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Based on observations and interview, the facility failed to maintain fire retardant applications on exposed structural steel to maintain the approved construction classification of the building. Failure to maintain the fire retardant coating can lead to early structural failure of the steel member in a fire event endangering the patients, staff, and other building occupants.

The findings include:

While on tour on March 16, 2015 at 2:40 PM in penthouse/roof with the Director of Facility Services, it was observed multiple structural members which had the fire retardant coating scrapped off exposed the structural support member.

The Director of Facility Services confirmed on March 16, 2015 at 2:40 PM, the structural members were exposed. Facility was plan approved as a Type II (111) classification and fire retardant materials must be replaced to maintain the rating in accordance with NFPA 101 (2000) 19.1.6.2, 19.3.5.1

Based on observations and interview, the facility failed to maintain the proper operation of corridor door assemblies. Corridor door assemblies must properly self-close and latch upon release to maintain the fire resistance rated barrier penetration. Failure to maintain the door assembly will allow for the travel of fire and smoke gases from one compartment to another endangering patients, staff, or other building occupants.

The findings include:

1) While on tour March 16-17, 2015 at 3:30 PM in x-ray room , at 3:37 PM on PACU/clean utility room, at 11:10 AM on dietary corridor, at 11:30 AM on medical wing/clean utility room, at 11:35 on medical wing/lounge, at 11:42 on medical wing/physical therapy, with the Director of Facility Services, the entry door to the rooms were observed to be out of alignment and would not come to a fully closed and latch position upon release. The Director of Facility Services confirmed the doors wouldn't fully close and latch. NFPA 101 (2000 edition) chapter 19.3.63 requires corridor doors to resist smoke and latch.

2) While on tour March 16-17, 2015 at 3:10 PM on ICU/nourishment room, at 3:20 PM old ER door, at 10:54 AM in kitchen/janitor closet, the entry doors to the rooms were observed to have drilled holes through the door. NFPA 101 (2000) chapter 19.3.6.3 requires that corridor doors shall be maintained in operable conditions at all times to include the proper self-closing and fully latching of the doors to maintain the smoke barrier resistance. The Director of Facility Services confirmed that the door wouldn't resist the passage of smoke.

3) While on tour March 17, 2015 at 10:30 AM in purchasing/storage area, at 12:20 PM nursery door, at 12:45 PM in gift shop, the entry doors were observed to be held open with wooden wedges and self-closer disconnected. NFPA 101 (2000) chapter 19.3.6.3 requires that corridor doors shall be maintained in operable conditions at all times to include the proper self-closing and fully latching of the doors to maintain the smoke barrier resistance shall be no impediment to the closing of the door. The Director of Facility Services confirmed that the doors were held open with wooden wedges and would not resist the passage of smoke.

Based on observation and interview, the facility failed to maintain their egress signs. A non-required egress door was missing egress signage. Residents, visitors and staff would lack egress direction during an emergency.

The findings include:

While on tour March 17, 2015 at 11:17 AM in cafe/dining area, at 11:47 AM, in police officers, office with the Director of Facility Services, observed non-required exit doors missing egress signage.The Director of Facility Services confirmed the missing signage. NFPA 101 (2000 edition) chapter 19.2.10; chapter 7.10 requires any door or passage that is not an exit or exit passage to be identified.

Based on observation and interview, the facility failed to maintain their egress corridor/aisle clear of obstructions. A blocked egress corridor during emergency endangers patients, visitors and staff.

The findings include:

While on tour March 16, 2015 at 3:40 PM in PACU/corridor with the Director of Facility Services, observed furnishings and equipment in egress corridor.

The Director of Facility Services on march 16, 2015 at 3:40 PM, confirmed the corridor was obstructed. NFPA 101 (2000 edition) chapter 19.2.1 & chapter 7.1 requires that exits are readily accessible at all times.

Based on record review and interview, the facility failed to conduct a fire drill for each shift during each quarter. Fire drills are necessary to insure the staff is familiar with the signals and emergency action required under varied conditions.

The findings include:

During record review on March 16, 2015 at 10:55 AM with the Director of Facility Services, the facility failed to produce documentation of a fire drill for all personnel on each shift during each quarter as required by NFPA 101 (2000 edition) chapter 19.7.

The Director of Facility Services on march 16, 2015 at 10:55 AM, confirmed that fire drills for all facility personnel were not conducted.

Based on record review and interview, the facility failed to properly maintain their fire sprinkler system.

1) The facility failed to produce documentation for the quarterly testing of the fire sprinkler system during 2nd, 3rd, and 4th quarter of 2014. A failed fire sprinkler could allow a fire to grow, endangering residents, visitors and staff.

2) Solid storage shelving is an obstruction to the spray pattern of the fire sprinklers. The obstruction will allow a fire to grow, endangering residents, visitors and staff.

3) Three fire sprinkler risers were "RED TAG", red tags on an fire sprinkler riser indicates an inoperable sprinkler system depending on deficiencies. Last report dated 3/6/15, listed 86 deficiencies.

4) Two fire sprinkler heads located within eighteen inches of each other.

The finding include:

1) During record review March 16, 2015 at 10:30 AM the facility failed to produce documentation for the quarterly testing of the facility's fire sprinkler system as required by NFPA 25 (1998 edition) chapter 2.3. The Director of Facility Services confirmed the fire sprinkler system were not tested during the 2nd, 3rd, and 4th quarter of 2014.

2) While on tour on March 16, 2015 at 4:00 PM with the Director of Facility Services, in OR/ storage room, observed solid shelving being used and is obstructing the existing fire sprinkler. NFPA 13 (1999 edition) chapter 8.5.5.1 requires fire sprinklers be located so as to minimize obstructions or add additional heads. The Director of Facility Services confirmed that solid shelving were installed.

3) While on tour March 16, 2015 at 2:15-2:45 PM in the fire sprinkler system riser rooms with the Director of Facility Services, observed the sprinkler risers "RED TAG", red tags on an fire sprinkler riser indicates an inoperable sprinkler system depending on deficiencies. Last report dated 3/6/15, listed 86 deficiencies. The Director of Facility Services confirmed the fire sprinkler systems was inoperable due to deficiencies. NFPA 101 (2000 edition) 19.7.6 & 9.7.5 requires fire sprinkler systems to be in operable condition at all times.

4) While on tour March 16, 2015 at 11:25 AM in sleep lab #1 with the Director of Facility Services, two sprinkler heads were observed approximately eighteen inches from each other. Sprinkler heads too close in proximity are an obstruction to the sprinkler heads water spray and also affect the sprinkler response time in case of a fire. NFPA 13 (1999 edition) chapter 8.5.5 prohibits obstructions to sprinkler discharge. The Director of Facility Services confirmed the fire sprinkler heads were too close to each other.

Based on observation and interview, the facility failed to maintain their portable fire extinguishers. An fire extinguisher cabinet was missing location signage. Delayed access to a fire extinguisher during a fire emergency would endanger patients, visitors and staff.

The findings include:

While on tour March 17, 2015 at 11:20 AM in cafe/dining area with the Director of Facility Services, observed fire extinguisher cabinet missing location signage.

The Director of Facility Services confirmed on March 17, 2015 at 11:20 AM, the missing signage. NFPA 101 (2000 edition) chapter 19.3.5.6 & NFPA 10 (1998 edition) requires a means to be provided to identified extinguisher location.

Based on observation and interview, the facility failed to maintain their HVAC and ventilating system.
1) The residents bath exhaust on one wing was inoperative.
2) Dryer ventilating system not maintained.

The findings include:

1) While on tour March 17, 2015 at 12:15 PM in room 104 with the Director of Facility Services, the bath exhaust grille failed to retain a sheet of toilet tissue when held to the grille by the Director of Facility Services. Room 105 & 106's grille also failed to retain tissue. The remaining rooms in the 100 wing are on the same power roof ventilator. NFPA 101 (2000 edition) chapter 9.2., 19.5.2.2 & NFPA 90A (1999 edition) requires maintenance of required systems.
2) While on tour March 17, 2015 at 11:00 AM in housekeeping area with Director of Facility Services, observed lint build-up behind, around, and in dryer's filter.
3) The Director of Facility Services confirmed on March 17, 2015 at 11:00AM, that the dryer's ventilating system was not maintained. NFPA 101 (2000 edition) chapter 9.2., 19.5.2.2 & NFPA 90A (1999 edition) requires maintenance of required systems.

Based on records review, observation, and interview, the facility failed to maintain kitchen hood system.

1) Kitchen hood system monthly "quick check" inspection not performed. Delays in activation of hood system fire suppression, endanger residents, visitors, and staff during an emergency.
2) Hood fire suppression nozzles aligned improperly and cooking equipment aligned incorrectly. Malfunction of hood fire suppression system increases injury for residents, visitors, and staff.

Finding include:
1) While on tour March 17, 2015 at 10:48 AM in the kitchen with the Director of Facility Services, the kitchen hood fire suppression nozzles were aligned improperly and cooking equipment aligned incorrectly.

The Director of Facility Services confirmed on March 17, 2015 at 10:48 AM, the kitchen hood nozzles were aligned improperly. NFPA 96 (1998 edition) chapter 8.2.2 requires all hood system components to be checked for proper operation and location.

2) During records review on March 16, 2015 at 11:05 AM with the Director of Facility Services, the facility faiedl to produce documentation for kitchen hood system monthly inspections.

The Director of Facility Services confirmed on March 16, 2015 at 11:05 AM, the kitchen hood system were inspected quarterly. NFPA 17A (1998 edition) chapter 5.2.1 requires monthly "quick check" inspection.

Based on observation and interviews, the facility failed to provide an environment free from electrical hazards.

1) The facility failed to maintain, test, and inspect patient care equipment which can render a piece of equipment out of compliance and could fail to perform properly endangering the patients, staff, and other building occupants.
2) Observation on March 16, 2015 at 10:55 AM showed that the power strip was plugged into another power strip.

The findings include:
1) During record review on March 16, 2015 at 10:55 AM with the Director of Facility Services, the facility failed to produce documentation for testing of patient care equipment (electric beds). Equipment is required to be tested annually and was found to be out of compliance. The Director of Facility Services acknowledged the equipment was not in compliance at the time of survey and Bio-medical company will be contacted. All equipment shall be properly serviced, tested and repaired in accordance with NFPA 70 (1999) Article 517 & NFPA 99 (1999 edition).

2) While on tour March 16, 2015 at 3:00 PM in Meds room/2nd floor with the Director of Facility Services, observed two refrigerators plugged into a power strip. Director of Facility Services confirmed use of power strip. NFPA 101 (2000 edition) 9.1.2 & NFPA 70 (1999 edition) article 400-8 prohibits cords as a substitute for fixed wiring.

3) While on tour March 17, 2015 at 12:30 PM in nursery/doctor's sleeping room with the Director of Facility Services, observed a power strip plugged into a power strip with several electrical devices plugged into power strip. Director of Facility Services confirmed use of power strips. NFPA 101 (2000 edition) 9.1.2 & NFPA 70 (1999 edition) article 400-8 prohibits cords as a substitute for fixed wiring.

Based on observations and interview, the facility failed to maintain alcohol based hand rub dispensers were not installed over or adjacent to an ignition source which could lead to a flash fire endangering the residents, staff, and other building occupants.

The findings include:

While on tour March 17, 2015 at 12:38 PM in infection control office with the Director of Facility Services, observed an alcohol based hand rub dispenser was placed directly over an electrical outlet which is not in accordance with NFPA 101 (2000) Interim Amendment 19.3.2.7, CFR 403.744, 418.100, 460.72, 482.41, 483.70, 483.623, 485.623.

The Director of Facility Services confirmed on March 17, 2015 at 12:38 PM, that the ABHR was located directly over an electrical source.

Based on observations and interview, the facility failed to maintain fire retardant applications on exposed structural steel to maintain the approved construction classification of the building. Failure to maintain the fire retardant coating can lead to early structural failure of the steel member in a fire event endangering the patients, staff, and other building occupants.

The findings include:

While on tour on March 16, 2015 at 2:40 PM in penthouse/roof with the Director of Facility Services, it was observed multiple structural members which had the fire retardant coating scrapped off exposed the structural support member.

The Director of Facility Services confirmed on March 16, 2015 at 2:40 PM, the structural members were exposed. Facility was plan approved as a Type II (111) classification and fire retardant materials must be replaced to maintain the rating in accordance with NFPA 101 (2000) 19.1.6.2, 19.3.5.1

Based on observations and interview, the facility failed to maintain the proper operation of corridor door assemblies. Corridor door assemblies must properly self-close and latch upon release to maintain the fire resistance rated barrier penetration. Failure to maintain the door assembly will allow for the travel of fire and smoke gases from one compartment to another endangering patients, staff, or other building occupants.

The findings include:

1) While on tour March 16-17, 2015 at 3:30 PM in x-ray room , at 3:37 PM on PACU/clean utility room, at 11:10 AM on dietary corridor, at 11:30 AM on medical wing/clean utility room, at 11:35 on medical wing/lounge, at 11:42 on medical wing/physical therapy, with the Director of Facility Services, the entry door to the rooms were observed to be out of alignment and would not come to a fully closed and latch position upon release. The Director of Facility Services confirmed the doors wouldn't fully close and latch. NFPA 101 (2000 edition) chapter 19.3.63 requires corridor doors to resist smoke and latch.

2) While on tour March 16-17, 2015 at 3:10 PM on ICU/nourishment room, at 3:20 PM old ER door, at 10:54 AM in kitchen/janitor closet, the entry doors to the rooms were observed to have drilled holes through the door. NFPA 101 (2000) chapter 19.3.6.3 requires that corridor doors shall be maintained in operable conditions at all times to include the proper self-closing and fully latching of the doors to maintain the smoke barrier resistance. The Director of Facility Services confirmed that the door wouldn't resist the passage of smoke.

3) While on tour March 17, 2015 at 10:30 AM in purchasing/storage area, at 12:20 PM nursery door, at 12:45 PM in gift shop, the entry doors were observed to be held open with wooden wedges and self-closer disconnected. NFPA 101 (2000) chapter 19.3.6.3 requires that corridor doors shall be maintained in operable conditions at all times to include the proper self-closing and fully latching of the doors to maintain the smoke barrier resistance shall be no impediment to the closing of the door. The Director of Facility Services confirmed that the doors were held open with wooden wedges and would not resist the passage of smoke.

Based on observation and interview, the facility failed to maintain their egress signs. A non-required egress door was missing egress signage. Residents, visitors and staff would lack egress direction during an emergency.

The findings include:

While on tour March 17, 2015 at 11:17 AM in cafe/dining area, at 11:47 AM, in police officers, office with the Director of Facility Services, observed non-required exit doors missing egress signage.The Director of Facility Services confirmed the missing signage. NFPA 101 (2000 edition) chapter 19.2.10; chapter 7.10 requires any door or passage that is not an exit or exit passage to be identified.

Based on observation and interview, the facility failed to maintain their egress corridor/aisle clear of obstructions. A blocked egress corridor during emergency endangers patients, visitors and staff.

The findings include:

While on tour March 16, 2015 at 3:40 PM in PACU/corridor with the Director of Facility Services, observed furnishings and equipment in egress corridor.

The Director of Facility Services on march 16, 2015 at 3:40 PM, confirmed the corridor was obstructed. NFPA 101 (2000 edition) chapter 19.2.1 & chapter 7.1 requires that exits are readily accessible at all times.

Based on record review and interview, the facility failed to conduct a fire drill for each shift during each quarter. Fire drills are necessary to insure the staff is familiar with the signals and emergency action required under varied conditions.

The findings include:

During record review on March 16, 2015 at 10:55 AM with the Director of Facility Services, the facility failed to produce documentation of a fire drill for all personnel on each shift during each quarter as required by NFPA 101 (2000 edition) chapter 19.7.

The Director of Facility Services on march 16, 2015 at 10:55 AM, confirmed that fire drills for all facility personnel were not conducted.

Based on record review and interview, the facility failed to properly maintain their fire sprinkler system.

1) The facility failed to produce documentation for the quarterly testing of the fire sprinkler system during 2nd, 3rd, and 4th quarter of 2014. A failed fire sprinkler could allow a fire to grow, endangering residents, visitors and staff.

2) Solid storage shelving is an obstruction to the spray pattern of the fire sprinklers. The obstruction will allow a fire to grow, endangering residents, visitors and staff.

3) Three fire sprinkler risers were "RED TAG", red tags on an fire sprinkler riser indicates an inoperable sprinkler system depending on deficiencies. Last report dated 3/6/15, listed 86 deficiencies.

4) Two fire sprinkler heads located within eighteen inches of each other.

The finding include:

1) During record review March 16, 2015 at 10:30 AM the facility failed to produce documentation for the quarterly testing of the facility's fire sprinkler system as required by NFPA 25 (1998 edition) chapter 2.3. The Director of Facility Services confirmed the fire sprinkler system were not tested during the 2nd, 3rd, and 4th quarter of 2014.

2) While on tour on March 16, 2015 at 4:00 PM with the Director of Facility Services, in OR/ storage room, observed solid shelving being used and is obstructing the existing fire sprinkler. NFPA 13 (1999 edition) chapter 8.5.5.1 requires fire sprinklers be located so as to minimize obstructions or add additional heads. The Director of Facility Services confirmed that solid shelving were installed.

3) While on tour March 16, 2015 at 2:15-2:45 PM in the fire sprinkler system riser rooms with the Director of Facility Services, observed the sprinkler risers "RED TAG", red tags on an fire sprinkler riser indicates an inoperable sprinkler system depending on deficiencies. Last report dated 3/6/15, listed 86 deficiencies. The Director of Facility Services confirmed the fire sprinkler systems was inoperable due to deficiencies. NFPA 101 (2000 edition) 19.7.6 & 9.7.5 requires fire sprinkler systems to be in operable condition at all times.

4) While on tour March 16, 2015 at 11:25 AM in sleep lab #1 with the Director of Facility Services, two sprinkler heads were observed approximately eighteen inches from each other. Sprinkler heads too close in proximity are an obstruction to the sprinkler heads water spray and also affect the sprinkler response time in case of a fire. NFPA 13 (1999 edition) chapter 8.5.5 prohibits obstructions to sprinkler discharge. The Director of Facility Services confirmed the fire sprinkler heads were too close to each other.

Based on observation and interview, the facility failed to maintain their portable fire extinguishers. An fire extinguisher cabinet was missing location signage. Delayed access to a fire extinguisher during a fire emergency would endanger patients, visitors and staff.

The findings include:

While on tour March 17, 2015 at 11:20 AM in cafe/dining area with the Director of Facility Services, observed fire extinguisher cabinet missing location signage.

The Director of Facility Services confirmed on March 17, 2015 at 11:20 AM, the missing signage. NFPA 101 (2000 edition) chapter 19.3.5.6 & NFPA 10 (1998 edition) requires a means to be provided to identified extinguisher location.

Based on observation and interview, the facility failed to maintain their HVAC and ventilating system.
1) The residents bath exhaust on one wing was inoperative.
2) Dryer ventilating system not maintained.

The findings include:

1) While on tour March 17, 2015 at 12:15 PM in room 104 with the Director of Facility Services, the bath exhaust grille failed to retain a sheet of toilet tissue when held to the grille by the Director of Facility Services. Room 105 & 106's grille also failed to retain tissue. The remaining rooms in the 100 wing are on the same power roof ventilator. NFPA 101 (2000 edition) chapter 9.2., 19.5.2.2 & NFPA 90A (1999 edition) requires maintenance of required systems.
2) While on tour March 17, 2015 at 11:00 AM in housekeeping area with Director of Facility Services, observed lint build-up behind, around, and in dryer's filter.
3) The Director of Facility Services confirmed on March 17, 2015 at 11:00AM, that the dryer's ventilating system was not maintained. NFPA 101 (2000 edition) chapter 9.2., 19.5.2.2 & NFPA 90A (1999 edition) requires maintenance of required systems.

Based on records review, observation, and interview, the facility failed to maintain kitchen hood system.

1) Kitchen hood system monthly "quick check" inspection not performed. Delays in activation of hood system fire suppression, endanger residents, visitors, and staff during an emergency.
2) Hood fire suppression nozzles aligned improperly and cooking equipment aligned incorrectly. Malfunction of hood fire suppression system increases injury for residents, visitors, and staff.

Finding include:
1) While on tour March 17, 2015 at 10:48 AM in the kitchen with the Director of Facility Services, the kitchen hood fire suppression nozzles were aligned improperly and cooking equipment aligned incorrectly.

The Director of Facility Services confirmed on March 17, 2015 at 10:48 AM, the kitchen hood nozzles were aligned improperly. NFPA 96 (1998 edition) chapter 8.2.2 requires all hood system components to be checked for proper operation and location.

2) During records review on March 16, 2015 at 11:05 AM with the Director of Facility Services, the facility faiedl to produce documentation for kitchen hood system monthly inspections.

The Director of Facility Services confirmed on March 16, 2015 at 11:05 AM, the kitchen hood system were inspected quarterly. NFPA 17A (1998 edition) chapter 5.2.1 requires monthly "quick check" inspection.

Based on observation and interviews, the facility failed to provide an environment free from electrical hazards.

1) The facility failed to maintain, test, and inspect patient care equipment which can render a piece of equipment out of compliance and could fail to perform properly endangering the patients, staff, and other building occupants.
2) Observation on March 16, 2015 at 10:55 AM showed that the power strip was plugged into another power strip.

The findings include:
1) During record review on March 16, 2015 at 10:55 AM with the Director of Facility Services, the facility failed to produce documentation for testing of patient care equipment (electric beds). Equipment is required to be tested annually and was found to be out of compliance. The Director of Facility Services acknowledged the equipment was not in compliance at the time of survey and Bio-medical company will be contacted. All equipment shall be properly serviced, tested and repaired in accordance with NFPA 70 (1999) Article 517 & NFPA 99 (1999 edition).

2) While on tour March 16, 2015 at 3:00 PM in Meds room/2nd floor with the Director of Facility Services, observed two refrigerators plugged into a power strip. Director of Facility Services confirmed use of power strip. NFPA 101 (2000 edition) 9.1.2 & NFPA 70 (1999 edition) article 400-8 prohibits cords as a substitute for fixed wiring.

3) While on tour March 17, 2015 at 12:30 PM in nursery/doctor's sleeping room with the Director of Facility Services, observed a power strip plugged into a power strip with several electrical devices plugged into power strip. Director of Facility Services confirmed use of power strips. NFPA 101 (2000 edition) 9.1.2 & NFPA 70 (1999 edition) article 400-8 prohibits cords as a substitute for fixed wiring.