was held open with a door wedge and was not self closing.

D. The entry door from Dining into the Kitchen was observed to have the fire rating label painted. Verification of the required fire rating for the door could not be done.

E. The Cast Room (as shown on the life safety floor plan) is being used for equipment storage. This room is not designated as a hazardous area on the life safety floor plan.




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Based on random observation during the survey walk-through, not all exit doors are arranged so that exits are readily accessible at all times to comply with 19.2.1 and Chapter 7. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. The deficiencies listed below were observed, relative to the discharge door located adjacent to the Reception desk. The door is equipped with a push bar and a thumbturn deadbolt retractor:

1. When locked, the door requires 2 operations for egress which does not comply with 7.2.1.5.4.

2. When extended, the deadbolt may prevent the door from latching to comply with 19.3.6.3.2.

B. The exterior egress path for the exit door west of the Wellness Center and adjacent to the basement stair was observed to not be in compliance with 7.1.6.3. due to the amount of combustible items stored in the egress path. These items include, a barbecue grille, wooden pallets, discarded generator batteries, old cabinets, outdoor furniture etc.

C. The exterior path of egress for the West wing Medsurg discharge door was observed to be less than 6 feet from combustible materials. Surveyor observed a wooden fence along with wood pallets, rubber tires and a garbage dumpster all located directly adjacent to the exterior egress path.




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Based on random observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies to comply with 8.2.3.2.4.2. These deficiencies could affect all patients, staff and visitors in the facility, because the lack of compartmentation could result in smoke compromising the use of the facility's exit access corridors.


Findings include:

A. The indicated 2-hour barrier separating the "staff only" wing housing the laundry, central supply, maintenance shop, cart room, clean linen and other rooms was observed to not be constructed as a continuous fire rated separation due to the following:

1. The type of installation at the barrier door sidelights to comply with a U.L. listed assembly for a 2-hour wall. The existing sidelight framing along with gypsum board placed on both sides of the glazed opening does not constitue a 2-hour fire rated barrier assembly.

2. The type of installation within the same barrier wall contains a large window (once was the nursery viewing window unit) that is framed in with gypsum board placed on both sides of the glazed opening, this does not constitue a 2-hour fire rated barrier assembly.


B. An indicated 2-hour fire barrier separating the building in half is located east west from Diatary, to the exterior wall at hazardous waste was observed to contain an unprotected steel beam as part of the barrier assembly. Location observed The North section of the wall across the corridor from Diatary.

C. The sprinklered Medical Records/Office corridor door located in the 2-hour barrier (refer to item B) contains a hardware latchset which is not listed to comply with 8.2.3.2.4.2 for a fire rated door assembly.



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Based on random observation during the survey walk through not all components of the fire alarm system are maintained to comply with NFPA 72, 1999. This deficiency could affect staff, visitors and patients in the Kitchen, Dining and East corridor by causing a delay in the activation of the fire alarm during a fire emergency.

Finding includes:

A. Dining Room (once part of Long Term Care) contains a single heat detector which was disconnected from the ceiilng.


26665


Based on random observation during the survey walk-through on January 30, 2012, not all portions of the facility's fire alarm system are installed in accordance with NFPA 72 1999.

Findings include:

B. During the walk-through of the corridor by laboratory a smoke detector was observed to be less than 3' from a supply diffuser and not in accordance with 2-3.5.1 for more than 3'.

This deficience could cause injury to patients or staff due to a delay in detection.




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Based on random observation and staff interview during the survey walk-through on January 30, 2012, not all portions of the facility's automatic sprinkler system are installed in accordance with NFPA 13 1999 and NFPA 101 2000.

Findings include:

A. During the survey walk-through of the Cat Scan Room and Medical Records areas were observed with 2 sprinkler heads in CT and 6 sprinkler heads in Medical Records all supplied by the same 1" copper pipe and not in accordance with 101 9.7.1.2 for up to 6 sprinkler heads on the domestic water system.

B. The sprinkler supply valve between the domestic water system and the sprinklers was observed to be a valve with no indicator to show what position the valve was in and not in accordance with 13 5-14.1.1.2.

C. The sprinkler piping observed above the ceiling in CT was observed to be reduced to 1/2" piping from the branch line and not 1" to the sprinkler head, thus not in accordance with 13 5-13.20.1.

D. The sprinkler piping observed above the ceiling in CT was observed without a sign to indicate what portion of the sprinkler system it controlled and not in accordance with 5-14.1.1.12.

E. The sprinkler valve observed above the ceiling in CT was observed without a supervisory circuit for monitoring the valve position in accordance with 13 5-14.1.1.3 (2).

These deficiencies could cause injury to patients and staff due to no warning and improper water flow to put out the fire.



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Based on random observation during the survey walk through it was observed that not all exits contain a manually operated fire alarm box to comply with 9.6.2.3. This deficiency could affect patients, staff and visitors in the area adjacent to the Wellness Center.

Finding includes:

A. The designated exit discharge door located close to the Wellness Center and basement stair was observed to lack a manually operated pull station.




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Based on random observation and staff interview during the survey walk-through on January 30, 2012, not all portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 25 1998 and NFPA 13 1999.

Findings include:

A. During the document review process records were not available for any quarterly testing of flow switches in accordance with NFPA 25 2-3.3. There was no documentation available for the annual sprinkler inspection which includes from the floor visual to comply with NFPA 25 2-2.1.1.

These deficiencies could cause injury to patients due to equipment failure.




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Based on random observation and staff interview during the survey walk-through on January 30, 2012, not all portions of the facility's commercial cooking equipment are installed and maintained in accordance with NFPA 96 1998.

Findings include:

A. During the survey of the Dietary Department the exhaust hood was observed with a hose connected to the drip tray and ran down to a 5 gallon bucket and not drained to an enclosed metal container with a capacity of less than 1 gallon in accordance with 3-2.6.

B. During an interview held at the hood location with the Director of Maintenance it was confirmed the electric supply to the fat fryer, the 6 burner stove and the griddle top did not automatically disconnect with the activation of the fire suppression system in accordance with 7-4.1.

C. During the survey of the Dietary Department the class "K" fire extinguisher was not provided with a placard explaining it's use only after the hood system had activated in accordance with 7- 2.1.1.

These deficiencies could cause injury to patients and staff during a fire condition.




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Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency to comply with 19.2.3.3. This deficiency could affect all patients in the facility, as well as any staff and visitors present, because the location of furniture could obstruct the required width of the means of egress and compromise the use of the facility's exit access corridors.

Findings include:

A. A waiting area with multiple chairs and other furnishings is stationed outside the Reception area and Lab which obstructs the 8'-0" corridor.





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Based on random observation and staff interview during the survey walk-through on January 30, 2012, not all portions of the facility's piped medical gas system are installed and maintained in accordance with NFPA 50 1996 and NFPA 99 1999.

Findings include:

A. The bulk oxygen supply location was observed with a vehicle parked less than 10' from the tank and not in accordance with 50 2-2.12.

B. The bulk supply location was observed to have a concrete pad approximately 3' in the direction of the vehicle axis and not 8' in accordance with 2-1.4.

C. During the survey of the basement area the medical vacuum system was observed with a manifolded exhaust pipe without check valves, a valve or other arrangement for isolating the running pump from the malfunctioning pump for maintenance in accordance with 99 4-3.2.1.9.

D. During the survey of the Emergency Room area a medical gas zone valve box labeled as Recovery Room was observed. During an interview held at that location with the Director of Maintenance, it was discovered the Recovery room had been changed to storage and the zone valve box was labeled incorrectly and not in accordance with 99 4-3.1.2.14 (b).

E. Trauma room 1 zone valve box was observed to be labeled as OR 1 and not in accordance with 99 4.3.1.2.14 (b).

F. Trauma room 1 was observed to only have a shut off valve for oxygen and not vacuum for anesthetizing locations in accordance with 99 4-3.1.2.3 (n).

These deficiencies could cause injury to patients and staff due to fire or explosion.




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Based on random observation during the survey walk-through on January 30, 2012, not all portions of the facility's emergency generator are installed in accordance with NFPA 110 1999.

Findings include:

A. During the survey of the generator location normal utility distribution electrical equipment was observed in the generator enclosure and not separated in accordance with 110 5-2.2

This deficiency could cause injury to patients and staff due to failure of both electrical systems.




.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.




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Based on random observation during the survey walk-through on January 30, 2012, not all portions of the facility's Laboratory area are in compliance with NFPA 99 1999.

Findings include:

A. During the survey of the Laboratory an emergency eye wash was observed to be mounted on a faucet goose neck and not installed in accordance with 10-6.

This deficiency could cause injury to staff due to injurious water pressure.




.

Based on random observation, document review and staff interview during the survey walk-through on January 30, 2012, not portions of the facility's emergency electrical system are test in accordance with NFPA 110 1999.

Findings include:

A. During the document review process records were not available for the monthly testing of the transfer switch in accordance with 6-4.5.

B. During the document review process records were not available for the annual transfer switch maintenance in accordance with 6-3.5.

C. During the document review process records for the amperage during monthly load testing showed less than 30% load with no load bank test in accordance with 6-4.2.

D. During the document review process records for the weekly generator inspection did show electrolyte level checking in accordance with 6-3.6 for verifying the battery meets the generator manufacture requirements.

These deficiencies could cause injury to patients due to equipment failure.




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Based on random observation and staff interview during the survey walk-through on January 30, 2012, not all portions of the facility's emergency electrical system are installed and maintained in accordance with NFPA 99 and 110 1999.

Findings include:

A. During the survey of the generator location an interview was held with the Director of Maintenance and it was discovered the monthly generator test was initiated by turning off the normal electrical main breaker and not in accordance with 110 4-2.4.10.

B. The transfer switch at the generator location was not provided with pilot lights to indicate switch position in accordance with 4-2.4.11.

C. During the survey of the facility various electrical panels were observed with normal and emergency electrical circuits fed from the same panel and not separated in accordance with 99 3-4.2.2.4 (a). Example location - panel EM located in the partial basement housing the water heaters contains breakers marked for equipment, medical gas and fire alarm.

These deficiencies could cause injury to patients and staff due to loss of electric circuits.




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Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised by the loss of a single transfer switch. Should the transfer switch fail upon return to normal power, the facility could be left with no power even though utility power is available.

Findings include:

A. All power serving the facility including the emergency department, patient rooms, the clinic, etc. is fed through a single transfer switch. This was confirmed during an interview held with the Director of Maintenance, who confirmed that everything is on emergency power. There are no normal power circuits which feed these areas without going through the transfer switch. This creates a single point of failure that could leave the facility completely out of power during critical care and does not meet the intent of NFPA-70, Section 517-30 through 35.



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