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Based on observation and interview with staff, the facility failed to provide doors that are provided with a means suitable for keeping the door closed. Findings:

Roller latches are installed on doors to the Doctors Lounge, Medical Records, Business Office, Dietary Office and two doors to the kitchen.

Based on observation and interview with staff, the facility failed to provide approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants. Findings:

The double egress doors located adjacent to the Chapel are not marked by readily visible signs.

Based on observation, review of records and interview with staff, the facility failed to
provide documentation that fire drills are conducted quarterly on each shift. Finding::

The were no records of fire drills for the first quarter of 2012.

Based on observation, review of records and interview with staff, the facility failed to provide a testing program complying with applicable requirements of NFPA 70 and 72.
9.6.1.4 Findings:

The documentation of the fire alarm system test completed October 4, 2011 failed to provide all information required to comply with applicable requirements of NFPA 70 and 72.

Based on observation , review of documents and interview with staff, the facility failed to maintain the sprinkler system in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems and to provide complete coverage for all portions of the building. Findings:

(1) The sprinkler system has not been inspected since April 7, 2009.
(2) There was no coverage in the west corridor adjacent to the Lab, over the soffit or over the soffit outside the boiler room.

Based on observation and interview with staff, the facility failed to continuously maintain means of egress that are free of all obstructions or impediments. Findings:

A love seat and chair are located in the corridor outside of the MRI room, three chairs and a table are located in the west egress corridor adjacent to the lab; and in various areas, equipment was left in the corridors.

Based on observation and interview with staff, the facility failed to provide a piped medical gas system that comply's with NFPA 99, Chapter 4. Finding:,

The Main Gas Shut off for the facility was located outside of the bottle supply fence and was unprotected. The valve is required to be secured from tampering (locked and tagged).

Based on observation and interview with staff, the facility failed to test appliances used in a critical care area every 6 months as required by NFPA 99, 1999 Edition, Chapter 7-6.2.1.2. Finding:

The tag on the EKG Machine located in the ER did not document the machine had been tested every 6 months as required.

Based on observation and interview with staff, the facility could not provide documentation that the Generator was inspected weekly and exercised under load for 30 minutes per month in accordance with NFPA 99.