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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 18, Section 18.3.6.3.1, 18.3.6.3.2, 18.3.6.3.3. Section 18. 18.3.6.3.1 "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 18.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 18.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On November 5, and 6 of 2014 the surveyor, accompanied by the Director of Facilities and staff, observed the following doors:

1. Door B 156 B, tested three of three times, will not positively latch.
2. Door B 158, tested three of three times, will not positively latch.
3. ED, Dr office/dictation room, two of two doors held open with an impediment.
4. Forth floor, door, 4 A 136 B & B, two door closing devices removed.
5. Forth floor, door 4 B 108,door closing devices removed.
6. Second floor, clinical educators office. Door 2 B 261, no door closing device, heavy fire load of combustibles.

During the Exit conference on November 6, 2014 the above findings were again acknowledged by the CEO, CNO, CFO, Chief Quality Officer, Quality Admin. Ast. and the Director of Facilities.

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 18, Section 18.3.7.6 "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 November 5, and 6 of 2014 the surveyor, accompanied by the Director of Facilities and staff, observed the smoke barrier doors labled B172 A & B are not smoke tight.

During the Exit conference on November 6, 2014 the above findings were again acknowledged by the CEO, CNO, CFO, Chief Quality Officer, Quality Admin. Ast. and the Director of Facilities.

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 did not maintain the integrity, smoke resistance, of doors in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 18, Section 18.3.2.1 requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls and doors must be able to resist the passage of smoke. NFPA 80 "Fire Doors and Fire Windows" Chapter 2, Section 2-3.1.7 "The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. +/- 1/16 in for steel doors and shall not exceed 1/8 in. for wood doors."

Findings include:

On November 5, and 6 of 2014 the surveyor, accompanied by the Director of Facilities and staff, observed the following hazardous area doors:

1. Door B 184 B, Decon room, door tested three of three times, will not positively latch.
2. Door B 181 A, door closing device removed.
3. Doors B 139 A & B, impeded by installed kick down door hold open devices.
4. B 144 no door closing device, room contains micro wave, toaster oven, coffee maker, and refrigerator.
5. Cath Lab, B 131 A & B impeded by installed kick down door hold open devices.
6. D 187, no door closing device, room contains flammables and combustibles.
7. Dry food storage, no door closing device, and the door is wedged open with an impediment.
8. Kitchen, door D 192, janitors closet, no door closing device, room contains chemicals.
9. Central supply, double rated doors and closing devices removed.
10. C 130 A door tested three of three times, will not close and positively latch.( storage of combustible goods on pallets).
11. Door 2 A 238, janitors closet with chemicals, no door closing device.

During the Exit conference on November 6, 2014 the above findings were again acknowledged by the CEO, CNO, CFO, Chief Quality Officer, Quality Admin. Ast. and the Director of Facilities.

When heat and smoke spread into the exit corridor this could cause harm to residents.

Based on observation and testing it was determined the facility failed to keep exit doors unlocked.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.2.1 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 7.2.1.5.1...Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided , shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side."

Findings include:

On November 5, and 6 of 2014 the surveyor, accompanied by the Director of Facilities and staff, observed and tested the two Pharmacy exit doors (C 117 & 120 A). Each exit door requires two motions to exit.

During the Exit conference on November 6, 2014 the above findings were again acknowledged by the CEO, CNO, CFO, Chief Quality Officer, Quality Admin. Ast. and the Director of Facilities.

Failure to have all exits unlocked during a fire or emergency will cause harm to the residents/patients.

Based on document review, and staff interview, it was determined, the facility failed to train the staff on life safety procedures and devices.

NFPA 101, Life Safety Code, 2000, Chapter 18, Section 18.7.1.3 "Employees of health care occupancies shall be instructed in life safety procedures and devices."

NFPA 101, Life Safety Code, 2000, Chapter 18, Section 18.7.1.2 "Fire exit drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions." "When drills are conducted between 9:00 p.m. and 6:00 a.m., a coded announcement shall be permitted to be used instead of a audible alarms."

Findings include:

On November 5, and 6 of 2014 the surveyor, accompanied by the Director of Facilities and staff, reviewed the Fire Prevention Management Plan, Fire Response Plan and the Fire Drill documents. Staff members were interviewed about their participation during the facilities Fire Drill training.

The facility does not practice the elements required by there Management Plans and CMS for all facility personnel on a quarterly requirement. Several employees in numerous departments stated they participated in one or two Fire Drills a year, several employees stated one fire drill per year. Two Nursing supervisors stated they do not clear the exit access corridors for the fire drills. Two Hospital areas (PACU and ED) have equipment that is not necessary for the immediate treatment of patients and reduced the exit access from eight feet to five feet six inches when measured. The equipment in the corridor are three stored beds, and a copy machine.
The facility has no Fire Drill training documentation for the Second quarter first shift of 2014.
The Third quarter first shift at 0956 AM, First floor Material control and the Kitchen did not activate the fire alarm.

During the Exit conference on November 6, 2014 the above findings were again acknowledged by the CEO, CNO, CFO, Chief Quality Officer, Quality Admin. Ast. and the Director of Facilities.

Failure to train and drill the staff on fire procedures could result in harm to the patients.

Based on observation it was determined the facility did not assure that all parts of the sprinkler system were in accordance with the UL Listing.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.3.1.5, "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.1.1 "Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems." NFPA 13, Chapter 3, Section 3-2.7.2, "Escutcheon Plates used with a recessed or flushed sprinkler shall be part of a listed sprinkler assembly."

Findings include:

On November 5, and 6 of 2014 the surveyor, accompanied by the Director of Facilities and staff, observed the OR 6 escutcheon plates are not smoke tight. The Escutcheon plate is part of the UL Listing of the sprinkler assembly.

During the Exit conference on November 6, 2014 the above findings were again acknowledged by the CEO, CNO, CFO, Chief Quality Officer, Quality Admin. Ast. and the Director of Facilities.

The gap in the escutcheon plate could allow heat and smoke to effect other areas of the building, which could cause harm to the residents/patients.

Based on observation, it was determined the facility failed to clean the kitchen exhaust hood system, filters and grease drip tray.

NFPA 101 Life Safety Code 2000, Chapter 18, Section 18-3.2.6,"Cooking facilities shall be protected in accordance with 9-2.3" Section 9-2.3 "Commercial cooking equipment shall be installed in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations." Chapter 8, Section 8-3.1, " Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge."

Findings include:

On November 5, and 6 of 2014 the surveyor, accompanied by the Director of Facilities and staff, inspected the kitchen exhaust system hood, the short line has three of five filters with an excessive amount of grease buildup.

During the Exit conference on November 6, 2014 the above findings were again acknowledged by the CEO, CNO, CFO, Chief Quality Officer, Quality Admin. Ast. and the Director of Facilities.

Failing to keep the entire kitchen exhaust hood system clean from grease could cause a delay in the fire suppression system to activate which could cause more damage to the kitchen and could cause harm to the residents.

Based on observation it was determined the facility exceeded the capacity of 32 gal (121 L ) within any 65-ft2 ( 5.9-m2)

NFPA 101 Life Safety Code, 2000 Chapter 18 Section 18.7.5.5 ' Soiled linen or trash collection receptacles shall not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gal/ft2 (20.4 L/m2). A capacity of 32 gal (121 L) shall not be exceeded within any 64-ft2 (5.9-m2) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) shall be located in a room protected as a hazardous area when not attended."

Findings include:

On November 5, and 6 of 2014 the surveyor, accompanied by the Director of Facilities and staff, observed the following:

1. ED, three 30 gal blue mobil soiled linen containers in a 64 square foot area to include recycle paper containers.
2. PACU, two combustible containers in excess of 32 gallons each.

During the Exit conference on November 6, 2014 the above findings were again acknowledged by the CEO, CNO, CFO, Chief Quality Officer, Quality Admin. Ast. and the Director of Facilities.

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

Based on observation, it was determined the facility failed to provide a medical gas cylinder storage room free of combustible materials.

NFPA 101 Life Safety Code 2000, Chapter 18, Section 18.3.2.4 "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...."

Findings include:

On November 5, and 6 of 2014 the surveyor, accompanied by the Director of Facilities and staff, observed room A 228 the bed repair shop. The room was not occupied and has combustibles stored in it. The room contains five E O2 bottles surrounded by the combustibles.

During the Exit conference on November 6, 2014 the above findings were again acknowledged by the CEO, CNO, CFO, Chief Quality Officer, Quality Admin. Ast. and the Director of Facilities.

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

Based on observation and testing it was determined the facility failed to maintain a medical gas alarm.

NFPA 101, Life Safety Code, 2000, Chapter 18 Section 18.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99 Standard for Health Care Facilities" Chapter 4, Section 4-5.1.2.8 "Warning Systems for gases." Section 4-5.1.2.8 (b) "A master system as required in 4-5.1.2.8 (a) shall be installed in each single treatment facility served by the supply system. The warning system shall be comprised of an audible and noncancellable visual signal and shall be installed to be heard and seen at a continuously attended location during the time of operation of the facility."

Findings include:

On November 5, of 2014 the surveyor, accompanied by the Director of Facilities and staff, attempted the functional test of the Medical Gas alarms, located in the Maintenance office and the Hospitals first floor. The alarm (s) system (s) did not function when tested.

During the Exit conference on November 6, 2014 the above findings were again acknowledged by the CEO, CNO, CFO, Chief Quality Officer, Quality Admin. Ast. and the Director of Facilities.

Failing to provide operating medical gas warning systems which will notify the Staff, if a leak should occur, may cause harm to the residents/patients.

Based on observation it was determined the facility allowed the use of a multiple outlet adapter, power strips and did not use the wall outlet receptacles for appliances.

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 November 5, of 2014 the surveyor, accompanied by the Director of Facilities and staff, observed refrigerators, microwaves, and medical equipment plugged into multi-outlet power strips, and power strips daise chained and not directly plugged in to the wall outlet receptacles in the following areas:

1. Extension cord plugged into medical equipment in surgery.
2. Surgery staff lounge, microwave plugged into power strip.
3. B 144, micro wave, refrigerator, coffee maker and toaster oven plugged into a power strip.
4. A 181, Cardio pulmonary break room, power strip with a micro wave plugged in.
5. Pharmacy narcotics room, refrigerators plugged into power strip.
6. Lab, Power strip daise chained to a power strip on Mobil cart.

During the Exit conference on November 6, 2014 the above findings were again acknowledged by the CEO, CNO, CFO, Chief Quality Officer, Quality Admin. Ast. and the Director of Facilities.

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.

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 18, Section 18.3.6.3.1, 18.3.6.3.2, 18.3.6.3.3. Section 18. 18.3.6.3.1 "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 18.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 18.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On November 5, and 6 of 2014 the surveyor, accompanied by the Director of Facilities and staff, observed the following doors:

1. Door B 156 B, tested three of three times, will not positively latch.
2. Door B 158, tested three of three times, will not positively latch.
3. ED, Dr office/dictation room, two of two doors held open with an impediment.
4. Forth floor, door, 4 A 136 B & B, two door closing devices removed.
5. Forth floor, door 4 B 108,door closing devices removed.
6. Second floor, clinical educators office. Door 2 B 261, no door closing device, heavy fire load of combustibles.

During the Exit conference on November 6, 2014 the above findings were again acknowledged by the CEO, CNO, CFO, Chief Quality Officer, Quality Admin. Ast. and the Director of Facilities.

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 18, Section 18.3.7.6 "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 November 5, and 6 of 2014 the surveyor, accompanied by the Director of Facilities and staff, observed the smoke barrier doors labled B172 A & B are not smoke tight.

During the Exit conference on November 6, 2014 the above findings were again acknowledged by the CEO, CNO, CFO, Chief Quality Officer, Quality Admin. Ast. and the Director of Facilities.

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 did not maintain the integrity, smoke resistance, of doors in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 18, Section 18.3.2.1 requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls and doors must be able to resist the passage of smoke. NFPA 80 "Fire Doors and Fire Windows" Chapter 2, Section 2-3.1.7 "The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. +/- 1/16 in for steel doors and shall not exceed 1/8 in. for wood doors."

Findings include:

On November 5, and 6 of 2014 the surveyor, accompanied by the Director of Facilities and staff, observed the following hazardous area doors:

1. Door B 184 B, Decon room, door tested three of three times, will not positively latch.
2. Door B 181 A, door closing device removed.
3. Doors B 139 A & B, impeded by installed kick down door hold open devices.
4. B 144 no door closing device, room contains micro wave, toaster oven, coffee maker, and refrigerator.
5. Cath Lab, B 131 A & B impeded by installed kick down door hold open devices.
6. D 187, no door closing device, room contains flammables and combustibles.
7. Dry food storage, no door closing device, and the door is wedged open with an impediment.
8. Kitchen, door D 192, janitors closet, no door closing device, room contains chemicals.
9. Central supply, double rated doors and closing devices removed.
10. C 130 A door tested three of three times, will not close and positively latch.( storage of combustible goods on pallets).
11. Door 2 A 238, janitors closet with chemicals, no door closing device.

During the Exit conference on November 6, 2014 the above findings were again acknowledged by the CEO, CNO, CFO, Chief Quality Officer, Quality Admin. Ast. and the Director of Facilities.

When heat and smoke spread into the exit corridor this could cause harm to residents.

Based on observation and testing it was determined the facility failed to keep exit doors unlocked.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.2.1 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 7.2.1.5.1...Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided , shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side."

Findings include:

On November 5, and 6 of 2014 the surveyor, accompanied by the Director of Facilities and staff, observed and tested the two Pharmacy exit doors (C 117 & 120 A). Each exit door requires two motions to exit.

During the Exit conference on November 6, 2014 the above findings were again acknowledged by the CEO, CNO, CFO, Chief Quality Officer, Quality Admin. Ast. and the Director of Facilities.

Failure to have all exits unlocked during a fire or emergency will cause harm to the residents/patients.

Based on document review, and staff interview, it was determined, the facility failed to train the staff on life safety procedures and devices.

NFPA 101, Life Safety Code, 2000, Chapter 18, Section 18.7.1.3 "Employees of health care occupancies shall be instructed in life safety procedures and devices."

NFPA 101, Life Safety Code, 2000, Chapter 18, Section 18.7.1.2 "Fire exit drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions." "When drills are conducted between 9:00 p.m. and 6:00 a.m., a coded announcement shall be permitted to be used instead of a audible alarms."

Findings include:

On November 5, and 6 of 2014 the surveyor, accompanied by the Director of Facilities and staff, reviewed the Fire Prevention Management Plan, Fire Response Plan and the Fire Drill documents. Staff members were interviewed about their participation during the facilities Fire Drill training.

The facility does not practice the elements required by there Management Plans and CMS for all facility personnel on a quarterly requirement. Several employees in numerous departments stated they participated in one or two Fire Drills a year, several employees stated one fire drill per year. Two Nursing supervisors stated they do not clear the exit access corridors for the fire drills. Two Hospital areas (PACU and ED) have equipment that is not necessary for the immediate treatment of patients and reduced the exit access from eight feet to five feet six inches when measured. The equipment in the corridor are three stored beds, and a copy machine.
The facility has no Fire Drill training documentation for the Second quarter first shift of 2014.
The Third quarter first shift at 0956 AM, First floor Material control and the Kitchen did not activate the fire alarm.

During the Exit conference on November 6, 2014 the above findings were again acknowledged by the CEO, CNO, CFO, Chief Quality Officer, Quality Admin. Ast. and the Director of Facilities.

Failure to train and drill the staff on fire procedures could result in harm to the patients.

Based on observation it was determined the facility did not assure that all parts of the sprinkler system were in accordance with the UL Listing.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.3.1.5, "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.1.1 "Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems." NFPA 13, Chapter 3, Section 3-2.7.2, "Escutcheon Plates used with a recessed or flushed sprinkler shall be part of a listed sprinkler assembly."

Findings include:

On November 5, and 6 of 2014 the surveyor, accompanied by the Director of Facilities and staff, observed the OR 6 escutcheon plates are not smoke tight. The Escutcheon plate is part of the UL Listing of the sprinkler assembly.

During the Exit conference on November 6, 2014 the above findings were again acknowledged by the CEO, CNO, CFO, Chief Quality Officer, Quality Admin. Ast. and the Director of Facilities.

The gap in the escutcheon plate could allow heat and smoke to effect other areas of the building, which could cause harm to the residents/patients.

Based on observation, it was determined the facility failed to clean the kitchen exhaust hood system, filters and grease drip tray.

NFPA 101 Life Safety Code 2000, Chapter 18, Section 18-3.2.6,"Cooking facilities shall be protected in accordance with 9-2.3" Section 9-2.3 "Commercial cooking equipment shall be installed in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations." Chapter 8, Section 8-3.1, " Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge."

Findings include:

On November 5, and 6 of 2014 the surveyor, accompanied by the Director of Facilities and staff, inspected the kitchen exhaust system hood, the short line has three of five filters with an excessive amount of grease buildup.

During the Exit conference on November 6, 2014 the above findings were again acknowledged by the CEO, CNO, CFO, Chief Quality Officer, Quality Admin. Ast. and the Director of Facilities.

Failing to keep the entire kitchen exhaust hood system clean from grease could cause a delay in the fire suppression system to activate which could cause more damage to the kitchen and could cause harm to the residents.

Based on observation it was determined the facility exceeded the capacity of 32 gal (121 L ) within any 65-ft2 ( 5.9-m2)

NFPA 101 Life Safety Code, 2000 Chapter 18 Section 18.7.5.5 ' Soiled linen or trash collection receptacles shall not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gal/ft2 (20.4 L/m2). A capacity of 32 gal (121 L) shall not be exceeded within any 64-ft2 (5.9-m2) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) shall be located in a room protected as a hazardous area when not attended."

Findings include:

On November 5, and 6 of 2014 the surveyor, accompanied by the Director of Facilities and staff, observed the following:

1. ED, three 30 gal blue mobil soiled linen containers in a 64 square foot area to include recycle paper containers.
2. PACU, two combustible containers in excess of 32 gallons each.

During the Exit conference on November 6, 2014 the above findings were again acknowledged by the CEO, CNO, CFO, Chief Quality Officer, Quality Admin. Ast. and the Director of Facilities.

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

Based on observation, it was determined the facility failed to provide a medical gas cylinder storage room free of combustible materials.

NFPA 101 Life Safety Code 2000, Chapter 18, Section 18.3.2.4 "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...."

Findings include:

On November 5, and 6 of 2014 the surveyor, accompanied by the Director of Facilities and staff, observed room A 228 the bed repair shop. The room was not occupied and has combustibles stored in it. The room contains five E O2 bottles surrounded by the combustibles.

During the Exit conference on November 6, 2014 the above findings were again acknowledged by the CEO, CNO, CFO, Chief Quality Officer, Quality Admin. Ast. and the Director of Facilities.

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

Based on observation and testing it was determined the facility failed to maintain a medical gas alarm.

NFPA 101, Life Safety Code, 2000, Chapter 18 Section 18.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99 Standard for Health Care Facilities" Chapter 4, Section 4-5.1.2.8 "Warning Systems for gases." Section 4-5.1.2.8 (b) "A master system as required in 4-5.1.2.8 (a) shall be installed in each single treatment facility served by the supply system. The warning system shall be comprised of an audible and noncancellable visual signal and shall be installed to be heard and seen at a continuously attended location during the time of operation of the facility."

Findings include:

On November 5, of 2014 the surveyor, accompanied by the Director of Facilities and staff, attempted the functional test of the Medical Gas alarms, located in the Maintenance office and the Hospitals first floor. The alarm (s) system (s) did not function when tested.

During the Exit conference on November 6, 2014 the above findings were again acknowledged by the CEO, CNO, CFO, Chief Quality Officer, Quality Admin. Ast. and the Director of Facilities.

Failing to provide operating medical gas warning systems which will notify the Staff, if a leak should occur, may cause harm to the residents/patients.

Based on observation it was determined the facility allowed the use of a multiple outlet adapter, power strips and did not use the wall outlet receptacles for appliances.

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 November 5, of 2014 the surveyor, accompanied by the Director of Facilities and staff, observed refrigerators, microwaves, and medical equipment plugged into multi-outlet power strips, and power strips daise chained and not directly plugged in to the wall outlet receptacles in the following areas:

1. Extension cord plugged into medical equipment in surgery.
2. Surgery staff lounge, microwave plugged into power strip.
3. B 144, micro wave, refrigerator, coffee maker and toaster oven plugged into a power strip.
4. A 181, Cardio pulmonary break room, power strip with a micro wave plugged in.
5. Pharmacy narcotics room, refrigerators plugged into power strip.
6. Lab, Power strip daise chained to a power strip on Mobil cart.

During the Exit conference on November 6, 2014 the above findings were again acknowledged by the CEO, CNO, CFO, Chief Quality Officer, Quality Admin. Ast. and the Director of Facilities.

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.