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1) Based on observation and interview with staff, the facility failed to protect corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas with substantial doors, such as those constructed of 1? inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in sprinkled buildings are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Doors shall be provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted. 19.3.6.3 Roller latches are prohibited by CMS regulations in all health care facilities. Findings include:

a) Door to Dietary did not have latching hardware.

1) Based on observation and interview with staff, the facility failed to provide a fire alarm system that is required for life safety and is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. The system did not have an approved maintenance and testing program complying with applicable requirements of NFPA 70 and 72. 9.6.1.4 Findings include:

a) The combination fire and smoke damper that opens and closes on the activation of the fire alarm was not documented on the annual fire alarm inspection report, dated May 8, 2013.

b) The facility did not have a Directory of Points and had not conducted an assessment of inspection that all devices were tested. No documentation of assessment, performance improvement, or evaluation of services provided by the Fire Alarm Contractor was made .


c) The Annual inspection of May 8, 2013 left the system Yellow Tagged. On June 19, 2013 the system was Green Tagged, however no acceptance test documenting corrections was made.

1) Based on observation, interview with staff, the facility failed to provide heating, ventilating, and air conditioning systems that comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2 Findings include:

a) Exhaust fans located on the roof did not work. Fans belts were cracked and broken, motors were burnt out.

b) The Isolation Room exhaust did not function.

1) Based on observation and interview with staff, the facility failed to continuously maintain egress corridors that are free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects obstruct exits, access to, egress from, or visibility of exits. 7.1.10 Findings include:

a) The copy machine and three shredding bins were staged and being used in the egress corridor on the east wing by Dietary.

1) Based on observation and interview with staff, the facility failed to inspect weekly and exercis the Generator under load for 30 minutes per month in accordance with NFPA 99. 3.4.4.1. Findings include:

a) The Emergency Generator Testing Record adopted by the facility was not filled out completely. The Transfer Switch Time Automatic Mode Box was not checked. The run time does not indicate under load or gives what percent of name plate rating the generator is run on.

1) Based on observation and interview with staff, the facility failed to provide Electrical wiring and equipment that is in accordance with NFPA 99,70, National Electrical Code. 9.1.2. Findings include:

a) Impedance testing of patient care areas is not a part of a Preventive Maintenance Program. 3-3.3.2.5. Measurements plus or minus of +/- 20% shall be made in patient Care Areas

b) Receptacle Testing in Patient Care Areas is not a part of a Preventive Maintenance Program in accordance with 3-3.3.3. Physical Integrity, continuity of the ground, correct polarity, and retention shall be documented.

c) The hospital failed to adopt regulations and practices concerning the use of electric appliances and failed to establish programs for the training of physicians, nurses, and other personnel who might be involved in the procurement, application, use inspection, testing, and maintenance of electrical appliances for the care and use around patients NFPA 99 7-6.5.
The governing body failed to document or ensure that the services performed under a contract are provided in a safe and effective manner. No documentation of assessment, performance improvement, or evaluation of services provided by the BIO-Medical Contractor.

1) Based on observation and interview with staff, the facility failed to protect corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas with substantial doors, such as those constructed of 1? inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in sprinkled buildings are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Doors shall be provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted. 19.3.6.3 Roller latches are prohibited by CMS regulations in all health care facilities. Findings include:

a) Door to Dietary did not have latching hardware.

1) Based on observation and interview with staff, the facility failed to provide a fire alarm system that is required for life safety and is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. The system did not have an approved maintenance and testing program complying with applicable requirements of NFPA 70 and 72. 9.6.1.4 Findings include:

a) The combination fire and smoke damper that opens and closes on the activation of the fire alarm was not documented on the annual fire alarm inspection report, dated May 8, 2013.

b) The facility did not have a Directory of Points and had not conducted an assessment of inspection that all devices were tested. No documentation of assessment, performance improvement, or evaluation of services provided by the Fire Alarm Contractor was made .


c) The Annual inspection of May 8, 2013 left the system Yellow Tagged. On June 19, 2013 the system was Green Tagged, however no acceptance test documenting corrections was made.

1) Based on observation, interview with staff, the facility failed to provide heating, ventilating, and air conditioning systems that comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2 Findings include:

a) Exhaust fans located on the roof did not work. Fans belts were cracked and broken, motors were burnt out.

b) The Isolation Room exhaust did not function.

1) Based on observation and interview with staff, the facility failed to continuously maintain egress corridors that are free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects obstruct exits, access to, egress from, or visibility of exits. 7.1.10 Findings include:

a) The copy machine and three shredding bins were staged and being used in the egress corridor on the east wing by Dietary.

1) Based on observation and interview with staff, the facility failed to inspect weekly and exercis the Generator under load for 30 minutes per month in accordance with NFPA 99. 3.4.4.1. Findings include:

a) The Emergency Generator Testing Record adopted by the facility was not filled out completely. The Transfer Switch Time Automatic Mode Box was not checked. The run time does not indicate under load or gives what percent of name plate rating the generator is run on.

1) Based on observation and interview with staff, the facility failed to provide Electrical wiring and equipment that is in accordance with NFPA 99,70, National Electrical Code. 9.1.2. Findings include:

a) Impedance testing of patient care areas is not a part of a Preventive Maintenance Program. 3-3.3.2.5. Measurements plus or minus of +/- 20% shall be made in patient Care Areas

b) Receptacle Testing in Patient Care Areas is not a part of a Preventive Maintenance Program in accordance with 3-3.3.3. Physical Integrity, continuity of the ground, correct polarity, and retention shall be documented.

c) The hospital failed to adopt regulations and practices concerning the use of electric appliances and failed to establish programs for the training of physicians, nurses, and other personnel who might be involved in the procurement, application, use inspection, testing, and maintenance of electrical appliances for the care and use around patients NFPA 99 7-6.5.
The governing body failed to document or ensure that the services performed under a contract are provided in a safe and effective manner. No documentation of assessment, performance improvement, or evaluation of services provided by the BIO-Medical Contractor.