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Based on tests to doors and observations made during the survey for life safety from fire with the facility's Engineer (employee #1), it was determined that patient's doors protecting corridors on the second floor do not close completely (do not latch) as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.3.6.3.

Findings include:

1. During the tour for life safety from fire, patient's sleeping room doors were tested from 8/21/12 from 10:00 am till 3:00 pm and from 8/28/12 through 8/30/12 from 9:00 am till 3:30 pm with the facility's Engineer (employee #1), it was found that the following patient's rooms do not have the capability of latching when the doors are in the closed position, this can permit smoke, fire and noxious gases to enter the rooms in the event of a fire:

a. Patient's rooms on the second floor: #210 and #217 (all patient sleeping room doors shall be verified for compliance).

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #1), it was determined that the facility failed to provide readily visible illuminated "exit" signs where the exit or way to reach the exit is not readily apparent to its occupants such as the Neonatal Intensive Care Unit (N.I.C.U) and the Intensive Care Unit (I.C.U) as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.10.1.2.

Findings include:

1. There is the need of an illuminated exit sign for the main entrance door located in the N.I.C.U as observed with the facility's Engineer (employee #1) on 8/29/12 at 10:00 am.
An illuminated exit sign in this area will help to safely guide patients and staff out of this area.

2. There is the need of an illuminated exit sign for the side exit door located in the I.C.U as observed with the facility's Engineer (employee #1) on 8/29/12 at 10:20 am. An illuminated exit sign in this area will help to safely guide patients and staff out of this area.

Based on tests to doors and observations made during the survey for life safety from fire with the facility's Engineer (employee #1), it was determined that the smoke barrier doors near patient's room #208 did not latch closed when released from their hold open devices as required by the 2000 edition of the Life Safety Code of the NFPA Sections 19.3.7.3 and 19.3.7.5.

Findings include:

During the tour for life safety from fire near patient's sleeping rooms on 8/21/12 from 10:00 am till 3:00 pm and from 8/28/12 through 8/30/12 from 9:00 am till 3:30 pm with the facility's Engineer (employee #1), it was found that the smoke barrier doors near patient's sleeping room #208 did not latch closed when released from their hold open devices, this can permit smoke, fire and noxious gases to enter the rooms in the event of a fire.

Based on tests to doors and observations made during the survey for life safety from fire with the facility's Engineer (employee #1), it was determined that the door of the small storage closet located at the means of egress at the food line preparation area has a louver which will not resist the passage of smoke in accordance with the 2000 edition of the Life Safety Code of the NFPA Section 8.3.4.1.

Findings include:

The food tray preparation area was visited on 8/28/12 at 9:50 am with the facility's Engineer (employee #1) and a small closet located in this area was found with a large accumulation of cleaning chemical (this room did not have an air extractor or smoke detector) and the front door has a louver which will not protect the outside of this room from smoke and fire from exiting this room and filling the means of egress with smoke.

Based on observations of the exit staircase located on the second floor near the nursing counter of the Central Medicine ward during the survey for life safety from fire with the facility's Engineer (employee #1), it was determined that this exit component does not provide protection against fire or smoke from other parts of the building due to the lack of a door as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.3.1.1 and 19.3.2.1.

Findings include:

During the tour for life safety from fire of the second floor Central Medicine ward, it was found that the exit component (staircase next to the nursing station) was inspected and found that it does not have a door to provide enclosure as observed on 8/29/12 at 10:00 am with the facility's Engineer (employee #1). The lack of a fire door will permit fire and toxic gases to enter this means of egress and affect both the first and second floors.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #1), it was determined that the facility failed to ensure that emergency lighting (battery operated lamps) which provides light for a period of 90 minutes, enabling those inside to move about safely in an emergency are provided at the outside entrance/exit of the emergency room and ambulance entrance, at some medication preparation rooms, in operating suites #1 through #4, at the Nuclear Medicine department and X-ray department as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.9.

Findings include:

1. The facility lacks emergency battery operated lamps (EBOL) for a period of 90 minutes as determined by the observational tour with the facility's Engineer (employee #1) on 8/21/12 from 10:00 am till 4:00 pm and from 8/28/12 through 8/30/12 from 9:00 am till 3:30 pm in the following areas:
a. At the outside entrance/exit to the waiting room of the emergency room and the ambulance drop off point of the emergency room.
b. At some medication preparation room of the emergency room.
c. In operating suites #1, #2, #3 and #4.
d. For the Nuclear Medicine department including the exit hallway.
e. Near the back exit door of the X-ray department and within the X-ray rooms.
(Emergency lamps are required to ensure adequate lighting until the essential electrical system (generator) turns on or in the event that the essential electrical system fails as required since March 13 of 2006).

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #1), it was determined that the facility failed to ensure that the emergency room and some wards of the hospital have written plans for staff to follow with respect to their duties in the event of an emergency as required by the 2000 edition of the Life Safety Code of the NFPA Section 18.7.1.1.

Findings include:

No evidence was found on 8/21/12 from 10:00 am till 4:00 pm and from 8/28/12 through 8/30/12 from 9:00 am till 3:30 pm that emergency room personnel and ward personnel (Medicine II, Medicine III, Obstetric/Gynecology and Medicine/Surgical wards) have a plan or assignments with specific tasks in the event of an emergency (for example: extinguisher use, circuit breaker shut off, oxygen valve shut off, opening of locked windows). All personnel trained related to emergency procedures must be instructed related to their assignments and periodically tested for its implementation and the assignment must be posted for review by staff.

Based on the review of written documents related to conducted fire drills during the survey for life safety from fire with the facility's Engineer (employee #1) and interview, it was determined that the facility failed to ensure that fire drills are conducted under varying conditions and that kitchen employees are properly trained related to fire procedures as required by the 2000 edition of the Life Safety Code of the NFPA 19.7.1.2 and 5.5.

Findings include:

1. Written documents about conducted fire drills for the hospital were reviewed on 8/30/12 at 11:25 am with the facility's Engineer (employee #1) and provided evidence that fire drills are not performed under varying conditions related to:
a. Initial fire location.
b. Early rate of growth in the fire severity.
c. Smoke generation.
LSC 2000 section 5.5 has eight "Design Fire Scenarios" that should be considered to comply with the above. Fire drills provide opportunities to improve on tasks during emergency and hurried events and should be used to constantly improve. Of the fire drills reviewed, none were found with task improvement.

2. Kitchen personnel (employees #30, #31 and #32) were interviewed on 8/28/12 at 10:45 am related to fire drill procedures in the event of a fire at the stoves and they did not know the standard steps to follow, where control valves are located or who is responsible for specific tasks.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #1), it was determined that the facility failed to ensure that smoke detectors are available at all required areas such as janitor's closets, chemical storage closet at the kitchen, in all pantries, biohazardous trash closets, dirty linen closet and the catheterism department as required by the applicable requirements of NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include:

1. Smoke detectors connected to the fire alarm panel are needed in the following areas as observed with the facility's Engineer (employee #1) from 8/21/12 from 10:00 am till 4:00 pm and 8/28/12 through 8/30/12 from 9:00 am till 3:30 pm:
a. In the janitor's storage closet of the operating room department.
b. In the closet filled with cleaning chemicals near the food tray preparation area which was visited on 8/28/12 at 9:50 am with the facility's Engineer (employee #1) which was found with a large accumulation of cleaning chemical.
c. In the pantry of the laboratory department which was found with a microwave and a refrigerator.
d. At the biohazardous storage room and pantry of the Medicine III ward on the third floor.
e. In the pantry of the Central Medicine ward which was found with a microwave.
f. In the pantry of the Intensive Care Unit (I.C.U) which was found with a microwave.
g. In the pantry of the Pediatric ward which was found with a microwave.
h. The dirty linen closet of the Annex on the first floor.
i. Smoke detectors are needed in the catheterism department in the hallway.

Based on the review of written documents related to the preventive maintenance of the fire alarm system and its components during the survey for life safety from fire with the facility's Engineer (employee #1), it was determined that the facility is not performing visual inspections and battery tests to the fire alarm system in accordance with NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include:

1. Written evidence reviewed on 8/30/12 at 11:35 am with the facility's Engineer (employee #1) about the tests to the fire alarm system and its components indicates that the facility is not performing the following tests:

a. Visual inspections to the main control panel to verify trouble signals and check battery electrolyte level (monthly).

b. Ability of batteries to meet standby and alarm requirements shall be verified, corrosion and leakage, tightness of connections and battery terminals shall be cleaned (monthly).

c. Location of pull-down stations and tests (monthly).

d. Visible (strobe lights) and audible signal tests (monthly).

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #1), it was determined that the facility failed to ensure that patient sleeping rooms at the annex on the first floor and rooms #238 and #239 on the second floor Medicine/Surgical ward have an outside window as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.3.8

Findings include:

1. Eight patient's sleeping beds on the first floor (Annex) were visited on 8/29/12 from 11:40 am till 12:10 pm with the facility's Engineer (employee #1) and the following was determined:
a. All patient's rooms did not have windows that give direct light and air from the outside.

2. The Medicine/Surgical ward with twelve patient's sleeping beds on the second floor was visited on 8/28/12 from 3:10 pm till 3:30 pm with the facility's Engineer (employee #1) and the following was determined:
a. Patient's rooms #238 and #239 do not have windows that give direct light and air from the outside (they have skylights).

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #1), it was determined that the facility failed to ensure that the automatic sprinkler system for the new construction is continuously maintained in reliable operating condition and inspected and tested periodically as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5.

Findings include:

1. Review of documentation and observations of the sprinkler system on 8/30/12 from 1:20 pm till 1:40 pm, the following was determined with the facility's Engineer (employee #1):
a. No evidence was found of sprinkler maintenance documentation.
b. No evidence was found of the control valve with the identification with a sign indicating the system or portion of the system it controls.
c. No evidence was found of the weekly valve inspection (hose valves, pressure-regulating valves and valves that isolate backflow prevention devices).
d. No evidence of the annual control valve test with the valve in the open position.
e. No evidence was found of the fire department connection inspection on a quarterly bases to verify visibility and accessibility, coupling and swivels not damaged and rotate smoothly.
f. No evidence was found of tests performed on the sprinkler system (such as weekly no-flow tests and annual flow condition test of the fire pump).
g. No evidence was found that the fire pump system is inspected on a weekly basis.
h. No evidence was found of the generator maintenance (along with all aspects including battery verification, oil level, belts, temperature, etc) April 2012. This maintenance varies according with the manufacturer's suggestions and NFPA 25.
i. No evidence was found of valve identification signs for the control valve, drain valve or inspector test valve.
j. No evidence was provided of installation documentation.
k. No evidence was found that the facility has spare sprinklers (at least six of each different types), a sprinkler wrench or a cabinet to place them in.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #1), it was determined that the facility failed to ensure that portable fire extinguisher are maintained related to appropriate heights and are located at all required areas and are easily identifiable as states in the 2000 edition of the Life Safety Code of the NFPA Section 9.7.4.1 and NFPA 10 Section 1.5.10.

Findings include:

1. During observations made of the emergency room with the facility's Engineer (employee #1) on 8/21/12 from 10:00 am till 3:00 pm, the following was determined related to fire extinguishers:
a. The fire extinguisher located near the waiting room entrance/exit and the fire extinguisher located in the pantry of the emergency room were observed mounted to the wall above five feet high from the floor and both weighed less than 40 pounds. According with NFPA 10, section 1.5.10, fire extinguishers weighing less than 40 pounds shall be installed so that the top part of the fire extinguisher is not more than five feet in height. The facility must lower the fire extinguishers to ensure that they at five feet or lower so that they can be accessible to all persons if needed.

2. Fire extinguishers were observed throughout the hospital from 8/21/12 from 10:00 am till 3:00 pm and from 8/28/12 through 8/30/12 from 9:00 am till 3:30 pm with the facility's Engineer (employee #1) and the following was found:
a. The emergency room was found with only one fire extinguisher to cover the entire department.
b. The fire extinguisher (type B,C) located near the food line preparation table of the kitchen was found with the funnel nozzle turned up and a glove was found inside. Also, this fire extinguisher is to be used for a fire in the electric room located near the food preparation table, but this area needs an A,B,C extinguisher to protect the food preparation room where the steam table is located.

3. The kitchen was visited on 8/28/12 at 10:05 am and provided evidence that the type K fire extinguisher located near the back door had something black over the outlet of the nozzle. This can limit its use if needed in the event of a fire.

4. The second floor Medicine II and third floor Medicine III wards were reviewed on 8/28/12 at 1:35 pm and 2:10 pm with the facility's Engineer (employee #1) and provided evidence that they do not identify where the fire extinguishers are located:
a. The fire extinguisher located near the biohazardous storage room is not visible from the hallway. A sign is needed at the hallway where persons can see it from either side to ensure that they know where it is.
b. The two exit stairs located on the third floor Medicine II ward contains the fire hose cabinets and it also has fire extinguishers, but no signs were found in the hallway that identified the site of this fire equipment.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #1) and interview, it was determined that the facility failed to ensure that dirty linen is stored in an appropriate manner as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.7.5.5.

Findings include:

During the observational tour of the facility the dirty linen storage room located in the emergency room on 8/21/12 at 10:45 am with the facility's Engineer (employee #1), it was determined that personnel are using this closets to place dirty linen, it had two large hampers full of dirty linen and the air extractor was not working (covered in dust). The facility's Engineer (employee #1) stated during an interview on 8/21/12 at 10:45 am that this closet is used as a holding area until personnel make their rounds and remove them from the closet. This closet has a smoke detectors connected to the fire alarm panel but the extractor did not work. The construction of closets for this purpose must be verified to ensure one hour fire rating (with 3/4 hour fire-rated doors) with positive latching and door closers and containers can not exceed 32 gallons within any 64 square foot area.

Based on observations during the survey for Life safety from fire with the facility's Engineer (employee #1) and interview, it was found that this facility does not comply with other Life Safety Code requirements not in CMS-2786-R related to standpipe maintenance, propane gas tanks do not have seismic shut off devices, oxygen storage, use of extension cords, a suppression sprinkler head was not above the fryer, an electric stove is used in the ante-room of the bacteriologic room, evacuation plans do not identify where the fire extinguishers are and the actual plan is not updated related to the location of some rooms and no documentation was found of tests to the large oxygen container system.

Findings include:

1. When oxygen cylinders are not in use (connected to a patient), they are to be stored in an appropriate area as stated in the National Fire Protection Association (NFPA) 99, 1999 edition, section 4-3.1.1.2. However, during the observational tour of the entire facility from 8/21/12 from 10:00 am till 4:00 pm and from 8/28/12 through 8/30/12 from 9:00 am till 3:30 pm with the facility's Engineer (employee #1) type H and Type E oxygen tanks were found in areas that do not meet minimum requirements:
a. Six type H oxygen cylinders were found in the Endoscope department on the first floor.
b. Two type E oxygen cylinders were found in respiratory therapy department.
c. One type E oxygen cylinder was found in front of the nursing station of the surgery ward.

2. The back exit of the emergency room was visited on 8/21/12 at 10:25 am with the facility's Engineer (employee #1) and it was found that the exit wraps around a portion of the facility where type E and Type H oxygen cylinders are located. A portion of the type H oxygen cylinders are located behind a closed and locked area which are used for in-line oxygen use. However, ten type H oxygen cylinders were found directly on the cement floor (rust stains were found on the floor) and were not enclosed to prevent tampering and one tank did not have its valve protective cover and ten type E oxygen cylinders were in a moveable protective base but they were accessible to non-authorized persons.

3. The hood suppression system located above the stove and fryer were observed on 8/28/12 at 10:25 am and it was determined that the suppression sprinkler head was not above the fryer to ensure an even and direct flow to the fryer.

4. Standpipes (fire hoses) were observed during the life safety observational tour with the facility's Engineer (employee #1) and maintenance documentation was reviewed on 8/21/12 from 10:00 am till 4:00 pm and from 8/28/12 through 8/30/12 from 9:00 am till 3:30 pm and the following was determined:
a. No evidence was found of standpipe and Hose System Inspection, Testing and maintenance in accordance with NFPA 25 chapter 6 related with: control valves, pressure regulating devices, piping, hose connections, cabinet, hose, hose storage device, alarm device, hose nozzle, pressure control device, pressure reducing valve, hydrostatic test, flow test, main drain test, hose connections and valves (all types).

5. The facility has an area with three large propane gas tanks located at the back of the hospital's kitchen in front of the maintenance house as observed on 8/28/12 at 11:00 am with the facility's Engineer (employee #1) and provided evidence that they are not prepared to turn off in the event of an earthquake. The movement from an earthquake can cause metal tubing to crack which may leak gas and can cause an explosion. Seismic shut off devices which automatically turns off the gas at the source is required.

6. The ante-room of the bacteriologic room of the laboratory department was found with an electric stove used to perform the Wellcogen Rapid Test on 8/28/12 at 11:30 am. The laboratory will need to find an appropriate device and place it in an area that is protected with the appropriate electrical outlets and fire control precautions.

7. The ante-room of the bacteriologic room of the laboratory department was visited on 8/28/12 at 11:30 am with the facility's Engineer (employee #1). The ante-room has a large refrigerator located at the back wall and it is next to the door that leads into the bacteriologic room. The ante-room is approximately 72 square feet in area and the bacteriologic room is approximately 120 square feet in area. The door to the bacteriologic room swings into the ante-room and was found to hit the refrigerator and reduced the walk through width to half (approximately two and a half feet). In the event of an emergency where a hurried egress is needed by staff who work in this area, the reduced width of the door is a risk to evacuate this room (the bacteriologic room was found packed with electric equipment and limited space to move around in).

8. The pantry and the blood bank area of the laboratory department were visited on 8/28/12 at 11:40 am with the facility's Engineer (employee #1) and provided evidence that a regular wall two outlet receptacles had six out plugs placed over it. This increase the risk that this receptacle can over heat and cause a fire.

9. Evacuation plans located at the second floor Medicine II and third floor Medicine III wards were reviewed on 8/28/12 at 1:35 pm and 2:10 pm with the facility's Engineer (employee #1) and provided evidence that they do not identify where the fire extinguishers are and the actual plan is not updated related to the location of some rooms.

10. The second floor (Central Medicine ward) was visited on 8/29/12 at 9:05 am with the facility's Engineer (employee #1) and the following was determined:
a. Employee #35 (Escort) was observed walking down the stairs next to the nursing counter of this ward with a type E oxygen cylinder. The employee was holding the oxygen cylinder from its regulator which is a safety risk.

11. The pantry of the pharmacy department was visited on 8/29/12 at 11:50 am with the facility's Engineer (employee #1) and provided evidence that they are using a multiple plug. This increase the risk that this receptacle can over heat and can cause a fire.

12. The facility has a large oxygen tank that supplies oxygen to the hospital located at the front of the hospital as observed on 8/30/12 at 10:30 am with the facility's Engineer (employee #1). The facility was requested evidence of periodic master alarm panel testing related to the audible and visual signals (high/low alarms for +/- 20% operating pressure), however the Engineer (employee #1) stated on 8/30/12 at 10:35 am that the system is working properly and so are the alarms, however he does not have documentation of tests performed to verify the alarms' status.

Based on the review of written documents during the survey for life safety from fire with the facility's Engineer (employee #1), it was determined that the facility failed to ensure that personnel perform weekly inspections of the electrical generator as required by the NFPA 99, section 3.4.4.1.

Findings include:

The facility lacks complete written evidence of the weekly inspections of the generator as reviewed on 8/30/12 at 10:40 am. The facility does not have a check list which includes coolant level, belts, oil pressure and oil change, hoses and pipes, main fuel tank level, leaks if any, oil filter, air filter, battery contacts and battery condition (when last changed) and other checks from NFPA-99.