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National Fire Protection Association (NFPA) 101, Life Safety Code, (2012 Edition)

19.2.3.4 (5)* Where the corridor width is at least 8 ft (2440 mm), projections into the required width shall be permitted for fixed furniture, provided that all of the following conditions are met:
(a) The fixed furniture is securely attached to the floor or to the wall.
(b) The fixed furniture does not reduce the clear unobstructed corridor width to less than 6 ft (1830 mm), except as permitted by 19.2.3.4(2).
(c) The fixed furniture is located only on one side of the corridor.
(d) The fixed furniture is grouped such that each grouping does not exceed an area of 50 ft2 (4.6 m2).
(e) The fixed furniture groupings addressed in 19.2.3.4(5)(d) are separated from each other by a distance of at least 10 ft (3050 mm).
(f)* The fixed furniture is located so as to not obstruct access to building service and fire protection equipment.
(g) Corridors throughout the smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4 or the fixed furniture spaces are arranged and located to allow direct supervision by the facilty staff from a nurses' station or similar space.
(h) The smoke compartment is protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.8.

Federal Register/Vol. 81, No. 86/Wednesday, May 4, 2016/Rules and Regulations/Pg. 26888.

The Department of Health and Human Services (DHHS), Centers for Medicare and Medicaid Services (CMS), published Medicaid Programs; Fire Safety Requirements for Certain Health Care Facilities; Final Rule, May 4, 2016. In the Final Rule, CMS adopted the 2010 ADA Standards for Accessible Design, published by the Department of Justice on September 15, 2010. In adopting the ADA Standards, CMS restricted protrusions from walls to a 4 inch limit for wall-mounted protruding objects and a 4 1/2 inch limit for handrails. The ADA Standard is the most stringent when compared to the National Fire Protection Association (NFPA), Life Safety Code (LSC), 2012.

Americans with Disabilities Act (ADA)
307.1 General - Protruding objects shall comply with 307.
307.2 Protrusion Limits. Objects with leading edges more than 27 inches and not more than 80 inches above the finished floor or ground shall protrude 4 inches maximum horizontally onto the circulation path.
Exception: Handrails shall be permitted to protrude 4-1/2 inches maximum.

Based on observation and measurement, the facility failed to ensure that corridors were unobstructed and maintained the proper clearance width.

Findings include:

1) During the facility tours 11/12/19 - 11/14/19, observation and measurement revealed that the facility failed to ensure that wall signs and fixtures that protruded into corridors were installed and maintained within the protrusion and height requirements listed in section 307 of the ADA at the following locations:

a) Corridor at Main Entrance - The Portable Fire Extinguisher (PFE) locator sign protruded 7.25 inches into the corridor and was mounted at a height of 72.5 inches above the finished floor.
b) Administrative Corridor (next to ATM) - The PFE locator sign protruded 6.5 inches into the corridor and was mounted at a height of 75.5 inches above the finished floor.
c) Emergency Department Corridor (Outside Room 7) - The PFE locator sign protruded 6.25 inches into the corridor and was mounted at a height of 72.75 inches above the finished floor.
d) Emergency Department Corridor (Outside Room 1) - The PFE locator sign protruded 6.75 inches into the corridor and was mounted at a height of 76.75 inches above the finished floor.
e) Emergency Department Corridor - The speaker for the facility announcement system protruded 10 inches into the corridor and was mounted at a height of 77 inches above the finished floor.
f) Emergency Department Corridor - The water fountain protruded 12.5 inches into the corridor and was mounted at a height of 42 inches above the finished floor.
g) Skilled Nursing Facility Corridor (Outside MDS Coordinator Office)- The speaker for the facility announcement system protruded 10 inches into the corridor and was mounted at a height of 75 inches above the finished floor.
h) Dining Room Corridor - The speaker for the facility announcement system protruded 10 inches into the corridor and was mounted at a height of 76 inches above the finished floor.
i) Administrative Corridor (outside Human Resources) - The water fountain protruded 13 inches into the corridor and was mounted at a height of 38 inches above the finished floor.
j) Administration Corridor (outside Human Resources) - The hand sanitizer station protruded 5.5 inches into the corridor and was mounted at a height of 61 inches above the finished floor.
k) Corridor (outside Respiratory Therapy office) - The hand sanitizer station protruded 5.5 inches into the corridor and was mounted at a height of 61 inches above the finished floor.

2) Observation and measurement revealed that the facility failed to ensure that corridors, exit discharges, and exit locations were consistently maintained free of all obstructions in the following locations:

a) Radiology/Emergency Department Corridor - The corridor width was reduced to 31 inches by an unattended soiled linen bin (29 inches wide) and a clean linen cart (22 inches wide).
b) Main Supply - The corridor leading to the exit was reduced to 30 inches by storage boxes and shelving.
c) Surgery Suite - The corridor leading to the exit was reduced to 60 inches by an unattended patient bed.

All observations were made in the presence of, and acknowledged by, the Maintenance Director.

National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 Edition
7.9.3 Periodic Testing of Emergency Lighting Equipment.
7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.
7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).
(2)* The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Based on interview, the facility failed to document periodic testing of the emergency lighting system.

Findings include:

On 11/14/19, the Maintenance Director indicated the emergency lighting system was tested when the generator was tested, and the Director was not aware of the requirement to document visual inspections and tests of the system.

National Fire Protection Association (NFPA) 101, Life Safety Code (2012 Edition).

7.10.8.3 No Exit. Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows:
NO
EXIT
7.10.8.3.2 The NO EXIT sign shall have the word NO in letters 2 in (51 mm) high, with a stroke width of 3/8 in. (9.5 mm), and the word EXIT in Letters 1 in. (25 mm) high, with the word EXIT below the word NO, unless such sign is an approved existing sign.

Based on observation, the facility failed to ensure 2 of 3 doors leading to courtyards without egress access were clearly marked with "NO EXIT" signs.

Findings include:

1) The atruim in the Administrative corridor and the fenced outdoor break area in the Psychiatric Unit did not have a NO EXIT sign posted.


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2) On 11/13/19, the illuminated exit sign at the northwest exit (between the emergency department and laboratory) was visually obstructed by an internal door. The exit sign was installed directly above the external exit, however, the door separating the entry way from the corridor obstructed the line of vision of the exit sign from the egress path.

3) On 11/14/19, observation revealed that the door located on the west side of the kitchen was marked with signage that identified the door as an exit. The door labeled as an exit directs traffic through an intervening storage room before discharging on to the staff smoking area. An interview with the Maintenance Director and Dietary Supervisor indicated the door was, at one time, an exit, but is no longer utilized as such. This observation was made in the presence of the Maintenance Director and Dietary Supervisor.

Based on observation and measurement, the facility failed to ensure that hazardous areas protected by an automatic fire extinguishing system were separated from other spaces by smoke resistant partitions.

Findings include:

1) During the facilty tours conducted 11/12/19 through 11/14/19, observation revealed the facility failed to ensure that the hazardous areas protected by an automatic fire sprinkler system were separated from other spaces by smoke resistant partitions:

a) Water Heater Room - An approximately 1 1/2 inch penetration was not sealed in the ceiling above the water heater.
b) Main Electrical Room - Twenty six, 1-2 inch penetrations were not sealed in the ceiling and walls.
c) Soiled Linen Room (Room 415) - A 4 inch penetration without approved fire caulking was observed on the 1-hour Fire Barrier wall (directly through the fire wall stenciling) in the interstitial space above the door. Additionally, several pieces of cloth, cords, and an emesis basin were found in the interstitial space above the door.
d) Laboratory- Five, 1 - 2 inch penetrations were unsealed along the 2 hour fire separation along the north wall above the air conditioner.
e) Information Technology Server Room - Six, 1 - 2 inch penetrations were unsealed in the ceiling. Additionally, several ceiling tiles were missing, leaving the interstitial space above the ceiling exposed.
f) Radiology Reading Room - A 7 inch by 3 inch hole, with various cables and cords ran through it, was observed above the desk.

These observations were made in the presence of the Maintenance Director.

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National Fire Protection Association (NFPA) 10, Standard for Portable Fire Extinguishers (2010 Edition).

6.1.3.8 Installation Height.
6.1.3.8.1 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire
extinguisher is not more than 5 ft (1.53 m) above the floor.
6.1.3.8.2 Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be installed
so that the top of the fire extinguisher is not more than 3.5 ft (1.07 m) above the floor.
6.1.3.8.3 In no case shall the clearance between the bottom of the hand portable fire extinguisher and the floor be less
than 4 in. (102 mm).

Based on document review, observation, and interview, the facility failed to ensure portable fire extinguishers were installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

Findings include:

1) On 11/13/19 and 11/14/19, during the facility tours, observation and measurement of the portable fire extinguishers revealed the following deficiencies:

a) Radiology Corridor - The pressure indicating gauge on the portable fire extinguisher indicated it was overcharged.
b) Radiology Office - The portable fire extinguisher was mounted with the top of the fire extinguisher handle measured at 70 inches above the floor.
c) Laboratory- The portable fire extinguisher located near the laboratory entrance was mounted with the top of the handle measured at 64 inches above the floor. The portable fire extinguisher was obstructed by a privacy curtain mounted to the ceiling.
d) Laboratory - The portable fire extinguisher located next to the emergency eye wash station was mounted with the top of the handle measured at 64 inches above the floor.
e) Geriatric Psychiatric Unit - The portable fire extinguisher in the administrative space was mounted with the top of the handle measured at 61 1/2 inches above the floor.
f) Medical Records - The portable fire extinguisher was mounted with the top of the handle measured 63 inches above the floor.
g) Central Supply - The portable fire extinguisher was obstructed by a file cabinet and folders. The portable fire extinguisher was mounted with the top of the handle 76 inches above the floor.

All observations were made in the presence of the Maintenance Director.

National Fire Protection Association (NFPA) 70, National Electric Code, 2011 Edition

110.26 Spaces About Electrical Equipment. Access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operations and maintenance of such equipment.
(A) Working Space. Working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of 110.26 (A)(1), (A)(2), and (A)(3) or as required or permitted elsewhere in this Code.

(1) Depth of Working Space. The depth of the working space in the direction of live parts shall not be less than that specified in Table 110.26 (A)(1) unless the requirements of 110.26 (A)(1)(a), (A)(1)(b), or (A)(1)(c) are met. Distances shall be measured from the exposed live parts or from the enclosure or opening if the live parts are enclosed. (Nominal Voltage to Ground of 0 -150 = 3 feet).

Article 314 - Outlet, Device, Pull, and Junction Boxes; Conduit bodies; Fittings; and Handhole Enclosures
314.25 Covers and Canopies. In completed installations, each box shall have a cover, faceplate, lampholder, or luminaire canopy, except where the installation complies with 410.24(B).
314.28(c) Pull and Junction Boxes and Conduit Bodies.
(c) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where used, metal covers shall comply with the grounding requirements of 250.110.

Article 400 - Flexible Cords and Cables
400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
1) As a substitute for the fixed wiring of a structure
2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
3) Where run through doorways, windows, or similar openings
4) Where attached to building surfaces
Exception to 4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B)
5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
6) Where installed in raceways, except as otherwise permitted in the Code
7) Where subject to physical damage

Article 408.4 - Field Identification Required
A) Circuit Directory of Circuit Identification. Every circuit and circuit modification shall be legibly identified as to its clear, evident, and specific purpose or use. The identification shall include an approved degree of detail that allows each circuit to be distinguished from all others. Spare positions that contain unused overcurrent devices or switches shall be described accordingly. The identification shall be included in a circuit directory that is located on the face or inside of the panel door in the case of a panelboard and at each switch or circuit breaker in a switchboard or switchgear. No circuit shall be described in a manner that depends on transient conditions of occupancy.

Article 590.2 All Wiring Installations.
Article 590.2(A) Other Articles. Except as specifically modified in this article, all other requirements of this Code, for permanent wiring shall apply to temporary wiring installations.

Article 400.8 Uses Not Permitted. Unless specifically permitted in Article 400.7, flex cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure.
(2) Where run through holes in walls, structural ceilings, suspended ceiling, dropped ceilings or floors.
(3) Where run through doorways, windows or similar openings.
(4) Where attached to building surfaces.
exception to (4): Flex cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56.
(5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings.
(6) Where installed in raceways, except as otherwise permitted by the Code.
(7) Where subject to physical damage.

PANELBOARD LABELING
Article 408.4 - Field Identification Required
A) Circuit Director of Circuit Identification. Every circuit and circuit modification shall be legibly identified as to its clear, evident, and specific purpose or use. The identification shall include an approved degree of detail that allows each circuit to be distinguished from all others. Spare positions that contain unused overcurrent devices or switches shall be described accordingly. The identification shall be included in a circuit directory that is located on the face or inside of the panel door in the case of a panelboard and at each switch or circuit breaker in a switchboard or switchgear. No circuit shall be described in a manner that depends on transient conditions of occupancy.

NFPA 99, Health Care Facilities Code (2012 Edition)
10.2.4. Adapters and Extension Cords
10.2.4.1 Three-prong to two prong adapters shall not be permitted.

Based on observation, the facility failed to ensure electrical equipment was maintained in accordance with NPFA 70, National Electric Code.

Findings include:

1) The facility was toured on 11/12/19 through 11/14/19. The following deficiencies were identified:

a) Panel P5, the Field Identification listed was inaccurate.
b) Panel EL2, the Field Identification listed was inaccurate.
c) Panel EP2 was obstructed by a trash can.


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2) On 11/12/19 through 11/14/19, during tours of the facility, the following electrical receptacles were observed to be broken, cracked, or missing:

a) External, East side of building - The water proof cover on the Ground-Fault Circuit Interrupt (GFCI) outlet located outside of the ATS room was missing.
b) External, Southwest side of building - The waterproof cover on the GFCI outlet located outside of the riser room was missing and the ground plug on the receptacle was broken.
c) ATM Machine - The ground plug on the receptacle next to the facility's ATM machine was broken.
d) Kitchen - The water proof cover on the GFCI outlet located below the prep sink was broken.

3) On 11/13/19, during a tour of the radiology office, a relocatable power tap (RPT) was used to provide power to a refrigerator.
4) On 11/13/19, the junction box located in the radiology reading room was observed to be broken, revealed exposed wires, and was missing a cover.
5) On 11/13/19, the RPT used to power the desk top computer and components in the Chief Nursing Officer's office was plugged into an outlet at a distance that suspended the RPT between the wall and the desk.
6) On 11/13/19, the electrical receptacle located above the counter in the Long Term Care area Activity Room was installed 34 inches from the edge of the sink. The receptacle was not a GFCI outlet.
7) On 11/14/19, during a tour of the dining area, an extension cord was used as a substitute for permanent wiring to provide power to the facility's cash register. The extension cord did not have markings to verify its UL listing and was installed under a floor mat behind the register counter.
8) On 11/14/19, during a tour of the respiratory therapy office, a 6-plug RPT was used to provide power to a refrigerator and a microwave.
9) On 11/14/19, the electrical receptacle located in the kitchen, to the right of the prep sink, was installed 20 inches from the edge of the sink. The receptacle was not a GFCI outlet.
10) On 11/14/19, a tour of the Information Technology (IT) office revealed multiple 6-plug RPTs used to power IT equipment were "daisy chained" together. Specifically, 6-plug RPTs mounted on the IT equipment rack were plugged into other 6-plug RPTs that were plugged into a wall outlet. (This deficiency was observed on all equipment racks in the IT office).
11) On 11/14/19, the junction box located in the ceiling of the IT office revealed exposed wires due to a missing cover plate.
12) On 11/14/19, a tour of the pharmacy revealed a non-UL listed, 3-plug RPT was used to power office equipment.
13) On 11/14/19, in the pharmacy, an extension cord was used as a substitute for permanent wiring to provide power to office equipment.
14) On 11/14/19, a 6-plug RPT was used to provide power to the pharmacy refrigerator.

All observations were made in the presence of the Maintenance Director.

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Based on record review and interview, the facility failed to conduct fire drills at unexpected times under varying conditions.

Findings include:

On 11/14/19, document review revealed the evening (swing) shift fire drills were not conducted at unexpected times. With the exception of one drill conducted in the second quarter of 2019, the times of the evening shift fire drills were all within one hour of the last drill and were not conducted at various times throughout the shift. Evening shift drills were conducted as follows:
a. Fourth Quarter 2018 - Evening Shift (2:10 pm)
b. First Quarter 2019 - Swing Shift (2:30 pm)
c. Second Quarter 2019 - Swing Shift (2:15 pm & 7:25 pm)
d. Third Quarter 2019 - Swing Shift (3:04 pm)

On 11/14/19, the Maintenance Director acknowledged the fire drills for the evening shift were not staggered throughout the year.

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National Fire Protection Association (NFPA) Life Safety Code 101, 2012 edition

19.7.4 Smoking.
Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or individual enclosed space where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted
with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances,
secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 19.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available
to all areas where smoking is permitted.

Based on observation, interview, and record review, the facility failed to include all required provisions.

Findings include:

On 11/14/19 in the afternoon, the facility's Smoking Policy reviewed for the House-Wide Non-Clinical Department, revised 07/09/19, documented, the facility promotes being a Tobacco Free facility but allowed residents and employees to smoke in designated smoking areas. The secondary Smoking Policy reviewed for the Skilled Nursing Facility/Long-term Care (SNF/LTC), revised 08/20/19, promotes safe tobacco use by LTC residents which also allows residents to smoke within the designated area outside of the building.

The facility's policies for the House-Wide Non-Clinical Department, the SNF/LTC residents and staff failed to include metal containers with self-closing cover devices into which ashtrays can be emptied and shall be readily available to all areas where smoking is permitted.

Observations of the resident smoking area located outside the long-term care unit and the employee smoking area located adjacent to the laundry warehouse verified required metal containers with self-closing cover devices were not present.

On 11/14/19 in the afternoon, the Chief Nursing Officer and Maintenance Director acknowledged all the required provisions were not included in the facility's smoking policy.

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Based on document review and interview, the facility failed to provide evidence that smoke and fire door assemblies satisfactorily resisted the passage of smoke .

Findings include:

On 11/12/19, document review revealed the annual door inspection report, conducted in October 2019, demonstrated 63% of smoke and fire door assemblies failed the annual inspection.

The Maintenance Director acknowledged the deficiency at the exit interview. The Maintenance Director explained repairs were pending for all failed doors but that no date had yet been set for repairs.

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National Fire Protection Association (NFPA 99), Health Care Facilities Code, 2012 Edition
6.3.3.2 Receptacle Testing in Patient Care Rooms.
6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking type receptacles) shall be not less than 115 g (4 oz).

6.3.4.2 Record Keeping.
6.3.4.2.1* General.
6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modification.
6.3.4.2.1.2 At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter.


Based on observation, interview, and record review, the facility failed to maintain electrical receptacles at patient bed locations as required.

Findings include:

On 11/12/19, document review revealed the facility was documenting the required electrical receptacle testing and inspections. The report indicated that numerous electrical receptacles had failed the annual inspection dated October 2019.

On 11/12/19 - 11/14/19, during the tour of the facility, the annual report's findings of deficient receptacles were confirmed with broken receptacles throughout the facility.

The Maintenance Director acknowledged the broken electrical receptacles had not yet been repaired.