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Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not sealing holes and gaps in ceilings and/or walls or by not ensuring that ceilings have full integrity and/or proper flame spread ratings.

The findings include:

During the initial survey on November 6, 2013 with the Assistant Vice President of Operations, the Safety & Emergency Management Director, and other administrative staff, it was observed between 9:25 am and 12:35 pm that one small office had two sliding doors to closets that also housed electrical panels - there were gaps in the drywall above the right hand electrical panel where conduits and wires penetrated and had not been properly sealed with fire stop caulk.

These penetrations and/or deficient ceiling tiles could allow smoke or flames to travel above the ceiling or from one section of the building to another in the event of a fire.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not having all doors protecting corridor openings provided with a means suitable for keeping the door closed.

The findings include:

During the initial survey on November 6, 2013 with the Assistant Vice President of Operations, the Safety & Emergency Management Director, and other administrative staff, it was observed between 9:25 am and 12:35 pm that the corridor door to patient room #5218 failed to latch when closed - the door strike mechanism had been removed; additionally, on this same door, there was an exterior key-pad deadbolt with a knob-handle deadbolt on the interior side of the door. This type of locking mechanism is not permitted on a patient room door.

This impediment could prevent the door from being quickly and easily closed and latched in the event of an emergency and could effect the residents of the listed room and up to 20% of the residents in the corridor.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not ensuring that hazardous areas are separated from other spaces by smoke resisting partitions and doors.

The findings include:

During the initial survey on November 6, 2013 with the Assistant Vice President of Operations, the Safety & Emergency Management Director, and other administrative staff, it was observed between 9:25 am and 12:35 pm that the door to the main laundry folding and storage room was held open with a wooden wedge and a large laundry cart; when tested, the door also failed to close tightly and latch. Note - there are no washer or dryer facilities in this building - all laundry is shipped out for processing.

Partitions that are not smoke resisting or doors to hazardous areas that are not self-closing could allow smoke to travel from hazardous areas of the facility to other sections in the event of a fire.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not having stairwells free of storage.

The findings include:

During the initial survey on November 5, 2013 with the Assistant Vice President of Operations and other administrative and maintenance staff, it was observed between 7:45 am and 1:00 pm that an arm-chair was found inside one stairwell on the upper landing and an umbrella rack with plastic bag dispenser was found on the lower level of a stairwell - both were removed during the survey.

Storage of any type could result in personal injury, blocked emergency egress, or fire in the stairwell.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not having the required emergency lighting operating properly.

The findings include:

During the initial survey on November 6, 2013 with the Assistant Vice President of Operations, the Safety & Emergency Management Director, and other administrative staff, it was observed between 9:25 am and 12:35 pm that one corridor wall-mounted emergency lamp failed to operate when tested - near room #5214.

The failure of the emergency lighting in these areas has the potential to promote harm to occupants of the facility in the event of a fire, power failure, or other type of emergency.

Based on a review of records, it was determined that the facility staff failed to provide a safe and hazard free environment by failing to hold regularly scheduled fire drills at unexpected times.

The findings include:

During the initial survey on November 5, 2013 with the Assistant Vice President of Operations and other administrative and maintenance staff, it was observed between 7:45 am and 1:00 pm after a review of records, that this hospital operates only two shifts - 7am to 7pm and 7pm to 7am; after reviewing fire drill logs, it was determined that fire drills for the second shift had not been scheduled in the evenings after 8:30 pm or before 7:00 am - most second shift drills had taken place near the beginning of the shift - usually between 7:00 pm and 8:30 pm.

Failure to hold required fire drills at unexpected times and under varying conditions for all staff has the potential to create a hazardous environment for patients as the staff would not be familiar with the procedures to follow in the event of a fire or other emergency. This could effect 100% of the patients and staff.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining the sprinkler system in a reliable operating condition.

The findings include:

During the initial survey on November 5, 2013 with the Assistant Vice President of Operations and other administrative and maintenance staff, it was observed between 7:45 am and 1:00 pm that one pendant sprinkler head in the 2nd floor pantry was showing signs of corrosion.

This item could lead to improper operation of the sprinkler system in the event of a fire.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by failing to have the kitchen hood and duct system properly maintained.

The findings include:

During the initial survey on November 6, 2013 with the Assistant Vice President of Operations, the Safety & Emergency Management Director, the Food Services Manager, and other administrative staff, it was observed between 9:25 am and 12:35 pm that several metal grease baffle filters over two cooking areas in the main kitchen were damaged and/or had missing elements - all filters also had significant grease buildup. These filters are designed to catch significant amounts of grease from cooking vapors and are also UL rated to minimize the chance of flames reaching further into the hood system.

This has the potential to cause harm to patients and staff if there was a fire in the cooking surfaces or in the duct work above the cooking areas due to flammable grease buildup.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by failing to have properly equipped and operating self-latching mechanisms on the soiled linen chute doors.

The findings include:

During the initial survey on November 6, 2013 with the Assistant Vice President of Operations, the Safety & Emergency Management Director, and other administrative staff, it was observed between 9:25 am and 12:35 pm that:

1.) The soiled linen chute hatch door on the 5th floor failed to self-close and latch;

2.) The basement level soiled linen chute hatch is arranged to close with a spring loaded mechanism that is controlled by a fusible link - there was no documentation showing that the mechanism had been tested for proper operation and that the fusible link had been replaced on a regular schedule.

This hardware must be installed so that the doors/hatches will self-close and automatically latch at all times as well as in the event of a fire emergency. This would prevent the spread of smoke or fire from down below into the upper level patient corridors.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by having locations where there were non-compliant electrical applications.

The findings include:

During the initial survey on November 5, 2013 with the Assistant Vice President of Operations and other administrative and maintenance staff, it was observed between 7:45 am and 1:00 pm that:

1.) Several 2nd floor exam rooms with small sinks all had electrical outlets with no ground fault circuit interrupter (GFCI) protection;

2.) The x-ray darkroom had an outlet near a large sink with no GFCI protection;

3.) The clean supply room had a light duty brown extension cord running from an outlet through a wall-mounted plastic channel to a power strip - the power strip was powering numerous chargers (6+) for medical devices.

Absence of a GFCI protected outlets in wet locations increases the potential for electrical shock to staff members. Item #3 could cause overheating or electrical short circuits resulting in fire. NFPA 70, National Electrical Code states that: 1.) extension cords shall not be used as a substitute for permanent wiring. 11.1.5; 2.) extension cords and flexible cords shall not be affixed to structures, extend through walls, ceilings or floors, or be subject to environmental or physical damage. 11.1.5.3.5. 3.) multi-plug adapters, such as multi-plug extension cords, cube adapters, strip plugs, and other devices, shall be listed and used in accordance with their listing.