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Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm systems was maintained in accordance with LSC 9.6.1.3. LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained in accordance with NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm Code. NFPA 72, Section 14.2.1.2.2 requires that system defects and malfunctions shall be corrected. This deficient practice could affect all occupants.

Findings include:

Based on observations with the Maintenance Supervisor between 09:37 a.m. and 2:34 p.m., the fire alarm control panel had a trouble notification illuminated on the main fire panel. The panel stated listed the trouble as "1FL FSD OR CORR O/S SUB-STER." Based on interview at the time of observation, the Maintenance Supervisor stated that an actuator for a fire/smoke damper in the sub-sterile room of the operating room was bad and has been awaiting parts to fix the device. Paperwork had been obtained from the facility indicating both the facility and alarm company know about the aforementioned condition. The Maintenance Supervisor later confirmed that the panel is still in trouble and the device still has not been fixed.
Findings were discussed with the Maintenance Supervisor, Director of Engineering, Director of Nursing and Safety Officer at exit conference.

Based on observation and interview, the facility failed to maintain the ceiling construction in 1 of 1 Informatics office in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, 2010 edition, Section 6.2.7.1 states plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler. This deficient practice could affect as many as 6 staff.

Findings include:

Based on observations made with the Maintenance Supervisor during a tour of the facility at 2:37 p.m. on 12/13/23, the Informatics office had an escutcheon that was not smoke tight. There was an annular gap around the escutcheon of approximately three-eighth of an inch in diameter. Based on interview at the time of observation, the Environmental Services Director and the Maintenance Technician #1 confirmed the escutcheon was missing, indicating it had fallen off recently and had not been replaced yet.

This finding was reviewed with the Maintenance Supervisor, the Director of Engineering, and the Safety Officer and the Director of Nursing on 12/13/23 at 4:00 p.m.

1) Based on record review and interview, the facility failed to maintain 1 of 1 automatic sprinkler systems. LSC 9.7.5 requires all sprinkler systems shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 2011 Edition, Section 4.1.4.1 states the property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test and maintenance required by this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor. NFPA 25, 4.3.1 requires records shall be made for all inspections, tests, and maintenance of the system components and shall be made available to the authority having jurisdiction upon request.
This deficient practice could affect all patients, staff, and visitors.

Findings include:

Based on review of the facility's quarterly sprinkler system inspection reports on 11/13/23 at 10:10 a.m. with the Miantenance Supervisor present, the quarterly sprinkler report dated 09/19/23 stated "Anti-freeze tested and indicate correct freeze points in the system - FAIL". When asked if he could show documentation that they had the anti-freeze added to the system, the Maintenance Supervisor stated that they had not seen that item on the aforementioned sprinkler system inspection. Based on further interview at the time of record review, the Maintenance Supervisor stated the anti-freeze has not yet been replaced.

This finding was reviewed with the Maintenance Supervisor, the Director of Engineering, and the Safety Officer and the Director of Nursing on 12/13/23 at 4:00 p.m.


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2) Based on observation and interview, the facility failed to maintain the ceiling construction of 1 of 1 CT rooms. The ceiling tiles trap hot air and gases around the sprinkler and cause the sprinkler to operate at a specified temperature. NFPA 13, 2010 edition, 8.5.4.11 states the distance between the sprinkler deflector and the ceiling above shall be selected based on the type of sprinkler and the type of construction. This deficient practice affect occupants on the first floor.

Findings include:

Based on observations during a tour of the facility with the Maintenance Supervisor on 12/13/23 between 09:37 a.m. and 2:34 p.m., the suspended ceiling of the CT room had a ceiling tile with an approximately four inch hole around a machine that had a pipe running through the ceiling which can lead to a potential delayed response to the nearby sprinkler head. Based on interview at the time of observation, the Maintenance Director stated that the hole does have an escutcheon plate to fill in the space of the ceiling tile, however the plate had slid down the pipe and left the ceiling above the tile exposed. The Maintenance Director confirmed the aforementioned issues.

The finding was reviewed with the Maintenance Supervisor, Director of Engineering, Director of Nursing and the Safety Officer at exit conference.

3) Based on observation and interview, the facility failed to ensure 1 of 1 sprinkler systems were provided with spare sprinklers, a spare sprinkler cabinet large enough to fit all spare sprinkler heads, and a sprinkler wrench on the premises. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 5.4.1.4 states a supply of spare sprinklers (never fewer than six) shall be maintained on the premises so that any sprinklers that have been operated or damaged in any way can be promptly replaced. The sprinklers shall correspond to the types and temperature ratings of the sprinklers on the property. The sprinklers shall be kept in a cabinet located where the temperature in which they are subjected will at no time exceed 100 degrees Fahrenheit. A special sprinkler wrench shall be provided and kept in the cabinet to be used in the removal and installation of sprinklers. This deficient practice could affect all occupants in the facility.

Findings include:

Based on observation with the Maintenance Supervisor on 12/13/23 between 09:37 a.m. and 2:34 p.m., the spare sprinkler cabinets in the riser room were not large enough to contain all sprinkler heads and prevent damage to the sprinkler heads. When the cabinet in riser room was opened, the cabinet contained more sprinkler heads than spots available. Approximately twenty sprinkler heads were unsecured on-top and inside of the sprinkler cabinets. Based on interview at the time of the observations, the Maintenance Supervisor agreed the two cabinets were not large enough to contain all spare sprinkler heads.

This finding was reviewed with the Maintenance Supervisor, Director of Engineering, Director of Nursing and Safety Officer during the exit conference.

1) Based on observation and interview, the facility failed to ensure 1 of 1 storage corridor doors on the third floor was provided with a means suitable for keeping the door closed, had no impediment to closing, latching and would resist the passage of smoke. This deficient practice could affect occupants on the third floor.

Findings include:

Based on observation with the Maintenance Supervisor on 12/13/23 between 09:37 a.m. and 2:34 p.m., the storage double doors across from the third floor nurses station did not latch. The inactive leaf of the door set had a latching device, however when closed, the door would not self-latch or engage after testing three times. Based on interview at the time of observation, the Maintenance Supervisor stated that they were unaware of the issue and agreed the inactive door did not self-latch. The latch was fixed during the survey.

The finding was reviewed with the Maintenance Supervisor, Safety Officer, Director of Nursing and Director of Engineering during the exit conference.

2) Based on observation and interview, the facility failed to ensure 1 of over 100 corridor doors were provided with a means suitable for keeping the door closed, had no impediment to closing, latching, and would resist the passage of smoke. This deficient practice could affect as many as 4 staff.

Findings include:

Based on observations made with the Maintenance Supervisor during a tour of the facility at 3:04 p.m. on 12/13/23, the corridor door for the Oncology Suite in the basement had a self-closing device on the corridor door. This door was propped in the open position with flip down door wedge. Based on interview at the time of observation, the Maintenance Director acknowledged the aforementioned corridor door to a patient care area was propped and held in the fully open position with a flip down door wedge.

This finding was reviewed with the Maintenance Supervisor, the Director of Engineering, and the Safety Officer and the Director of Nursing on 12/13/23 at 4:00 p.m.

Based on observation and interview, the facility failed to ensure penetrations through 1 of 1 smoke barrier wall was protected to maintain the smoke resistance of each smoke barrier. LSC Section 19.3.7.5 requires smoke barriers to be constructed in accordance with LSC Section 8.5 and shall have a minimum ½ hour fire resistive rating. LSC Section 8.5.2.1 requires smoke barriers to be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier, or by use of a combination thereof. 8.5.6.2 requires penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the movement of smoke. This deficient practice could affect occupants on the second floor.

Findings include:

Based on observations with the Maintenance Supervisor on 12/13/23 between 09:37 a.m. and 2:34 p.m., above the drop ceiling of the smoke wall separating the old OB wing and the old Alternacare dining room had an approximate half inch gap around conduit that was run through the fire/smoke wall. Based on interview at the time of observation, the Maintenance Supervisor agreed there where unsealed penetrations in the smoke barriers and would seal up the penetrations.

The finding was reviewed with the Maintenance Supervisor, Safety Officer, Director of Engineering and Director of Nursing during the exit conference.

Based on observation and interview, the facility failed to ensure 1 of 6 sets of barrier doors in the basement area would restrict the movement of smoke for at least 20 minutes. LSC 19.3.7.8 requires doors in smoke barriers shall comply with LSC Section 8.5.4. LSC 8.5.4.1 requires doors in smoke barrier shall close the opening leaving only the minimum clearance necessary for proper operation. This deficient practice could affect as many as 4 patients, 8 staff, and 1 visitor in the basement.

Findings include:

Based on observations made with the Maintenance Supervisor during a tour of the facility at 2:56 p.m. on 12/13/23, the set of barrier doors leading to "the old addition" or door set #056272 did not close completely due to air pressure from one side of the doors. There was a one-inch gap between the doors when closed to their fullest. Based on interview during the time of observations, the Maintenance Supervisor acknowledged these smoke barrier doors did not close completely due to air pressure pushing one door slightly open and added that he would adjust the self-closing devices to make sure that they closed fully in an emergency situation.

This finding was reviewed with the Maintenance Supervisor, the Director of Engineering, and the Safety Officer and the Director of Nursing on 12/13/23 at 4:00 p.m.

Based on observation and interview, the facility failed to ensure access and working space was maintained in 1 of 3 electrical panel in the Kitchen. NFPA 99, Health Care Facilities Code, 2012 Edition, Section 6.3.2.1 states electrical installation shall be in accordance with NFPA 70, National Electric Code. NFPA 70, 2011 Edition, Article 110.26 states access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment. Working space for equipment operating at 600 volts, nominal, or less and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of 110.26(A) (1), (2) and (3). 110.26(A)(1) states 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) which the minimum clear distance is 3feet. 110.26(A) (2) states the width of the working space in front of the electrical equipment shall be the width of the equipment or 762 mm (30 in.), whichever is greater. In all cases, the workspace shall permit at least a 90-degree opening of equipment doors or hinged panels. 110.26(A)(3) states the workspace shall be clear and extend from the grade, floor, or platform to a height of 6 and 1/2 feet or the height of the equipment, whichever is greater. Article 110.26(B) states the working space required by this section shall not be used for storage. This deficient practice could affect as many as 6 staff working in the kitchen.

Findings include:

Based on observations made with the Maintenance Supervisor during a tour of the facility at 2:50 p.m. on 12/13/23, there were two electrical panels located on the wall in the Kitchen. One of these electrical panels was obstructed by a plastic cart that was stored immediately in front of the electrical panels. Based on interview at the time of the observations, the Maintenance Supervisor agreed that the plastic cart was stored directly in front of the electrical panels and stated he would have the cart removed immediately.

This finding was reviewed with the Maintenance Supervisor, the Director of Engineering, and the Safety Officer and the Director of Nursing on 12/13/23 at 4:00 p.m.

Based on record review and interview, the facility failed to ensure 9 of 12 fire drills included the verification of transmission of the fire alarm signal to the monitoring station in fire drills for the last 4 quarters. LSC 19.7.1.4 requires fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. This deficient practice affects all patients in the facility as well as staff and visitors.

Findings include:

Based on record review of the facility's fire drill document entitled "Fire Drill Report" with the Miantenance Supervisor present, the documentation for the drills for January 2023 through September of 2023 lacked verification of the transmission of the signal for drills. Based on interview at the time of record review, the Maintenance Supervisor stated that he would advise the Security Department to request from the monitoring company confirmation of the signal being received during his fire drills.

This finding was reviewed with the Maintenance Supervisor, the Director of Engineering, and the Safety Officer and the Director of Nursing on 12/13/23 at 4:00 p.m.

Based on observation and interview, the facility failure to ensure 2 of 2 non-approved portable space heaters were used in the facility. This deficient practice could affect occupants on the second floor.

Findings include:

Based on observation during a tour of the facility with the Maintenance Supervisor on 12/13/23 between 09:37 a.m. and 2:34 p.m., two portable space heaters were located in the Patient Access and the Patient Financial Counselors offices on the second floor. During record review earlier during the survey, a policy was provided to the surveyor that stated only an approved foot board heater is allowed in offices only. The space heaters found in both offices were unapproved and not part of the designated maintenance program. Based on interview at the time of observations, the Maintenance Supervisor confirmed the space heaters in the offices and stated that the ones found are unregulated and not allowed to be in the facility.

Findings were discussed with the Maintenance Supervisor, Director of Engineering, Director of Nursing and Safety Officer at exit conference.

1. Based on observation and interview, the facility failed to ensure 1 of 1 flexible cords were installed properly and used in a safe manor. NFPA 99, Section 10.2.4.2 states adapters and extension cords meeting the requirements of 10.2.4.2.1 through 10.2.4.2.3 shall be permitted. Section 10.2.4.2.3 states the cabling shall comply with 10.2.3. Section 10.2.3.5.1 states cord strain relief shall be provided at the attachment of the power cord to the appliance so that mechanical stress, either pull, twist, or bend, is not transmitted to internal connections. This deficient practice could affect as many as 3 patients, 3 staff, and 1 visitor in the facility

Findings include:

Based on observation with the Maintenance Supervisor on 12/13/23 between 09:37 a.m. and 2:45 p.m., the Nuclear Medicine office contained a power strip used to power equipment, was not secured, and was dangling from a light fixture power cord. This condition could put stress on the power cord causing damage to the power cord. Based on interview at the time of observations, the Maintenance Supervisor agreed the power strip was dangling, not secured, and stated the power strip will need to be mounted or set on the floor. The power strip was secured and fixed during the survey.

This finding was reviewed with the Maintenance Supervisor, Safety Officer, Director of Nursing and the Director of Engineering during the exit conference.

2. Based on observation and interview, the facility failed to ensure 2 of 2 power cord daisy chains were not used as and as a substitute for fixed wiring. NFPA-70/2011, 400.8 state unless specifically permitted in 400.7 flexible cords and cables shall not be used for (1) as a substitute for fixed wiring. Article 400.8 (1) prohibits daisy chains, because the first extension cord (or power strip) is now acting as a substitute for the fixed wiring of a structure. This deficient practice could affect as many as 4 patients, 3 staff, and 1 visitor in the facility.

Findings include:

Based on observations during a tour of the facility with the Maintenance Supervisor on 12/13/23 between 09:37 a.m. and 2:34 p.m., in the Utilization Management office, on the third floor, contained a power strip that was plugged into and supplied power by another power strip that also powered computer equipment and a printer. Based on interview at the time of observation, the Maintenance Supervisor agreed there were daisy chained power strips under the desk and improperly used. The power strips were separated and fixed during the observation.

Findings were discussed with the Maintenance Supervisor, Safety Officer, Director of Engineering and Director of Nursing at exit conference.

3. Based on observation and interview, the facility failed to ensure 4 of 4 power strips were not used as a substitute for fixed wiring to provide power equipment with a high current draw. NFPA-70/2011, 400.8 state unless specifically permitted in 400.7 flexible cords and cables shall not be used for (1) as a substitute for fixed wiring. This deficient practice could affect all occupants on the third and second floors.

Findings include:

Based on observations during a tour of the facility with the Maintenance Supervisor on 12/13/23 between 09:37 a.m. and 2:34 p.m., the following deficiencies were noted:
a) The social services and patient financial counselor offices both contained a power strip that was powering an approved space heater. This was fixed upon observation
b) The med surge Managers and education offices both contained a minifridge that was plugged into a power strip. Both were fixed upon observation.
Based on interview at the time of observations, the Maintenance Supervisor confirmed all of the aforementioned issues and stated they were improperly used.

Findings were discussed with the Maintenance Supervisor, Safety Officer, Director of Engineering and Director of Nursing at exit conference.