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Based on observation and interview, the facility failed to ensure four of four pair of self-closing doors in smoke and fire barriers were equipped with astragals (a vertical metal or fire resistant strip on one or both doors to prevent the spread of smoke or fire into unaffected areas) in areas of new construction in accordance with 18.3.7.8.

The Centers for Medicare and Medicaid Services has determined that after March 13, 2003, any expansion or major modification in an existing facility involving 50 percent or more that 4,500 square feet of the involved smoke compartment must be surveyed under the 2000 New Life Safety Code. (Appendix I)

This deficient practice potentially affects all staff and patients by protecting them from the spread of smoke or fire throughout the structure into unaffected areas. The facility census was 10.

Findings included:

1. Observation on 03/03/14 from 3:30 PM through 3:55 PM showed the following:
- No astragal on a pair of smoke doors in the corridor outside of the Lab, across from the conference room.
- No astragal on a pair of badge-access secured smoke doors between the lobby and medical-surgical corridor.
- No astragal on a pair of smoke doors in a service corridor between the ambulance entrance and the medical-surgical corridor.
- No astragal on a pair of smoke doors in a service corridor outside of a mechanical room and ambulance entrance.

2. During an interview on 03/03/14, Staff S, Director of Engineering, stated that the doors were part of a 2009 project, a major expansion that more than doubled the size of the original 1960's hospital. He stated he did not know that astragals were required in new construction.

Based on observation and interview, the facility failed to maintain a one hour fire wall integrity of a large unassigned shell space being used for general storage of combustible products in accordance with 19.3.2.1, and failed to ensure a one hour wall and door integrity of a maintenance shop room where flammable paints, adhesives, and bottled propane gases are located. These deficient practices present a hazard of fire and smoke and potentially affect any staff and patients in the south portion of the old (original structure) building. The patient census was 10.

Findings included:

1. Observations on 03/03/14 at 3:00 PM showed a large, unsprinklered, unfinished room at the south end of the facility. The west wall was finished with drywall on both sides to the monolithic corridor ceiling outside. Exposed steel studs to the roof deck were on the east wall, finished only on the outside corridor connecting to general staff and public dining area. The entry door to the shell space was not rated, and was located off of a southwest corridor listed on the facility evacuation plan as an egress to a designated fire exit. The contents of the room were pieces of unused hospital furniture, plastic and wood materials, pallets and miscellaneous storage boxed in corrugated cardboard boxes.

2. Observations on 03/03/14 at 3:20 showed flammable paints, adhesives and three small bottles of propane gas (for propane stove or lantern) in a room used by maintenance located off of a service corridor of offices and storage in the old part of the building. The room smelled strongly of paint fumes and the non-rated door did not adequately protect the corridor.

During interviews on 03/03/14 at 3:30 PM, Staff S, Director of Engineering, stated that the fate of the unfinished room was still undecided and it was serving as temporary storage overflow for several departments. Regarding the small maintenance shop, he stated that the small unsprinklered and unvented room was used by maintenance as a shop, and it "could contain a little of anything." He stated that the walls did extend above the ceiling to the roof deck. He stated the facility did not currently have a protective cabinet specifically designed for storage of the hazardous and flammables materials.

Based on observation and interview, the facility failed to maintain a clear, unobstructed path of egress to an exit at the southwest corner of the building. This deficient practice affects one of three exits on the south and west side of the building and failure to provide a readily accessible exit in the event of a fire emergency potentially affects all staff working in the kitchen and surgical suites, and any visitors, staff or patients in the dining room. The facility census was 10.

Findings included:

1. Observation on 03/03/14 at 3:00 PM showed the eight foot wide unsprinklered exit corridor on the southwest side of the surgery suite was significantly reduced by excess equipment stored in the corner and along both walls within 25 feet of the exit door. Three large five foot long by two foot deep carts of bagged soiled linen, a wheeled gurney that measured six feet long by three feet wide, and a self-propelled floor scrubber that measured four feet long by 20 inches wide. A three foot wide by 12 inch deep metal radiator attached to the east wall further added to the conflicted space. At the narrowest point, the clear distance between the soiled linen carts and the floor scrubber measured three and one-half feet wide. The bagged soiled linen compounded the fire hazard due to the combustible nature of ammonia byproducts from urine soaked bedding packed into plastic bags, then stored in bulk in a unsprinklered exit corridor.

2. Observation on 03/04/14 at 12:53 AM showed the three large linen carts in the same location had not been moved, the floor scrubber and bed were also parked in relatively the same location and remained so throughout the afternoon, with the narrowest clear space about three feet wide.

3. Observation on 03/05/14 at 10:12 AM showed the three linen carts unmoved and each half full of bagged soiled linen. The floor scrubber was in approximately the same position and the gurney had been replaced with a four foot wide by 18 inches deep clean linen cart. The clear space width of the corridor was down to two and one half feet. A cloth cover over the linen cart represented the only separation between clean and soiled linen in this confined corridor space.

During interviews on 03/04/14 at 3:00 PM and 03/05/14 at 2:00 PM, Staff S, Director of Engineering, acknowledged the finding and stated that he would ask about finding another place for the linen carts. He stated that the linen from the medical-surgical beds and remainder of the hospital was collected there to be picked up by the contracted laundry service. He stated that the floor scrubber and gurney are used, but parked there when not in use.

During an interview on 03/05/14 at 10:12 PM, Staff HHH, Environmental Services Worker, stated that the soiled linen came from all over the hospital, mostly medical-surgical patient wing and was deposited daily into the containers. She stated that it was held there until picked up by the laundry service contractor, but she was not sure of the pick-up schedule.

Based on record review and interview, the facility failed to ensure it scheduled and conducted fire drills a minimum of quarterly on each shift in accordance with 19.7.1.2. This deficient practice affects staff preparedness and poor or inadequate fire safety training could directly affect the safety and lives of patients. The facility census was 10.

Findings included:

1. Record review on03/04/14 at 1:30 PM showed only one fire drill had been conducted in the past 12 months on 12/30/13. Only two fire drills were conducted the year before, on 01/19/12, and 02/17/12.

During an interview on 03/04/14 at 1:50 PM, Staff S, Director of Engineering, stated that fire drills are run quarterly. He stated that there is no written procedure to direct the scheduling of fire drills. He stated that he returned to work at the facility in May of 2012 and this was one of the areas where he had not caught up.

Based on observation and interview, the facility failed to ensure all smoke detection systems in the facility were tested and maintainedin accordance with 9.6.1.3 and NFPA72, Chapter 10.4. -This deficient practice could prevent timely early detection of smoke in patient bathrooms/bedrooms and puts residents and staff at risk in the Behavioral Health Unit (BHU). The facility census was 10.

Findings included:

1. Observation on 03/04/14 at 9:30 AM showed the smoke detectors in the bathrooms of patient room 110 and patient room 105 was covered with pink plastic covers (protective cover used during construction, typically removed during the final punch list phase, after the completion of installation and construction).

2. During interviews on 03/04/14 at 9:30 AM, Staff S, Director of Engineering, stated that the covers had probably been on them since installation, which was completed during the 2009 expansion. He stated that the smoke detection systems have been inspected since then but apparently no inspector ever noted or mentioned the covers.He stated that he does not test the smoke detectors; he "just pulls the fire alarms and checks the extinguishers." He stated that he did not know when the smoke detection system was last tested for sensitivity.

3. Record review on 03/04/14 at 1:30 PM showed the last annual inspection of the smoke detector and fire alarm system was completed on 04/02/13, following the installation of a new fire alarm panel for the Behavioral Health Unit.

Based on observation and interview the facility failed to ensure sprinkler coverage in all newly constructed areas of the facility in accordance with 8.15.8.2, (NFPA 13, 2010 edition) and provide sprinkler coverage to all areas of the facility constructed in 2009 with dimensions in excess of 24 square feet. This deficient practice creates a gap in the facility's sprinkler coverage that potentially affects all patients and staff in the Emergency Department area. The facility census was 10.

The Centers for Medicare and Medicaid Services has determined that after March 13, 2003, any expansion or major modification in an existing facility involving 50 percent or more that 4,500 square feet of the involved smoke compartment must be surveyed under the 2000 New Life Safety Code. (Appendix I)

Findings included:

1. Observation on 03/04/14 at 8:55 AM showed a janitor's storage closet in a corridor outside of the Emergency Department measured about four feet wide by four feet deep and was not equipped with an automatic sprinkler. The closet was enclosed by a one hour wall to the roof deck and protected by a self-closing rated door. However, the closet created an unprotected concealed space on a designated exit corridor which also served as the ambulance entrance for emergent cases arriving at the hospital.

2. During an interview at the same date and time, Staff S, Director of Engineering, acknowledged the observation and stated that the missing sprinkler head should have been noted on the punch list at the close of the 2009 construction project.

Based on observation, record review and interview, the facility failed to conduct quarterly and annual inspections on the automatic sprinkler system in accordance with 19.7.6 and 4.6.12, and NFPA 25, chapter 9.7.5. This deficient practice may cause mechanical or water pressure problems to go unnoticed and lead to failure of the system to function as designed in a fire emergency and potentially endangers the staff and patients in the hospital. The facility census was 10.

Findings included:

1. Observations on 03/03/14 at 3:00 PM through 03/05/14 at 10:00 AM showed half of the facility had automatic sprinklers and the older, original portion of the building was not sprinklered. The 2009 expansion, which provided accommodations for 13medical-surgical patient rooms, exam rooms, special procedure room, emergency department, CT (Computerized Tomography scanner), Pharmacy, and several business offices, was completely sprinklered in accordance with Centers for Medicare & Medicaid Services regulations for new construction after 2003.

2. Record review on 03/04/14 at 1:30 PM showed no documented quarterly inspections by maintenance and no annual inspections of the facility's automatic sprinkler system during the past 12 months. Facility records the last inspection of the facility's automatic sprinkler system was on 10/18/11, two years ago.

3. During an interview on 03/04/14 at 2:00 PM, Staff S, Director of Engineering, stated that he thought he had more current data but was not sure where it was. He stated that he returned to work at the facility in May of 2012 and this was one of the areas where he had not caught up.

Based on record review and interview, the facility failed to ensure the kitchen range hood received biannual (twice yearly) inspections and testing in accordance with 9.2.3. Failure to ensure this fire suppression system was deployable potentially endangers the kitchen personnel working in the area, and increases the chances of a grease fire getting out of control in an unsprinklered area of the building. The facility census was 10.

Findings included:

1. Record review on 03/04/14 at 1:30 PM showed the kitchen range hood's fire suppression system only received one inspection in 2013. The last semi-annual inspection of the kitchen range hood's fire suppression system was on 09/27/13. The previous one was conducted on 09/25/12 and there were no records to indicate an inspection had been performed within six months of the past one.

2. During an interview on 03/04/14 at 2:00 PM, Staff S, Director of Engineering, stated that he could not find the requested information, but would continue to look through his papers to see it if he could find out if two inspections were done during the past 12 months.

Based on observation and interview, the facility failed to provide for safe storage for large quantities of bagged soiled linen containing urine and wastes exceeding 32 gallons, in approved containers or within a 1-hour protected enclosure. This deficient practice is exacerbated by the combination of combustibles (ammonia vapors from urine soaked linen in plastic bags) stored in a corridor that is listed as a designated fire exit on the facility evacuation plans, and presents an imminent threat to any staff and patient evacuees trapped in the exit corridor. The facility census was 10.

Findings included:

1. Observation on 03/03/14 at 3:00 PM showed three large soiled linen holding carts were stored in the hallway (which is a designated fire exit) at the south end of the building. The three large soiled linen storage carts, each were five feet long by five feet wide by two foot deep and were packed half full of bagged soiled linen, each cart holding 354 gallons of soiled linen for a total of 1,062 gallons of stored soiled linen, this significantly increased the fire load in the eight foot wide unsprinklered exit corridor on the southwest side of the surgery suite. The bagged soiled linen compounded the fire hazard due to the combustible nature of ammonia byproducts from urine soaked bedding packed into plastic bags, then stored in bulk the exit corridor.

2. Observation on 03/04/14 at 12:53 AM showed the three large linen carts in the same location had not been moved.

3. Observation on 03/05/14 at 10:12 AM showed the three linen carts unmoved and each half full of bagged soiled linen.

During interviews on 03/04/14 at 3:00 PM and 03/05/14 at 2:00 PM, Staff S, Director of Engineering, acknowledged the finding and stated that he would ask about finding another place for the linen carts. He stated that the linen from the medical-surgical beds and remainder of the hospital was collected there to be picked up by the contracted laundry service.

During an interview on 03/05/14 at 10:12 PM, Staff HHH, Environmental Services Worker, stated that the soiled linen came from all over the hospital, mostly medical-surgical patient wing and was deposited daily into the containers. She stated that it was held there until picked up by the laundry service contractor.

(NFPA 101, Chapter 19.7.5.5)
Soiled linen or trash collection receptacles do not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space does not exceed 0.5 gal/sq ft (20.4 L/sq m). A capacity of 32 gal (121 L) is not exceeded within any 64 sq ft (5.9-sq m) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) are located in a room protected as a hazardous area when not attended.

Based on observation and interview, the facility failed to provide secure storage of medical gases in accordance with NFPA 99, (5.1.3.3.2(7)) with racks, chains or other fastenings to individually secure all cylinders, whether connected, unconnected, full, or empty, to prevent them from falling or inadvertently being tipped over during change-outs. This deficient practice creates the potential hazard of a cylinder becoming a projectile that could maim or kill, and a threat to staff, visitors and patients. The facility census was 10.

Findings included:

1. Observation on 03/03/14 at 3:15 PM 12 "H" size cylinders of compressed gases stored outdoors in a fenced plot next to the building. Several were group chained together with covers removed and tubing attached to manifolds that fed the facility medical gas system. The cylinders were not individually racked or restrained to sufficiently protect them from being tipped over during change out or to protect them during movement of other cylinders within the confines of the room.

2. Observation on 03/03/14 at 3:20 PM showed a room full of "E" size cylinders of compressed gases, chained together in a bundle of twos and threes against the wall. Most of the cylinders were in a rack, but several were group chained and six of the cylinders had missing caps, which exposed the vulnerable neck. Not individually restrained or equipped with a protective collar, or secured in a safe manner, there was nothing to prevent the cylinders from being tipped over and a valve knocked off or damaged.

3. During interviews on 03/03/14, at 3:30 PM, Staff S, Director of Engineering stated that he would add bridge supports between the cylinders so they could be individually chained.

Based upon observation and interview, the facility failed to store flammable liquids in an approved container suitable for storage of flammable and combustible liquids, in accordance with NFPA 30 and NFPA 99. This deficient practice-the storage of flammables in an unprotected, unsprinklered room, potentially affects the safety of staff and patients. The patient census was 10.

Findings included:

1.. Observations on 03/03/14 at 3:20 P.M. showed flammable paints, adhesives and three small bottles of propane gas (for propane stove or lantern) in a room used by maintenance located off of a service corridor of offices and storage in the old part of the building. The room unsprinklered and unvented room smelled strongly of paint fumes and the non-rated door did not adequately protect the corridor.

During interviews on 03/03/14 at 3:30 PM, Staff S, Director of Engineering, stated that the small room was used by maintenance as a shop, and it "could contain a little of anything." He stated that the walls did extend above the suspended ceiling to the roof deck. He stated the facility did not currently have a protective cabinet specifically designed for storage of the hazardous and flammables materials.

Based on observation and interview, the facility failed to ensure four of four pair of self-closing doors in smoke and fire barriers were equipped with astragals (a vertical metal or fire resistant strip on one or both doors to prevent the spread of smoke or fire into unaffected areas) in areas of new construction in accordance with 18.3.7.8.

The Centers for Medicare and Medicaid Services has determined that after March 13, 2003, any expansion or major modification in an existing facility involving 50 percent or more that 4,500 square feet of the involved smoke compartment must be surveyed under the 2000 New Life Safety Code. (Appendix I)

This deficient practice potentially affects all staff and patients by protecting them from the spread of smoke or fire throughout the structure into unaffected areas. The facility census was 10.

Findings included:

1. Observation on 03/03/14 from 3:30 PM through 3:55 PM showed the following:
- No astragal on a pair of smoke doors in the corridor outside of the Lab, across from the conference room.
- No astragal on a pair of badge-access secured smoke doors between the lobby and medical-surgical corridor.
- No astragal on a pair of smoke doors in a service corridor between the ambulance entrance and the medical-surgical corridor.
- No astragal on a pair of smoke doors in a service corridor outside of a mechanical room and ambulance entrance.

2. During an interview on 03/03/14, Staff S, Director of Engineering, stated that the doors were part of a 2009 project, a major expansion that more than doubled the size of the original 1960's hospital. He stated he did not know that astragals were required in new construction.

Based on observation and interview, the facility failed to maintain a one hour fire wall integrity of a large unassigned shell space being used for general storage of combustible products in accordance with 19.3.2.1, and failed to ensure a one hour wall and door integrity of a maintenance shop room where flammable paints, adhesives, and bottled propane gases are located. These deficient practices present a hazard of fire and smoke and potentially affect any staff and patients in the south portion of the old (original structure) building. The patient census was 10.

Findings included:

1. Observations on 03/03/14 at 3:00 PM showed a large, unsprinklered, unfinished room at the south end of the facility. The west wall was finished with drywall on both sides to the monolithic corridor ceiling outside. Exposed steel studs to the roof deck were on the east wall, finished only on the outside corridor connecting to general staff and public dining area. The entry door to the shell space was not rated, and was located off of a southwest corridor listed on the facility evacuation plan as an egress to a designated fire exit. The contents of the room were pieces of unused hospital furniture, plastic and wood materials, pallets and miscellaneous storage boxed in corrugated cardboard boxes.

2. Observations on 03/03/14 at 3:20 showed flammable paints, adhesives and three small bottles of propane gas (for propane stove or lantern) in a room used by maintenance located off of a service corridor of offices and storage in the old part of the building. The room smelled strongly of paint fumes and the non-rated door did not adequately protect the corridor.

During interviews on 03/03/14 at 3:30 PM, Staff S, Director of Engineering, stated that the fate of the unfinished room was still undecided and it was serving as temporary storage overflow for several departments. Regarding the small maintenance shop, he stated that the small unsprinklered and unvented room was used by maintenance as a shop, and it "could contain a little of anything." He stated that the walls did extend above the ceiling to the roof deck. He stated the facility did not currently have a protective cabinet specifically designed for storage of the hazardous and flammables materials.

Based on observation and interview, the facility failed to maintain a clear, unobstructed path of egress to an exit at the southwest corner of the building. This deficient practice affects one of three exits on the south and west side of the building and failure to provide a readily accessible exit in the event of a fire emergency potentially affects all staff working in the kitchen and surgical suites, and any visitors, staff or patients in the dining room. The facility census was 10.

Findings included:

1. Observation on 03/03/14 at 3:00 PM showed the eight foot wide unsprinklered exit corridor on the southwest side of the surgery suite was significantly reduced by excess equipment stored in the corner and along both walls within 25 feet of the exit door. Three large five foot long by two foot deep carts of bagged soiled linen, a wheeled gurney that measured six feet long by three feet wide, and a self-propelled floor scrubber that measured four feet long by 20 inches wide. A three foot wide by 12 inch deep metal radiator attached to the east wall further added to the conflicted space. At the narrowest point, the clear distance between the soiled linen carts and the floor scrubber measured three and one-half feet wide. The bagged soiled linen compounded the fire hazard due to the combustible nature of ammonia byproducts from urine soaked bedding packed into plastic bags, then stored in bulk in a unsprinklered exit corridor.

2. Observation on 03/04/14 at 12:53 AM showed the three large linen carts in the same location had not been moved, the floor scrubber and bed were also parked in relatively the same location and remained so throughout the afternoon, with the narrowest clear space about three feet wide.

3. Observation on 03/05/14 at 10:12 AM showed the three linen carts unmoved and each half full of bagged soiled linen. The floor scrubber was in approximately the same position and the gurney had been replaced with a four foot wide by 18 inches deep clean linen cart. The clear space width of the corridor was down to two and one half feet. A cloth cover over the linen cart represented the only separation between clean and soiled linen in this confined corridor space.

During interviews on 03/04/14 at 3:00 PM and 03/05/14 at 2:00 PM, Staff S, Director of Engineering, acknowledged the finding and stated that he would ask about finding another place for the linen carts. He stated that the linen from the medical-surgical beds and remainder of the hospital was collected there to be picked up by the contracted laundry service. He stated that the floor scrubber and gurney are used, but parked there when not in use.

During an interview on 03/05/14 at 10:12 PM, Staff HHH, Environmental Services Worker, stated that the soiled linen came from all over the hospital, mostly medical-surgical patient wing and was deposited daily into the containers. She stated that it was held there until picked up by the laundry service contractor, but she was not sure of the pick-up schedule.

Based on record review and interview, the facility failed to ensure it scheduled and conducted fire drills a minimum of quarterly on each shift in accordance with 19.7.1.2. This deficient practice affects staff preparedness and poor or inadequate fire safety training could directly affect the safety and lives of patients. The facility census was 10.

Findings included:

1. Record review on03/04/14 at 1:30 PM showed only one fire drill had been conducted in the past 12 months on 12/30/13. Only two fire drills were conducted the year before, on 01/19/12, and 02/17/12.

During an interview on 03/04/14 at 1:50 PM, Staff S, Director of Engineering, stated that fire drills are run quarterly. He stated that there is no written procedure to direct the scheduling of fire drills. He stated that he returned to work at the facility in May of 2012 and this was one of the areas where he had not caught up.

Based on observation and interview, the facility failed to ensure all smoke detection systems in the facility were tested and maintainedin accordance with 9.6.1.3 and NFPA72, Chapter 10.4. -This deficient practice could prevent timely early detection of smoke in patient bathrooms/bedrooms and puts residents and staff at risk in the Behavioral Health Unit (BHU). The facility census was 10.

Findings included:

1. Observation on 03/04/14 at 9:30 AM showed the smoke detectors in the bathrooms of patient room 110 and patient room 105 was covered with pink plastic covers (protective cover used during construction, typically removed during the final punch list phase, after the completion of installation and construction).

2. During interviews on 03/04/14 at 9:30 AM, Staff S, Director of Engineering, stated that the covers had probably been on them since installation, which was completed during the 2009 expansion. He stated that the smoke detection systems have been inspected since then but apparently no inspector ever noted or mentioned the covers.He stated that he does not test the smoke detectors; he "just pulls the fire alarms and checks the extinguishers." He stated that he did not know when the smoke detection system was last tested for sensitivity.

3. Record review on 03/04/14 at 1:30 PM showed the last annual inspection of the smoke detector and fire alarm system was completed on 04/02/13, following the installation of a new fire alarm panel for the Behavioral Health Unit.

Based on observation and interview the facility failed to ensure sprinkler coverage in all newly constructed areas of the facility in accordance with 8.15.8.2, (NFPA 13, 2010 edition) and provide sprinkler coverage to all areas of the facility constructed in 2009 with dimensions in excess of 24 square feet. This deficient practice creates a gap in the facility's sprinkler coverage that potentially affects all patients and staff in the Emergency Department area. The facility census was 10.

The Centers for Medicare and Medicaid Services has determined that after March 13, 2003, any expansion or major modification in an existing facility involving 50 percent or more that 4,500 square feet of the involved smoke compartment must be surveyed under the 2000 New Life Safety Code. (Appendix I)

Findings included:

1. Observation on 03/04/14 at 8:55 AM showed a janitor's storage closet in a corridor outside of the Emergency Department measured about four feet wide by four feet deep and was not equipped with an automatic sprinkler. The closet was enclosed by a one hour wall to the roof deck and protected by a self-closing rated door. However, the closet created an unprotected concealed space on a designated exit corridor which also served as the ambulance entrance for emergent cases arriving at the hospital.

2. During an interview at the same date and time, Staff S, Director of Engineering, acknowledged the observation and stated that the missing sprinkler head should have been noted on the punch list at the close of the 2009 construction project.

Based on observation, record review and interview, the facility failed to conduct quarterly and annual inspections on the automatic sprinkler system in accordance with 19.7.6 and 4.6.12, and NFPA 25, chapter 9.7.5. This deficient practice may cause mechanical or water pressure problems to go unnoticed and lead to failure of the system to function as designed in a fire emergency and potentially endangers the staff and patients in the hospital. The facility census was 10.

Findings included:

1. Observations on 03/03/14 at 3:00 PM through 03/05/14 at 10:00 AM showed half of the facility had automatic sprinklers and the older, original portion of the building was not sprinklered. The 2009 expansion, which provided accommodations for 13medical-surgical patient rooms, exam rooms, special procedure room, emergency department, CT (Computerized Tomography scanner), Pharmacy, and several business offices, was completely sprinklered in accordance with Centers for Medicare & Medicaid Services regulations for new construction after 2003.

2. Record review on 03/04/14 at 1:30 PM showed no documented quarterly inspections by maintenance and no annual inspections of the facility's automatic sprinkler system during the past 12 months. Facility records the last inspection of the facility's automatic sprinkler system was on 10/18/11, two years ago.

3. During an interview on 03/04/14 at 2:00 PM, Staff S, Director of Engineering, stated that he thought he had more current data but was not sure where it was. He stated that he returned to work at the facility in May of 2012 and this was one of the areas where he had not caught up.

Based on record review and interview, the facility failed to ensure the kitchen range hood received biannual (twice yearly) inspections and testing in accordance with 9.2.3. Failure to ensure this fire suppression system was deployable potentially endangers the kitchen personnel working in the area, and increases the chances of a grease fire getting out of control in an unsprinklered area of the building. The facility census was 10.

Findings included:

1. Record review on 03/04/14 at 1:30 PM showed the kitchen range hood's fire suppression system only received one inspection in 2013. The last semi-annual inspection of the kitchen range hood's fire suppression system was on 09/27/13. The previous one was conducted on 09/25/12 and there were no records to indicate an inspection had been performed within six months of the past one.

2. During an interview on 03/04/14 at 2:00 PM, Staff S, Director of Engineering, stated that he could not find the requested information, but would continue to look through his papers to see it if he could find out if two inspections were done during the past 12 months.

Based on observation and interview, the facility failed to provide for safe storage for large quantities of bagged soiled linen containing urine and wastes exceeding 32 gallons, in approved containers or within a 1-hour protected enclosure. This deficient practice is exacerbated by the combination of combustibles (ammonia vapors from urine soaked linen in plastic bags) stored in a corridor that is listed as a designated fire exit on the facility evacuation plans, and presents an imminent threat to any staff and patient evacuees trapped in the exit corridor. The facility census was 10.

Findings included:

1. Observation on 03/03/14 at 3:00 PM showed three large soiled linen holding carts were stored in the hallway (which is a designated fire exit) at the south end of the building. The three large soiled linen storage carts, each were five feet long by five feet wide by two foot deep and were packed half full of bagged soiled linen, each cart holding 354 gallons of soiled linen for a total of 1,062 gallons of stored soiled linen, this significantly increased the fire load in the eight foot wide unsprinklered exit corridor on the southwest side of the surgery suite. The bagged soiled linen compounded the fire hazard due to the combustible nature of ammonia byproducts from urine soaked bedding packed into plastic bags, then stored in bulk the exit corridor.

2. Observation on 03/04/14 at 12:53 AM showed the three large linen carts in the same location had not been moved.

3. Observation on 03/05/14 at 10:12 AM showed the three linen carts unmoved and each half full of bagged soiled linen.

During interviews on 03/04/14 at 3:00 PM and 03/05/14 at 2:00 PM, Staff S, Director of Engineering, acknowledged the finding and stated that he would ask about finding another place for the linen carts. He stated that the linen from the medical-surgical beds and remainder of the hospital was collected there to be picked up by the contracted laundry service.

During an interview on 03/05/14 at 10:12 PM, Staff HHH, Environmental Services Worker, stated that the soiled linen came from all over the hospital, mostly medical-surgical patient wing and was deposited daily into the containers. She stated that it was held there until picked up by the laundry service contractor.

(NFPA 101, Chapter 19.7.5.5)
Soiled linen or trash collection receptacles do not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space does not exceed 0.5 gal/sq ft (20.4 L/sq m). A capacity of 32 gal (121 L) is not exceeded within any 64 sq ft (5.9-sq m) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) are located in a room protected as a hazardous area when not attended.

Based on observation and interview, the facility failed to provide secure storage of medical gases in accordance with NFPA 99, (5.1.3.3.2(7)) with racks, chains or other fastenings to individually secure all cylinders, whether connected, unconnected, full, or empty, to prevent them from falling or inadvertently being tipped over during change-outs. This deficient practice creates the potential hazard of a cylinder becoming a projectile that could maim or kill, and a threat to staff, visitors and patients. The facility census was 10.

Findings included:

1. Observation on 03/03/14 at 3:15 PM 12 "H" size cylinders of compressed gases stored outdoors in a fenced plot next to the building. Several were group chained together with covers removed and tubing attached to manifolds that fed the facility medical gas system. The cylinders were not individually racked or restrained to sufficiently protect them from being tipped over during change out or to protect them during movement of other cylinders within the confines of the room.

2. Observation on 03/03/14 at 3:20 PM showed a room full of "E" size cylinders of compressed gases, chained together in a bundle of twos and threes against the wall. Most of the cylinders were in a rack, but several were group chained and six of the cylinders had missing caps, which exposed the vulnerable neck. Not individually restrained or equipped with a protective collar, or secured in a safe manner, there was nothing to prevent the cylinders from being tipped over and a valve knocked off or damaged.

3. During interviews on 03/03/14, at 3:30 PM, Staff S, Director of Engineering stated that he would add bridge supports between the cylinders so they could be individually chained.

Based upon observation and interview, the facility failed to store flammable liquids in an approved container suitable for storage of flammable and combustible liquids, in accordance with NFPA 30 and NFPA 99. This deficient practice-the storage of flammables in an unprotected, unsprinklered room, potentially affects the safety of staff and patients. The patient census was 10.

Findings included:

1.. Observations on 03/03/14 at 3:20 P.M. showed flammable paints, adhesives and three small bottles of propane gas (for propane stove or lantern) in a room used by maintenance located off of a service corridor of offices and storage in the old part of the building. The room unsprinklered and unvented room smelled strongly of paint fumes and the non-rated door did not adequately protect the corridor.

During interviews on 03/03/14 at 3:30 PM, Staff S, Director of Engineering, stated that the small room was used by maintenance as a shop, and it "could contain a little of anything." He stated that the walls did extend above the suspended ceiling to the roof deck. He stated the facility did not currently have a protective cabinet specifically designed for storage of the hazardous and flammables materials.