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By observation on 7/20/11 at approximately noon the following exit access was non-compliant, specific findings include courtyard between the hospital and the long term care facility had lockable passage hardware.

By observation on 7/20/11 at approximately noon the following fire alarm system requirement was non-compliant, specific findings include, "ER/OR/LAB Chimes" was in a trouble condition after the fire alarm system was tested. The trouble reset itself after a period of approximately 10 minutes. This bypass switch was not touched during the testing of the fire alarm system and should not have been in a trouble condition during the survey.

Based on record review and staff interview, the facility sprinkler system was not being tested in accordance with NFPA 25 - Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems (1999 edition), specific findings include;

A. Documentation indicated failure to demonstrate inspection, testing and maintenance in accordance with NFPA 25 1-4.2.

B. Annual sprinkler system certification noted "Tamper 21 in basement did not work". The item had not been corrected at the time of the survey.

By observation on 7/20/11 at approximately noon the facility's cooking system was not protected in accordance with NFPA 96 - Ventilation Control and Fire Protection of Commercial Cooking Operations.
Specific findings include; the deep fryer was located next to a prep serving area without the required splash guard in the dietary kitchen.

By observation on 7/20/11 at approximately noon the following medical gas storage was non-compliant, specific findings include, the nitrous oxide and oxygen e-tanks in gas storage was gang chained together. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation. [NFPA 99 4-3.1.1.2 a(3)]

By observation on 7/20/11 at approximately noon the following exit access was non-compliant, specific findings include courtyard between the hospital and the long term care facility had lockable passage hardware.

By observation on 7/20/11 at approximately noon the following fire alarm system requirement was non-compliant, specific findings include, "ER/OR/LAB Chimes" was in a trouble condition after the fire alarm system was tested. The trouble reset itself after a period of approximately 10 minutes. This bypass switch was not touched during the testing of the fire alarm system and should not have been in a trouble condition during the survey.

Based on record review and staff interview, the facility sprinkler system was not being tested in accordance with NFPA 25 - Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems (1999 edition), specific findings include;

A. Documentation indicated failure to demonstrate inspection, testing and maintenance in accordance with NFPA 25 1-4.2.

B. Annual sprinkler system certification noted "Tamper 21 in basement did not work". The item had not been corrected at the time of the survey.

By observation on 7/20/11 at approximately noon the facility's cooking system was not protected in accordance with NFPA 96 - Ventilation Control and Fire Protection of Commercial Cooking Operations.
Specific findings include; the deep fryer was located next to a prep serving area without the required splash guard in the dietary kitchen.

By observation on 7/20/11 at approximately noon the following medical gas storage was non-compliant, specific findings include, the nitrous oxide and oxygen e-tanks in gas storage was gang chained together. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation. [NFPA 99 4-3.1.1.2 a(3)]