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It was determined by observation during the course of the survey on July 6, 2010 that hazardous areas were not protected in accordance with NFPA 101 as evidenced by the following:

1. The surgery storage room in the basement adjacent to the staff elevators contained a large quantity of combustible storage. The room qualified as a hazardous area. There was no self-closing device on the door. This room is located in the adjacent facility.
2. The basement information systems storage area contained a large quantity of combustible materials. The closing device on the door to the exit corridor would not release when the door was opened 180 degrees. The door was in the open position during the survey. This room is located in the adjacent facility.
3. The storage closet across from central supply in the MOU wing was not provided with a door, and contained a quantity of cardboard boxes.

It was determined by observation during the course of the survey on July 6, 2010 that hazardous areas were not protected in accordance with NFPA 101 as evidenced by the following:

1. The surgery storage room in the basement adjacent to the staff elevators contained a large quantity of combustible storage. The room qualified as a hazardous area. There was no self-closing device on the door. This room is located in the adjacent facility.
2. The basement information systems storage area contained a large quantity of combustible materials. The closing device on the door to the exit corridor would not release when the door was opened 180 degrees. The door was in the open position during the survey. This room is located in the adjacent facility.
3. The storage closet across from central supply in the MOU wing was not provided with a door, and contained a quantity of cardboard boxes.

It was determined by observation during the course of the survey on July 6, 2010 that exit discharge was not in compliance with NFPA 101, Chapter 19.2.1 and the referenced Chapter 7.7.2 as evidenced by the following:

Fifty percent of stair exits did not discharge directly to the exterior of the building without passing through other areas on the level of discharge.
1. The Northwest exit follows a corridor of approximately 120 feet and passes three rooms. The exit to the exterior of the building is not readily visible from the point of discharge. The level of discharge is not provided with a complete automatic fire suppression system.
2. The Southwest exit enters a corridor and is open to the exit corridor in both directions. The exit is approximately 60 feet and passes six rooms. The exit to the exterior of the building is not readily visible from the point of discharge. The level of discharge is not provided with a complete automatic fire suppression system.

It was determined by observation during the course of the survey on July 6, 2010 that exits were not readily accessible at all times as evidenced by the following:

1. There was a dialysis chair and a mailbox located in the north hall exit corridor.
2. The smoke doors adjacent to the shower room on the main level would not release from their frames without the use of excessive force.

It was determined by observation during the course of the survey on July 6, 2010 that exit corridors were not accessible to resident rooms without the use of a key as evidenced by the following:

There was a double key deadbolt on room #2025. This room was not presently being used as a patient room but is capable of being changed to that purpose. In either case these locks are not permitted in health care occupancies.

It was determined by observation during the course of the survey on July 6, 2010 that the emergency back-up electrical system was not in compliance with NFPA 99 and NFPA 70 as evidenced by the following:

1. The three branches (Life Safety, Critical and Equipment) were not clearly labeled on Generator number two.
2. There was no red plug in the night pharmacy to indicate there was at least one outlet serviced by the emergency generator system.

It was determined by record review during the course of the survey on July 6, 2010 that fire drills were not documented quarterly on each shift as evidenced by the following:

1. There was no fire drill report for October 2009.
2. There were no staff signatures to indicate participation in the September 2009 fire drill report.

It was determined by observation during the course of the survey on July 6, 2010 that the existing automatic fire suppression was not maintained in compliance with NFPA 13 as evidenced by the following:

1. There were gaps around escutcheon plates on two sprinkle heads in the clean linen room across from room #2034.
2. The sprinkler head by the window in room #2032 was covered with foreign matter.
3. The closet next to the staff elevator in the basement has a hole around the escutcheon plate.
4. A ceiling tile adjacent to the sprinkler head in the former pulmonary function area was not in place. This condition as well as openings around escutcheon plates does not allow heat to collect at the sprinkler head fusible link.
5. The sprinkler head in the dish room by the sink was covered with foreign matter.
6. The escutcheon plate by the pots and pans scrubbing scullery in the south basement areas was not in place.
7. There was a gap around the escutcheon plate outside the dietary office.
8. There were two escutcheon plates missing in the basement old dining area.
9. The second floor shower room sprinkler head was corroded, and needs to be replaced.

It was determined by observation during the course of the survey on July 6, 2010 that oxygen was not stored in compliance with NFPA 99 as evidenced by the following:

There were two unsecured oxygen E-tanks in the hall outside the oxygen storage room.

It was determined by observation during the course of the survey on July 6, 2010 that electrical wiring and equipment were not in compliance with NFPA 70 as evidenced by the following:

1. The auxiliary Medication dispenser stored in the Medicine room on the second floor was using an extension cord as a replacement for permanent wiring.
2. There were also two refrigerators in the Medicine room plugged into a power strip. Power surge protectors can only be used to protect sensitive electronic equipment.
3. There was a damaged duplex outlet in the Medicine room.

It was determined by observation during the course of the survey on July 6, 2010 that three passenger elevators were not in compliance with firefighters service requirements as evidenced by the following:

There was no fire fighters phase I recall and automatic smoke detector recall. There was no phase II emergency in-car key operation.

It was determined by observation during the course of the survey on July 6, 2010 that alcohol gel was not installed in accordance with the Code of Federal Regulations as evidenced by the following:

Alcohol gel dispensers at the main elevators and in the west exit corridor were installed over carpet. This is only permitted if the building is fully sprinklered.