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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 19, 19.3.6.3.1 " Doors protecting corridor openings in other than required enclosures of vertical openings, exit, or hazardous areas shall be substantial doors, such as those constructed of 1 3/4 in. thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke...Section 19.3.6.4 "Transfer grilles, regardless of whether they are protected by fusible link-operated dampers, shall not be used in these walls or doors...."

Findings Include:

On April 14, and 15, of 2015, the surveyor, accompanied by the Plant Services Manager and the Plant Operator observed the following corridor doors:

1. ER Reception office door closing device removed.
2. Sleep study office, the door has a closing device, however the door will not close when tested.
3. Room 33, Housekeeping Supervisor office, door closing device disconnected.

During the exit conference on April 15, 2015, the above findings were again acknowledged by the CEO, CNO, Director of Compliance, Plant Services Manager, Rehab Services Manager and the Plant Operator.

The facility failed to protect patients from heat and smoke.

Based on Observation it was determined the facility failed to keep the laundry room dryers clean.

Based on observation it was determined the facility failed to provide a self-closing or an automatic-closing device in a hazardous area.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1.1, "Utilities shall comply with the provisions of Section 9.1. Section 9.1.1. "Equipment using gas and related gas piping shall be installed in accordance with NFPA 54 " National Fuel Gas Code" or NFPA 58 " Liquefied Petroleum Gas Code" , NFPA 54 Chapter 6, Section 6.4 "Clothes Dryers Section 6.4.5 (c) Type 2 Clothes Dryers shall be equipped or installed with lint controlling means. "

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.2.1, "Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

Findings include:

On April 14, and 15, of 2015, the surveyor, accompanied by the Plant Services Manager and the Plant Operator observed one of one dryer in the laundry room had an excessive amount of lint in the dryer.

On April 14,and 15, of 2015, the surveyor, accompanied by the Plant Services Manager and the Plant Operator observed the following hazardous area doors:

1. Two of three Medical Records storage doors with closing devices, when tested three of three times would not positively latch.
2. The Medical Records office door closing device was disconnected.

During the exit conference on April 15, 2015, the above findings were again acknowledged by the CEO, CNO, Director of Compliance, Plant Services Manager, Rehab Services Manager and the Plant Operator.

Failing to insure proper cleaning of the lint could cause a fire and cause harm to the patients.

Failing to install self-closing hardware on a smoke/fire resistance door could cause harm to residents in time of a fire.

Based on observation and staff interview it was determined the facility did not keep exits readily accessible at all times.

NFPA 101 Life Safety Code, 2000, Chapter 19 Section 19.2.1, and Section 19.2.3.3. Section 18.2.1 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 18.2.3.3 "Aisles, corridors and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft (Existing built to 8 feet must be maintained 8 feet clear) in clear and unobstructed width". Chapter 7 Section 7.5.1.1" Exits shall be so located and exit access shall be arranged so that exits are readily accessible at all times." Section 7.5.1.2 "Where exits are not immediately accessible from an open floor area, continuous passageways, aisles, or corridors leading directly to every exit and shall be maintained and shall be arranged to provide access for each occupant to not less than two exits by separate ways of travel."

Findings include:

On April 14, and 15, of 2015, the surveyor, accompanied by the Plant Services Manager and the Plant Operator observed storage of equipment by Room 19 in the Med.Surg corridor in excess of thirty one minutes. The following equipment was:

1. Stairs, reducing when measured two of two exit access from eight feet to four feet.
2. A hoyer lift, reducing when measured two of two exit access from eight feet to five feet six inches.
3. A pole secured at the floor and ceiling, when measured reducing two of two exit access from eight feet to six feet three inches.

Staff members interviewed stated the Hoyer lift has not moved all day. Staff members were asked what would they do with equipment in the corridor in the event of FIRE ? The staff did not readily respond.

During the exit conference on April 15, 2015, the above findings were again acknowledged by the CEO, CNO, Director of Compliance, Plant Services Manager, Rehab Services Manager and the Plant Operator.

Failure to keep the exit corridors and exit access clear could hinder the evacuation during an emergency and will cause harm to 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 19, Section 19.3.1.5, "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."

Finding include:

On April 14, and 15, of 2015, the surveyor, accompanied by the Plant Services Manager and the Plant Operator observed the following sprinklers:

1. Old Nurse Station, escutcheon plate with a gap greater than 1/4 inch, not smoke tight.
2. IT Room, one of one sprinkler no escutcheon plate.
3. CT scan room, two of six sprinklers, paint.

During the exit conference on April 15, 2015, the above findings were again acknowledged by the CEO, CNO, Director of Compliance, Plant Services Manager, Rehab Services Manager and the Plant Operator.

Failing to maintain sprinkler heads, missing escutcheon plates, which are part of the UL listing of the sprinkler assembly, will allow heat and smoke to effect other areas of the building. This will cause harm to the patients.

Based on observation it was determined the facility allowed the use of a portable space heater.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.7.8" Portable space heating shall be prohibited in all health care occupancies."
Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212 Degrees F.

Findings include:

On April 14, and 15, of 2015, the surveyor, accompanied by the Plant Services Manager and the Plant Operator observed a portable space heater in the sleep study room.

During the exit conference on April 15, 2015, the above findings were again acknowledged by the CEO, CNO, Director of Compliance, Plant Services Manager, Rehab Services Manager and the Plant Operator.

Allowing the use of portable space heaters, close to combustibles, will cause a fire which will cause harm to the patients.

Based on observation it was determined the facility failed to mount an electrical outlets five feet above the floor in the oxygen storage room.

NFPA 101 Life Safety Code, Chapter 19, Section 19.3.2.4 " Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 Chapter 8, Storage Requirements, Section 8-3.1.11.2 Storage for nonflammable gases less than 3000 cubic feet. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2 (a) 11d. Section 4-3.1.1.2 (a) 11(d) Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft. (1.5m) above the floor to avoid physical damage.

Findings include:

On April 14, and 15, of 2015, the surveyor, accompanied by the Plant Services Manager and the Plant Operator observed a total of nine EO2 oxygen tanks within five feet of electrical outlets and combustibles by the OR office.

During the exit conference on April 15, 2015, the above findings were again acknowledged by the CEO, CNO, Director of Compliance, Plant Services Manager, Rehab Services Manager and the Plant Operator.

Failing to mount a light switch five feet above the floor to prevent an accident/or possible fire could cause harm to the 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 April 14, and 15, of 2015, the surveyor, accompanied by the Plant Services Manager and the Plant Operator observed refrigerators and microwaves plugged into multi-outlet power strips and not directly plugged in to the wall outlet receptacles in the following rooms:

1. ER break room, one refrigerator and one microwave plugged into a power strip.
2. IT room, one refrigerator and one microwave plugged into a power strip.

During the exit conference on April 15, 2015, the above findings were again acknowledged by the CEO, CNO, Director of Compliance, Plant Services Manager, Rehab Services Manager and the Plant Operator.

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 19, 19.3.6.3.1 " Doors protecting corridor openings in other than required enclosures of vertical openings, exit, or hazardous areas shall be substantial doors, such as those constructed of 1 3/4 in. thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke...Section 19.3.6.4 "Transfer grilles, regardless of whether they are protected by fusible link-operated dampers, shall not be used in these walls or doors...."

Findings Include:

On April 14, and 15, of 2015, the surveyor, accompanied by the Plant Services Manager and the Plant Operator observed the following corridor doors:

1. ER Reception office door closing device removed.
2. Sleep study office, the door has a closing device, however the door will not close when tested.
3. Room 33, Housekeeping Supervisor office, door closing device disconnected.

During the exit conference on April 15, 2015, the above findings were again acknowledged by the CEO, CNO, Director of Compliance, Plant Services Manager, Rehab Services Manager and the Plant Operator.

The facility failed to protect patients from heat and smoke.

Based on Observation it was determined the facility failed to keep the laundry room dryers clean.

Based on observation it was determined the facility failed to provide a self-closing or an automatic-closing device in a hazardous area.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1.1, "Utilities shall comply with the provisions of Section 9.1. Section 9.1.1. "Equipment using gas and related gas piping shall be installed in accordance with NFPA 54 " National Fuel Gas Code" or NFPA 58 " Liquefied Petroleum Gas Code" , NFPA 54 Chapter 6, Section 6.4 "Clothes Dryers Section 6.4.5 (c) Type 2 Clothes Dryers shall be equipped or installed with lint controlling means. "

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.2.1, "Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

Findings include:

On April 14, and 15, of 2015, the surveyor, accompanied by the Plant Services Manager and the Plant Operator observed one of one dryer in the laundry room had an excessive amount of lint in the dryer.

On April 14,and 15, of 2015, the surveyor, accompanied by the Plant Services Manager and the Plant Operator observed the following hazardous area doors:

1. Two of three Medical Records storage doors with closing devices, when tested three of three times would not positively latch.
2. The Medical Records office door closing device was disconnected.

During the exit conference on April 15, 2015, the above findings were again acknowledged by the CEO, CNO, Director of Compliance, Plant Services Manager, Rehab Services Manager and the Plant Operator.

Failing to insure proper cleaning of the lint could cause a fire and cause harm to the patients.

Failing to install self-closing hardware on a smoke/fire resistance door could cause harm to residents in time of a fire.

Based on observation and staff interview it was determined the facility did not keep exits readily accessible at all times.

NFPA 101 Life Safety Code, 2000, Chapter 19 Section 19.2.1, and Section 19.2.3.3. Section 18.2.1 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 18.2.3.3 "Aisles, corridors and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft (Existing built to 8 feet must be maintained 8 feet clear) in clear and unobstructed width". Chapter 7 Section 7.5.1.1" Exits shall be so located and exit access shall be arranged so that exits are readily accessible at all times." Section 7.5.1.2 "Where exits are not immediately accessible from an open floor area, continuous passageways, aisles, or corridors leading directly to every exit and shall be maintained and shall be arranged to provide access for each occupant to not less than two exits by separate ways of travel."

Findings include:

On April 14, and 15, of 2015, the surveyor, accompanied by the Plant Services Manager and the Plant Operator observed storage of equipment by Room 19 in the Med.Surg corridor in excess of thirty one minutes. The following equipment was:

1. Stairs, reducing when measured two of two exit access from eight feet to four feet.
2. A hoyer lift, reducing when measured two of two exit access from eight feet to five feet six inches.
3. A pole secured at the floor and ceiling, when measured reducing two of two exit access from eight feet to six feet three inches.

Staff members interviewed stated the Hoyer lift has not moved all day. Staff members were asked what would they do with equipment in the corridor in the event of FIRE ? The staff did not readily respond.

During the exit conference on April 15, 2015, the above findings were again acknowledged by the CEO, CNO, Director of Compliance, Plant Services Manager, Rehab Services Manager and the Plant Operator.

Failure to keep the exit corridors and exit access clear could hinder the evacuation during an emergency and will cause harm to 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 19, Section 19.3.1.5, "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."

Finding include:

On April 14, and 15, of 2015, the surveyor, accompanied by the Plant Services Manager and the Plant Operator observed the following sprinklers:

1. Old Nurse Station, escutcheon plate with a gap greater than 1/4 inch, not smoke tight.
2. IT Room, one of one sprinkler no escutcheon plate.
3. CT scan room, two of six sprinklers, paint.

During the exit conference on April 15, 2015, the above findings were again acknowledged by the CEO, CNO, Director of Compliance, Plant Services Manager, Rehab Services Manager and the Plant Operator.

Failing to maintain sprinkler heads, missing escutcheon plates, which are part of the UL listing of the sprinkler assembly, will allow heat and smoke to effect other areas of the building. This will cause harm to the patients.

Based on observation it was determined the facility allowed the use of a portable space heater.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.7.8" Portable space heating shall be prohibited in all health care occupancies."
Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212 Degrees F.

Findings include:

On April 14, and 15, of 2015, the surveyor, accompanied by the Plant Services Manager and the Plant Operator observed a portable space heater in the sleep study room.

During the exit conference on April 15, 2015, the above findings were again acknowledged by the CEO, CNO, Director of Compliance, Plant Services Manager, Rehab Services Manager and the Plant Operator.

Allowing the use of portable space heaters, close to combustibles, will cause a fire which will cause harm to the patients.

Based on observation it was determined the facility failed to mount an electrical outlets five feet above the floor in the oxygen storage room.

NFPA 101 Life Safety Code, Chapter 19, Section 19.3.2.4 " Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 Chapter 8, Storage Requirements, Section 8-3.1.11.2 Storage for nonflammable gases less than 3000 cubic feet. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2 (a) 11d. Section 4-3.1.1.2 (a) 11(d) Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft. (1.5m) above the floor to avoid physical damage.

Findings include:

On April 14, and 15, of 2015, the surveyor, accompanied by the Plant Services Manager and the Plant Operator observed a total of nine EO2 oxygen tanks within five feet of electrical outlets and combustibles by the OR office.

During the exit conference on April 15, 2015, the above findings were again acknowledged by the CEO, CNO, Director of Compliance, Plant Services Manager, Rehab Services Manager and the Plant Operator.

Failing to mount a light switch five feet above the floor to prevent an accident/or possible fire could cause harm to the 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 April 14, and 15, of 2015, the surveyor, accompanied by the Plant Services Manager and the Plant Operator observed refrigerators and microwaves plugged into multi-outlet power strips and not directly plugged in to the wall outlet receptacles in the following rooms:

1. ER break room, one refrigerator and one microwave plugged into a power strip.
2. IT room, one refrigerator and one microwave plugged into a power strip.

During the exit conference on April 15, 2015, the above findings were again acknowledged by the CEO, CNO, Director of Compliance, Plant Services Manager, Rehab Services Manager and the Plant Operator.

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.