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Facility failed to ensure that hazardous areas were not protected in accordance with the 2000 edition of the Life Safety Code, NFPA(National Fire Protection Association) 101. Findings included:

Surveyor observed between 10 and 11am on April 05, 2011 that a clean linen storage room, approximatley 60 sq ft., was storing combustible linen. The corridor door was not self-closing. This is not in accordance with NFPA 101, 2000: 19.3.2.1.

Facility failed to maintain exits in accordance with 2000 edition of the Life Safety Code, NFPA 101. Findings included:

Surveyor observed between 1:00 pm and 1:30 pm on April 05, 2011 that front door to lobby had thumb lock deadbolt. This is not in accordance with NFPA 101, 7.2.1.5.4. Doors shall be operable with not more than one releasing operation.

Facility failed to provide complete maintenance records of kitchen hood fire protection equipment in accordance with NFPA 96, Standard for Ventilation Control of Commercial Cooking Operations. Finding included the following:

Surveyor observed between 10 am and 11am on April 05, 2001that records of kitchen hood maintenance were annual basis. This does not meet NFPA 96: 11.2.1. Inspect and servicing of fire extinguishing system at least every 6 months by properly trained and qualified person.

Facility failed to maintain ventilation system in accordance with NFPA 101, 2000 19.5.2 and Hospital Licensing Rules HLR and documentation of disaster drills were not in accordance with NFPA 99, Standard for Health Care Facilities.. Findings included the following:

a. Surveyor observed between 10 and 11 am on April 05, 2011 that Isolation room venlitation was not negative to the corridor and that janitor closet did not have functioning ventilation exhaust as required in HLR 133.169(c) Table 3 - Ventilation requirements for Hospitals and Outpatient Facilities.

b. Surveyor observed that facility had not complied with 25 ft setback for fresh air intake for roof top air handlers. Outside air intakes shall be located at least 25 feet from exhaust outlets of ventilating systems, combustion equipment stacks, medical-surgical vacuum systems, plumbing vents, or areas which may collect vehicular exhaust or other noxious fumes. (Prevailing winds and proximity to other structures may require more stringent requirements). Plumbing and vacuum vents that terminate five feet above the level of the top of the air intake may be located as close as 10 feet.

c. Surveyor observed that documentation of disaster drills was not complete in accordance with NFPA 99, 1999: 11-5.3.9. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both.

Facility failed to maintain electrical systems in accordance with 1999 edition of the NFPA 99, Standard for Health Facilities. Findings included:

Surveyor observed that renovation of the essential electrical system (EES) under plan of correction from survey dated 6.15.2010 was performed and was not inspected or approved by the department. Facility shall submit ceritfication by professional engineer that EES upgrade was in conformance with NFPA 3.4.2.2.2

Facility failed to maintain electrical system in accordance with 1999 edition of NFPA 99, Standard for Health Care Facilities. Findings included the following:

Surveyor observed between 10 am and 11 am on April 05, 2011 that receptacles in emergency exam room were not identified in accordance with NFPA 99 3-4.2.2.4. The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color (red) or markings so as to readily identifiable. This shall be provided throughout the facility.

Facility failed to ensure that hazardous areas were not protected in accordance with the 2000 edition of the Life Safety Code, NFPA(National Fire Protection Association) 101. Findings included:

Surveyor observed between 10 and 11am on April 05, 2011 that a clean linen storage room, approximatley 60 sq ft., was storing combustible linen. The corridor door was not self-closing. This is not in accordance with NFPA 101, 2000: 19.3.2.1.

Facility failed to maintain exits in accordance with 2000 edition of the Life Safety Code, NFPA 101. Findings included:

Surveyor observed between 1:00 pm and 1:30 pm on April 05, 2011 that front door to lobby had thumb lock deadbolt. This is not in accordance with NFPA 101, 7.2.1.5.4. Doors shall be operable with not more than one releasing operation.

Facility failed to provide complete maintenance records of kitchen hood fire protection equipment in accordance with NFPA 96, Standard for Ventilation Control of Commercial Cooking Operations. Finding included the following:

Surveyor observed between 10 am and 11am on April 05, 2001that records of kitchen hood maintenance were annual basis. This does not meet NFPA 96: 11.2.1. Inspect and servicing of fire extinguishing system at least every 6 months by properly trained and qualified person.

Facility failed to maintain ventilation system in accordance with NFPA 101, 2000 19.5.2 and Hospital Licensing Rules HLR and documentation of disaster drills were not in accordance with NFPA 99, Standard for Health Care Facilities.. Findings included the following:

a. Surveyor observed between 10 and 11 am on April 05, 2011 that Isolation room venlitation was not negative to the corridor and that janitor closet did not have functioning ventilation exhaust as required in HLR 133.169(c) Table 3 - Ventilation requirements for Hospitals and Outpatient Facilities.

b. Surveyor observed that facility had not complied with 25 ft setback for fresh air intake for roof top air handlers. Outside air intakes shall be located at least 25 feet from exhaust outlets of ventilating systems, combustion equipment stacks, medical-surgical vacuum systems, plumbing vents, or areas which may collect vehicular exhaust or other noxious fumes. (Prevailing winds and proximity to other structures may require more stringent requirements). Plumbing and vacuum vents that terminate five feet above the level of the top of the air intake may be located as close as 10 feet.

c. Surveyor observed that documentation of disaster drills was not complete in accordance with NFPA 99, 1999: 11-5.3.9. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both.

Facility failed to maintain electrical systems in accordance with 1999 edition of the NFPA 99, Standard for Health Facilities. Findings included:

Surveyor observed that renovation of the essential electrical system (EES) under plan of correction from survey dated 6.15.2010 was performed and was not inspected or approved by the department. Facility shall submit ceritfication by professional engineer that EES upgrade was in conformance with NFPA 3.4.2.2.2

Facility failed to maintain electrical system in accordance with 1999 edition of NFPA 99, Standard for Health Care Facilities. Findings included the following:

Surveyor observed between 10 am and 11 am on April 05, 2011 that receptacles in emergency exam room were not identified in accordance with NFPA 99 3-4.2.2.4. The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color (red) or markings so as to readily identifiable. This shall be provided throughout the facility.