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Based on observation during facility tour, facility schematics and staff interview it was determined this facility failed to ensure the building construction type and height met the requirement of having a complete fire suppression system, specifically in regard to providing services to inpatients within an area designated as a business occupancy. This had the potential to affect all those who utilized this facility. The facility census at the beginning of the survey was 10.

Findings include:

1. Facility tour took place with staff members A1 and B2 on 06/24/13 and the morning of 06/25/13. During facility tour and review of the facility floor plans, two sections of this facility was observed as separated from each other by a two hour fire rated wall. The northern half was observed to be fully suppressed while the southern half was not suppressed with the exception of the gift shop and another room south of and adjacent to the gift shop. The southern half of the building was classified as a business occupancy.

2. The physical therapy department was located in the business occupancy portion of the building in the southeast section. Interview with Staff C-3 took place on 06/25/13 at 11:30 AM. Staff C-3 said the physical therapy department is utilized as an outpatient facility, but occasionally patients are brought over from the health care side of the facility for treatment. When questioned if the patients brought over are capable of self-preservation, Staff C-3 said patients are brought over for treatment in wheel chairs.

3. At 12:10 PM on 06/25/13, during an interview staff members D-4 and E-5, who both worked in the therapy department, said most of the patients served are geriatric patients. Staff D-4 said, approximately 10% of physical therapy patients served are brought over from the healthcare side of the facility. Staff E-5 stated, regarding occupational therapy, there are no outpatient services and all occupational therapy patients served are from the healthcare side of the facility and of those, some are brought over to the therapy department from the healthcare side.

These findings confirm this facility provides in-patient services to geriatric and other patients who may be transported from the healthcare side of the facility to the business occupancy side of the facility. Additionally, due to their age, injuries or surgical status, these patients may not be capable of self-preservation in the event of an emergency.

Based on observation during facility tour and staff verification it was determined this facility failed to ensure the hazardous area was protected in regard to self-closing doors. This had the potential to affect all those who utilized this facility. The facility census at the beginning of the survey was 10.

Findings include:

1. Facility tour took place with staff members A1 and B2 on 06/24/13 and the morning of 06/25/13. Observation during tour of the hazardous room within the surgery department identified two entrance/exit doors to this room. Both doors were equipped with a self-closing device. One of the two doors was equipped with a mechanism on the self closing device which, when activated, would hold the door open until the mechanism was deactivated. This door was observed to be in the open position and the room was unattended. The opposite door of this room was equipped with a self-closing device which did not have a mechanism as the first one did. This door was observed to be held open with a rubber wedge placed between the bottom of the door and the floor.

This finding was acknowledged by both staff members present during tour of the facility.

Based on observation during facility tour and staff verification it was determined this facility failed to ensure all exit discharges had a safe access to a paved common way for all patients, visitors and staff in the event of an emergency. This had the potential to affect all those who utilized this facility. The facility census at the beginning of the survey was 10.

Findings include:

1. Facility tour took place with staff members A1 and B2 on 06/24/13 and the morning of 06/25/13. During the tour of the first floor exit discharge, located at the southwest section of the building, observation was made of cement steps leading down to a sidewalk which ended abruptly approximately 15 feet from a paved common way. The 15 foot section was observed to be a grassy area which sloped upward toward the paved common way.

2. During tour of the first floor exit discharge located at the northeast section of the building observation was made of a sidewalk which led to a gazebo located in the middle of a fenced in grassy area. Approximately 45 feet from the gazebo was a large open area in the fence which bordered a paved common way. This span of 45 feet between the gazebo and the paved common way was observed to be grass.

These findings were verified by both staff members during tour of the facility.

Based on observation during facility tour and staff verification it was determined this facility failed to ensure all exit discharges were equipped with illumination arranged so that failure of any single lighting fixture will not leave the area in darkness. This had the potential to affect all those who utilized this facility. The facility census at the beginning of the survey was 10.

Findings include:

1. Facility tour took place with staff members A1 and B2 on 06/24/13 and the morning of 06/25/13. During the tour of the first floor exit discharge located at the southwest section of the building, observation was made of a single light fixture mounted on the wall outside of the exit discharge door. There was no other light source observed in the immediate area.

2. During the tour of the first floor exit discharge located at the northeast section of the building, observation was made of a single light fixture mounted on the wall outside of the exit discharge door. There was no other light source observed in the immediate area.

These findings were verified by both staff members during tour of the facility.

Based on sprinkler documentation review and staff interview it was determined this facility failed to ensure the sprinkler system was inspected quarterly as required by the National Fire Protection Association (NFPA) 25, Chapter 2-1. This had the potential to affect all those utilizing this facility. The patient census for this facility at the beginning of the survey was 10.

Findings include:

During sprinkler documentation review on 06/27/13 at approximately 8:00 AM., observation was made of quarterly test reports generated by a professional outside company for the first three quarters of 2012 and the first quarter of 2013. No additional sprinkler documentation was available in order to verify the sprinkler tests were performed during the fourth quarter of 2012. Interview with Staff A1 took place on 06/27/13 at approximately 8:50 AM. Staff A1 stated they do not have the fourth quarter sprinkler test report but will contact the contracted company, responsible for conducting the sprinkler tests, to see if they have the fourth quarter report. This report was not available by the time of the life safety exit conference.

Based on observation during tour and staff interview it was determined this facility failed to ensure all portable fire extinguishers were mounted so the top of the fire extinguisher was not greater than five feet from the floor. This had the potential to affect all those utilizing this area of the facility. The facility census was 10 at the beginning of the survey.

Findings include:

Facility tour took place with staff members A1 and B2 on 06/24/13 and the morning of 06/25/13. During the tour of the first floor radiology unit, intensive care unit and information technology department, observation was made of one fire extinguisher within each department. Each of these five fire extinguishers was mounted with the top of the fire extinguisher exceeding the five feet requirement. This finding was verified by both staff members during tour of the facility.

Based on interview it was determined this facility failed to ensure the heating/ventilation and air conditioning (HVAC) system inspections complied with the National Fire Protection Association (NFPA) 90A, Chapter 3-4.7 in regard to the testing of fire/smoke dampers. This had the potential to affect all those utilizing this facility. The current census at the beginning of the survey was 10.

Findings include:

During review of the HVAC fire/smoke damper preventative maintenance and test reports, on 06/26/13, at approximately 3:10 PM., Staff A1 confirmed the finding no documentation was available regarding the testing of fire/smoke dampers, because the dampers have never been checked.

Based on observation during tour and staff verification it was determined this facility failed to ensure the medical gas storage location was protected in accordance with the National Fire Protection Association (NFPA) 99, Chapter 8-3.1.11.3, specifically in regards to signage. This had the potential to affect all those utilizing this area of the facility. The facility census at the beginning of the survey was 10.

Findings include:

Facility tour took place with staff members A1 and B2 on 06/24/13 and the morning of 06/25/13. During the tour of the first floor medical gas room located across from the radiology waiting room, observation was made of no signage displayed on the door to inform occupants that this room contained oxidizing gasses. Observation of the room revealed oxidizing gasses were stored in the room. This finding was confirmed by both staff members during tour.

Based on observation during tour and staff verification, this facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all patient's, staff and visitors utilizing the facility. The facility census was 10 at the beginning of the survey.

Findings include:

Facility tour took place with staff members A1 and B2 on 06/24/13 and the morning of 06/25/13. During the tour of the first floor emergency department, surgery and medical surgical units, observation was made of smoke detectors located near air flow devices in the following locations:

Within room number 27 of the emergency department,

Within the surgery waiting area,

Within the rehabilitation room, and

Within room 49 of the medical surgical unit.

This finding was acknowledged by both staff members during facility tour.

Based on review of the documentation of the sprinkler system testing results, and staff interview it was determined this facility failed to ensure the sprinkler system was inspected quarterly as required by the National Fire Protection Association (NFPA) 25, Chapter 2-1. Based on the review of the documentation of the testing of the battery operated emergency lights, and staff interview it was determined this facility failed to ensure all battery operated lights were tested monthly for 30 seconds and an annual 90 minute test was performed according to the NFPA 101, Chapter 7.9.3. This had the potential to affect all those utilizing this facility. The patient census for this facility the day of the survey was 13.

Findings include:

1. The offsite facility tour took place with staff members A1 and B2 on 06/25/13, at approximately 2:30 PM. The review of the facility's documentation of sprinkler tests revealed an annual sprinkler test report dated 08/21/12, which was generated by a professional outside company No additional sprinkler documentation was available for review verify quarterly sprinkler inspections were performed. During an interview on 06/25/13 at approximately 2:30 PM, Staff B2 stated the facility has not performed quarterly sprinkler inspections.

2. During review of the documentation of the facility's testing of battery operated emergency lighting on 06/25/13 at approximately 2:50 PM., revealed no documentation of monthly 30 second or 90 minute annual test reports. One document reviewed was from an outside professional company which indicated an annual test was performed on 03/23/13 but no detail was available as to what was included in the annual test. No monthly test reports were available. During an interview on 06/25/13 at approximately 2:50 PM., Staff B2 stated they probably had been completed but will have to see if the documentation can be found and made available for review as soon as possible. During an interview on 06/27/13, at approximately 9:10 AM., Staff B2 said the necessary documentation for the monthly tests could not be located.

Based on observation during facility tour, facility schematics and staff interview it was determined this facility failed to ensure the building construction type and height met the requirement of having a complete fire suppression system, specifically in regard to providing services to inpatients within an area designated as a business occupancy. This had the potential to affect all those who utilized this facility. The facility census at the beginning of the survey was 10.

Findings include:

1. Facility tour took place with staff members A1 and B2 on 06/24/13 and the morning of 06/25/13. During facility tour and review of the facility floor plans, two sections of this facility was observed as separated from each other by a two hour fire rated wall. The northern half was observed to be fully suppressed while the southern half was not suppressed with the exception of the gift shop and another room south of and adjacent to the gift shop. The southern half of the building was classified as a business occupancy.

2. The physical therapy department was located in the business occupancy portion of the building in the southeast section. Interview with Staff C-3 took place on 06/25/13 at 11:30 AM. Staff C-3 said the physical therapy department is utilized as an outpatient facility, but occasionally patients are brought over from the health care side of the facility for treatment. When questioned if the patients brought over are capable of self-preservation, Staff C-3 said patients are brought over for treatment in wheel chairs.

3. At 12:10 PM on 06/25/13, during an interview staff members D-4 and E-5, who both worked in the therapy department, said most of the patients served are geriatric patients. Staff D-4 said, approximately 10% of physical therapy patients served are brought over from the healthcare side of the facility. Staff E-5 stated, regarding occupational therapy, there are no outpatient services and all occupational therapy patients served are from the healthcare side of the facility and of those, some are brought over to the therapy department from the healthcare side.

These findings confirm this facility provides in-patient services to geriatric and other patients who may be transported from the healthcare side of the facility to the business occupancy side of the facility. Additionally, due to their age, injuries or surgical status, these patients may not be capable of self-preservation in the event of an emergency.

Based on observation during facility tour and staff verification it was determined this facility failed to ensure the hazardous area was protected in regard to self-closing doors. This had the potential to affect all those who utilized this facility. The facility census at the beginning of the survey was 10.

Findings include:

1. Facility tour took place with staff members A1 and B2 on 06/24/13 and the morning of 06/25/13. Observation during tour of the hazardous room within the surgery department identified two entrance/exit doors to this room. Both doors were equipped with a self-closing device. One of the two doors was equipped with a mechanism on the self closing device which, when activated, would hold the door open until the mechanism was deactivated. This door was observed to be in the open position and the room was unattended. The opposite door of this room was equipped with a self-closing device which did not have a mechanism as the first one did. This door was observed to be held open with a rubber wedge placed between the bottom of the door and the floor.

This finding was acknowledged by both staff members present during tour of the facility.

Based on observation during facility tour and staff verification it was determined this facility failed to ensure all exit discharges had a safe access to a paved common way for all patients, visitors and staff in the event of an emergency. This had the potential to affect all those who utilized this facility. The facility census at the beginning of the survey was 10.

Findings include:

1. Facility tour took place with staff members A1 and B2 on 06/24/13 and the morning of 06/25/13. During the tour of the first floor exit discharge, located at the southwest section of the building, observation was made of cement steps leading down to a sidewalk which ended abruptly approximately 15 feet from a paved common way. The 15 foot section was observed to be a grassy area which sloped upward toward the paved common way.

2. During tour of the first floor exit discharge located at the northeast section of the building observation was made of a sidewalk which led to a gazebo located in the middle of a fenced in grassy area. Approximately 45 feet from the gazebo was a large open area in the fence which bordered a paved common way. This span of 45 feet between the gazebo and the paved common way was observed to be grass.

These findings were verified by both staff members during tour of the facility.

Based on observation during facility tour and staff verification it was determined this facility failed to ensure all exit discharges were equipped with illumination arranged so that failure of any single lighting fixture will not leave the area in darkness. This had the potential to affect all those who utilized this facility. The facility census at the beginning of the survey was 10.

Findings include:

1. Facility tour took place with staff members A1 and B2 on 06/24/13 and the morning of 06/25/13. During the tour of the first floor exit discharge located at the southwest section of the building, observation was made of a single light fixture mounted on the wall outside of the exit discharge door. There was no other light source observed in the immediate area.

2. During the tour of the first floor exit discharge located at the northeast section of the building, observation was made of a single light fixture mounted on the wall outside of the exit discharge door. There was no other light source observed in the immediate area.

These findings were verified by both staff members during tour of the facility.

Based on sprinkler documentation review and staff interview it was determined this facility failed to ensure the sprinkler system was inspected quarterly as required by the National Fire Protection Association (NFPA) 25, Chapter 2-1. This had the potential to affect all those utilizing this facility. The patient census for this facility at the beginning of the survey was 10.

Findings include:

During sprinkler documentation review on 06/27/13 at approximately 8:00 AM., observation was made of quarterly test reports generated by a professional outside company for the first three quarters of 2012 and the first quarter of 2013. No additional sprinkler documentation was available in order to verify the sprinkler tests were performed during the fourth quarter of 2012. Interview with Staff A1 took place on 06/27/13 at approximately 8:50 AM. Staff A1 stated they do not have the fourth quarter sprinkler test report but will contact the contracted company, responsible for conducting the sprinkler tests, to see if they have the fourth quarter report. This report was not available by the time of the life safety exit conference.

Based on observation during tour and staff interview it was determined this facility failed to ensure all portable fire extinguishers were mounted so the top of the fire extinguisher was not greater than five feet from the floor. This had the potential to affect all those utilizing this area of the facility. The facility census was 10 at the beginning of the survey.

Findings include:

Facility tour took place with staff members A1 and B2 on 06/24/13 and the morning of 06/25/13. During the tour of the first floor radiology unit, intensive care unit and information technology department, observation was made of one fire extinguisher within each department. Each of these five fire extinguishers was mounted with the top of the fire extinguisher exceeding the five feet requirement. This finding was verified by both staff members during tour of the facility.

Based on interview it was determined this facility failed to ensure the heating/ventilation and air conditioning (HVAC) system inspections complied with the National Fire Protection Association (NFPA) 90A, Chapter 3-4.7 in regard to the testing of fire/smoke dampers. This had the potential to affect all those utilizing this facility. The current census at the beginning of the survey was 10.

Findings include:

During review of the HVAC fire/smoke damper preventative maintenance and test reports, on 06/26/13, at approximately 3:10 PM., Staff A1 confirmed the finding no documentation was available regarding the testing of fire/smoke dampers, because the dampers have never been checked.

Based on observation during tour and staff verification it was determined this facility failed to ensure the medical gas storage location was protected in accordance with the National Fire Protection Association (NFPA) 99, Chapter 8-3.1.11.3, specifically in regards to signage. This had the potential to affect all those utilizing this area of the facility. The facility census at the beginning of the survey was 10.

Findings include:

Facility tour took place with staff members A1 and B2 on 06/24/13 and the morning of 06/25/13. During the tour of the first floor medical gas room located across from the radiology waiting room, observation was made of no signage displayed on the door to inform occupants that this room contained oxidizing gasses. Observation of the room revealed oxidizing gasses were stored in the room. This finding was confirmed by both staff members during tour.

Based on observation during tour and staff verification, this facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all patient's, staff and visitors utilizing the facility. The facility census was 10 at the beginning of the survey.

Findings include:

Facility tour took place with staff members A1 and B2 on 06/24/13 and the morning of 06/25/13. During the tour of the first floor emergency department, surgery and medical surgical units, observation was made of smoke detectors located near air flow devices in the following locations:

Within room number 27 of the emergency department,

Within the surgery waiting area,

Within the rehabilitation room, and

Within room 49 of the medical surgical unit.

This finding was acknowledged by both staff members during facility tour.

Based on review of the documentation of the sprinkler system testing results, and staff interview it was determined this facility failed to ensure the sprinkler system was inspected quarterly as required by the National Fire Protection Association (NFPA) 25, Chapter 2-1. Based on the review of the documentation of the testing of the battery operated emergency lights, and staff interview it was determined this facility failed to ensure all battery operated lights were tested monthly for 30 seconds and an annual 90 minute test was performed according to the NFPA 101, Chapter 7.9.3. This had the potential to affect all those utilizing this facility. The patient census for this facility the day of the survey was 13.

Findings include:

1. The offsite facility tour took place with staff members A1 and B2 on 06/25/13, at approximately 2:30 PM. The review of the facility's documentation of sprinkler tests revealed an annual sprinkler test report dated 08/21/12, which was generated by a professional outside company No additional sprinkler documentation was available for review verify quarterly sprinkler inspections were performed. During an interview on 06/25/13 at approximately 2:30 PM, Staff B2 stated the facility has not performed quarterly sprinkler inspections.

2. During review of the documentation of the facility's testing of battery operated emergency lighting on 06/25/13 at approximately 2:50 PM., revealed no documentation of monthly 30 second or 90 minute annual test reports. One document reviewed was from an outside professional company which indicated an annual test was performed on 03/23/13 but no detail was available as to what was included in the annual test. No monthly test reports were available. During an interview on 06/25/13 at approximately 2:50 PM., Staff B2 stated they probably had been completed but will have to see if the documentation can be found and made available for review as soon as possible. During an interview on 06/27/13, at approximately 9:10 AM., Staff B2 said the necessary documentation for the monthly tests could not be located.