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Based on review of the fire drill reports dated 3-29-2011, 3-24-2011, 3-18-2011, 3-13,2011 and interview with the Director of Engineering, the facility failed to conduct fire drills that provide documentation that staff is familiar with procedures. Finding:

The fire drill reports turned into Engineering to document staff participation documented that staff did not bring fire extinguishers to the place of the reported alarm. There was no documentation that staff were in-serviced on the correct policy and procedures.

Based on review of the required Annual Fire Alarm Test Report, the facility failed to maintain fire alarm systems in accordance with NFPA 72. Findings:

(1) The was no documentation that the facility had reviewed the annual fire alarm report. The report was not signed by a representative of the Hospital.

(2) Several dampers could not be checked for operation because there are no access panels located in the duct for verification. One duct that had an access panel was found closed which restricted air from entering that area.

Based on observation and interview with the Director of Engineering, the facility failed to provide an automatic sprinkler system to provide complete coverage for all portions of the building. Findings:

There was no coverage under the outside exit leading out of the kitchen where soiled aprons used by kitchen staff are stored in a hamper.

Based on observation and review with the Director of Engineering, the facility failed to ensure mobile trash collection receptacles are located in a room protected as a hazardous area when not attended. Finding:

A mobile trash receptacle containing approximately 4 bags of trash was in front of the elevator unattended.

Based on observation and review with the Director of Engineering, the facility failed to test electrical appliances and equipment in accordance with 7-5.1.3.1 Finding:

Air Fresheners (Airken) blowers were found in the corridors with no initial test sticker.

Based on observation of the Liquid Oxygen Tank located in the corridor on the third floor across from the nurses station and review with the Director of Engineering, the facility failed to provide Transferring of oxygen in a room separated from any portion of a facility wherein patients are housed, examined, or treated by a separation of a fire barrier of 1-hour fire-resistive construction that is mechanically ventilated, sprinklered, and has ceramic or concrete flooring; and has signs indicating that transferring is occurring, and that smoking in the immediate area is not permitted. Finding:

The Director of Engineering stated that staff filled Portable Oxygen Bottles in the corridor on the third floor across from the nurses station.