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Based on observation and staff interview the facility failed to assure that door openings closed to resist the passage of smoke to corridors. This potentially exposed residents to a smoke/fire environment. Findings include:

During the facility tour on December 11, 2012 from 8:18 AM to 4:20 PM it was observed that the following door did not close, latch or open properly when tested:

1. Room 233 - door would not latch when tested from the full open position

These findings were acknowledged by the facility Maintenance Director.

Based on observation and staff interview the facility failed to assure that door openings closed to resist the passage of smoke to corridors. This potentially exposed residents to a smoke/fire environment. Findings include:

During the facility tour on December 11, 2012 from 8:18 AM to 4:20 PM it was observed that the following doors did not latch properly when tested:

1. Fire Sep doors in basement by Hazmat room
2. Fire sep doors in kitchen for elevator - blocked by cart and table

These findings were acknowledged by the facility Maintenance Staff.

Based on observation and staff interview, the facility failed to maintain the integrity of smoke barriers. This potentially allows the spread of smoke to other areas of the facility, exposing residents to a smoke or fire environment. The findings are as follows.

During the facility tour on December 11, 2012 from 8:18 AM to 4:20 PM penetrations were observed in the following location(s)

1. Ceiling tiles missing in data room

These findings were acknowledged by the Maintenance Director.

Based on observations and staff interview, the facility failed to provide functional fire doors in a hazardous area. This has the potential to expose residents to a fire or smoke environment. The findings are as follows:

During the facility tour on December 11, 2012 from 8:18 AM to 4:20 PM found doors that did not close and latch:

1. Hazmat door in the basement failed to latch securely when tested

These findings were acknowledged by the Maintenance Director.

Based on observation and staff interviews, the facility failed to maintain proper emergency egress lighting. This has the potential to misdirect residents or staff while exiting during an emergency

An examination of the facility ' s maintenance records for light checks on December 11, 2012 at 2:45 PM revealed that the facility was conducting monthly checks but not an annual battery test.

These findings were acknowledged by the Maintenance Director.

Based on record review, the facility failed to assure that the Hospital staff was adequately trained to respond to fires. This potentially exposed residents to smoke and fire in the facility. Findings include:

An examination of the facility ' s fire drill records on December 11, 2012 at 2:30 PM revealed that the fire drill records were missing for the month, quarter and shift as follows:

1. 1st quarter (2012) 1st shift
2. 1st quarter (2012) 2nd shift

These findings were acknowledged by the Maintenance Director.

Based on observation and record review, the facility failed to assure fire extinguishers are properly maintained. This potentially delays a quick response to contain a fire from spreading, exposing residents to fire in the environment.

1. During the facility tour on December 11, 2012 from 8:18 AM to 4:20 PM, observed fire extinguishers in the following locations out of service:

A. Elevator Room 1108 - extinguisher past due for annual servicing

2. The following portable fire extinguishers height from the floor to the top of the extinguisher exceeds 5 feet:

A. Across from Room 233
B. OR 1
C. OR 2
D. OR 3

The Maintenance Director acknowledged the findings.

Based on observation and staff interview, the facility failed to assure that exit egress remained clear and unobstructed. This potentially prevents residents from exiting a fire/smoke environment. Findings include:

During the facility tour on December 11, 2012 from 8:18 AM to 4:20 PM, observed that the corridors used for exiting were obstructed:

1. Blanket warmer by room 301
2. 2 Hoyer lifts by room 317
3. Patient transfer bed by 314

This finding was acknowledged by the Maintenance Director.

Based on observation and staff interview the facility failed to assure that wall coverings of a flammable nature did not exceed the protection value from the installed sprinkler system. This potentially exposed residents to a smoke/fire environment. Findings include:

During the facility tour on December 11, 2012 from 8:18 AM to 4:20 PM it was observed:

1. The following wall tapestry did not have documentation for being treated with approved fire retardant material:

a. By room 143
b. By room 2301
c. Dining area

2. The following doors had live wreaths hanging on them:

a. Room 136
b. Room 137

These findings were acknowledged by the facility Maintenance Director and Executive Director.

Based on observation and staff interview, the facility failed to maintain the proper distance for hand based alcohol hand gel from an electrical source. This potentially allows the spread of smoke and fire to other areas of the facility, exposing residents to a hazardous environment. The findings are as follows.

During the facility tour on December 11, 2012 from 8:18 AM to 4:20 PM improper mounting of alcohol based hand rub was observed in the following location(s)

1. Sleep Center Room 4 - next to door
2. Patient room 301 - above night light
3. Patient room 302 - above night light
4. Patient room 303 - above night light
5. Patient room 304 - above night light
6. Patient room 305 - above night light
7. Patient room 306 - above night light
8. Room 331 - above light switch by door
9. Nursery - above switch by door
10. OR 2 - above electrical outlets
11. Room 1210 - above outlet
12. Room 1310 - above light switch

These findings were acknowledged by the Maintenance Director.

Based on observations and staff interview the facility failed to post " Oxygen in use, No smoking " signs for resident rooms using oxygen in accordance with NFPA 99, 8-3.1.11.3 and *-6.4.2. This has the potential for exposing residents to a fire or explosive environment.

During the facility tour on December 11, 2012 from 8:18 AM to 4:20 PM, observed no " Oxygen in use, No smoking " signs posted. for the following room:

1. Room 323B

These observations were acknowledged by the Maintenance Director.

Based on observations, the facility failed to maintain proper electrical conditions per NFPA 70, National Electrical Code. This has the potential to expose staff and patients to a fire
environment. The findings are as follows:

During the facility tour on December 11, 2012 from 8:18 AM to 4:20 PM the following deficiencies were found:

1. Multi plug adapter to multi plug adapter in use in CCU Corridor by room 301
2. Extension cord powering Christmas tree in Room 141A
3. Extension cord powering Christmas tree in patient financial services office
4. Multi plug adapter to multi plug adapter in use in phone room (basement)
5. Extension cords powering Christmas decorations in main lobby

These findings were acknowledged by the Maintenance Director

Based on observation and staff interview, the facility failed to maintain the proper distance for hand based alcohol hand gel from an electrical source. This potentially allows the spread of smoke and fire to other areas of the facility, exposing residents to a hazardous environment. The findings are as follows.

During the facility tour on December 11, 2012, from 8:18 AM to 4:20 PM improper mounting of hand sanitizer rub was observed in the following location(s)

1. Wound Care - hand sanitizer mounted above electrical source at main entry door
2. OR 3 - hand sanitizer mounted above electrical source by entry door
3. Imaging Dept - by Room 1215 hand sanitizer located above electrical source

These findings were acknowledged by the Maintenance Director.

Based on observation and staff interview the facility failed to assure that door openings closed to resist the passage of smoke to corridors. This potentially exposed residents to a smoke/fire environment. Findings include:

During the facility tour on December 11, 2012 from 8:18 AM to 4:20 PM it was observed that the following door did not close, latch or open properly when tested:

1. Room 233 - door would not latch when tested from the full open position

These findings were acknowledged by the facility Maintenance Director.

Based on observation and staff interview the facility failed to assure that door openings closed to resist the passage of smoke to corridors. This potentially exposed residents to a smoke/fire environment. Findings include:

During the facility tour on December 11, 2012 from 8:18 AM to 4:20 PM it was observed that the following doors did not latch properly when tested:

1. Fire Sep doors in basement by Hazmat room
2. Fire sep doors in kitchen for elevator - blocked by cart and table

These findings were acknowledged by the facility Maintenance Staff.

Based on observation and staff interview, the facility failed to maintain the integrity of smoke barriers. This potentially allows the spread of smoke to other areas of the facility, exposing residents to a smoke or fire environment. The findings are as follows.

During the facility tour on December 11, 2012 from 8:18 AM to 4:20 PM penetrations were observed in the following location(s)

1. Ceiling tiles missing in data room

These findings were acknowledged by the Maintenance Director.

Based on observations and staff interview, the facility failed to provide functional fire doors in a hazardous area. This has the potential to expose residents to a fire or smoke environment. The findings are as follows:

During the facility tour on December 11, 2012 from 8:18 AM to 4:20 PM found doors that did not close and latch:

1. Hazmat door in the basement failed to latch securely when tested

These findings were acknowledged by the Maintenance Director.

Based on observation and staff interviews, the facility failed to maintain proper emergency egress lighting. This has the potential to misdirect residents or staff while exiting during an emergency

An examination of the facility ' s maintenance records for light checks on December 11, 2012 at 2:45 PM revealed that the facility was conducting monthly checks but not an annual battery test.

These findings were acknowledged by the Maintenance Director.

Based on record review, the facility failed to assure that the Hospital staff was adequately trained to respond to fires. This potentially exposed residents to smoke and fire in the facility. Findings include:

An examination of the facility ' s fire drill records on December 11, 2012 at 2:30 PM revealed that the fire drill records were missing for the month, quarter and shift as follows:

1. 1st quarter (2012) 1st shift
2. 1st quarter (2012) 2nd shift

These findings were acknowledged by the Maintenance Director.

Based on observation and record review, the facility failed to assure fire extinguishers are properly maintained. This potentially delays a quick response to contain a fire from spreading, exposing residents to fire in the environment.

1. During the facility tour on December 11, 2012 from 8:18 AM to 4:20 PM, observed fire extinguishers in the following locations out of service:

A. Elevator Room 1108 - extinguisher past due for annual servicing

2. The following portable fire extinguishers height from the floor to the top of the extinguisher exceeds 5 feet:

A. Across from Room 233
B. OR 1
C. OR 2
D. OR 3

The Maintenance Director acknowledged the findings.

Based on observation and staff interview, the facility failed to assure that exit egress remained clear and unobstructed. This potentially prevents residents from exiting a fire/smoke environment. Findings include:

During the facility tour on December 11, 2012 from 8:18 AM to 4:20 PM, observed that the corridors used for exiting were obstructed:

1. Blanket warmer by room 301
2. 2 Hoyer lifts by room 317
3. Patient transfer bed by 314

This finding was acknowledged by the Maintenance Director.

Based on observation and staff interview the facility failed to assure that wall coverings of a flammable nature did not exceed the protection value from the installed sprinkler system. This potentially exposed residents to a smoke/fire environment. Findings include:

During the facility tour on December 11, 2012 from 8:18 AM to 4:20 PM it was observed:

1. The following wall tapestry did not have documentation for being treated with approved fire retardant material:

a. By room 143
b. By room 2301
c. Dining area

2. The following doors had live wreaths hanging on them:

a. Room 136
b. Room 137

These findings were acknowledged by the facility Maintenance Director and Executive Director.

Based on observation and staff interview, the facility failed to maintain the proper distance for hand based alcohol hand gel from an electrical source. This potentially allows the spread of smoke and fire to other areas of the facility, exposing residents to a hazardous environment. The findings are as follows.

During the facility tour on December 11, 2012 from 8:18 AM to 4:20 PM improper mounting of alcohol based hand rub was observed in the following location(s)

1. Sleep Center Room 4 - next to door
2. Patient room 301 - above night light
3. Patient room 302 - above night light
4. Patient room 303 - above night light
5. Patient room 304 - above night light
6. Patient room 305 - above night light
7. Patient room 306 - above night light
8. Room 331 - above light switch by door
9. Nursery - above switch by door
10. OR 2 - above electrical outlets
11. Room 1210 - above outlet
12. Room 1310 - above light switch

These findings were acknowledged by the Maintenance Director.

Based on observations and staff interview the facility failed to post " Oxygen in use, No smoking " signs for resident rooms using oxygen in accordance with NFPA 99, 8-3.1.11.3 and *-6.4.2. This has the potential for exposing residents to a fire or explosive environment.

During the facility tour on December 11, 2012 from 8:18 AM to 4:20 PM, observed no " Oxygen in use, No smoking " signs posted. for the following room:

1. Room 323B

These observations were acknowledged by the Maintenance Director.

Based on observations, the facility failed to maintain proper electrical conditions per NFPA 70, National Electrical Code. This has the potential to expose staff and patients to a fire
environment. The findings are as follows:

During the facility tour on December 11, 2012 from 8:18 AM to 4:20 PM the following deficiencies were found:

1. Multi plug adapter to multi plug adapter in use in CCU Corridor by room 301
2. Extension cord powering Christmas tree in Room 141A
3. Extension cord powering Christmas tree in patient financial services office
4. Multi plug adapter to multi plug adapter in use in phone room (basement)
5. Extension cords powering Christmas decorations in main lobby

These findings were acknowledged by the Maintenance Director