HospitalInspections.org

Based on observation and interview, the provider failed to maintain the fire-resistive characteristics of the two-hour fire-resistive wall between building 02 and the tunnel. Findings include:

1. Observation at 8:45 a.m. on 2/15/11 revealed the two-hour separation between the tunnel and Building 02 had unsealed penetrations near door T-7 in the form of a one and one half inch condensate drain line and communication cables. Those penetrations removed the separation between Building 02 and the tunnel. Interview with the plant operations manager at the time of those observations confirmed those findings.

Based on observation and record review, the provider failed to meet the minimum construction standards of the 2000 Life Safety Code (LSC). Findings include:

1. Observation at 10:00 a.m. on 2/14/12 revealed the 1950 addition to Building 01 was a two-story, protected, noncombustible, Type II (111) structure without a complete automatic sprinkler system. Review of previous survey data confirmed that condition.

The building meets the FSES. Please mark an "F" in the completion date column to indicate correction of the deficiencies identified in K000.

Based on observation and interview, the provider failed to install system smoke detection in a randomly observed space open to the corridor that contained office equipment. Copier room 5-N-46 did not have system smoke detection. Findings Include:

1. Observation at 9:45 a.m. on 2/14/12 revealed room 5-N-46 contained two copy machines. The room had two corridor door frames, but the doors had been removed and the room was not equipped with a system smoke detector.

Based on observation and interview, the provider failed to maintain the smoke tight rating of corridor wall assemblies for door G-S-47 to the radiology area. Findings include:

1. Observation at 3:45 p.m. on 2/14/12 revealed corridor door G-S-47 to the radiology area was not provided with positive latching hardware. Interview with the safety officer at the time of the observation confirmed that finding. She stated it appeared the door had never had latching hardware installed since the original construction (it was equipped with a keyed deadbolt).

Based on observation, and interview the provider failed to maintain stair enclosures between floors (Ground floor and basement) enclosed with construction having a fire-resistance rating of at least one hour. Findings include:

1. Observation at 8:46 a.m. on 2/15/12 revealed the two-hour rated wall at door T-7 from the tunnel to the west stair enclosure for Building 02 had unsealed penetrations. By not properly sealing all penetrations in the two-hour fire wall with fire caulk that wall could not provide the required fire rating for stair enclosures. Interview with the plant operations manager at the time of the observation and testing confirmed that condition.

Based on observation, testing, and interview, the provider failed to maintain proper separation of hazardous areas. The 90 minute door from the electrical room to the tunnel (T-6) would not close and latch into the frame. Findings include:

1. Observation and testing at 9:07 a.m. on 2/15/12 revealed the north leaf of the self-closing door (T-6) to the electrical/mechanical room located in the basement would not close and latch into the frame on three of three attempts. Further observation and testing revealed the door would hit the horizontal sliding gate before it would travel far enough to latch. Interview with the plant operations manager at the time of observation confirmed that finding. That horizontal sliding gate had been installed to allow warm air to travel out of that room into the tunnel to provide heat for the tunnel. The plant operations manager stated he had not noticed that door was not properly latching.

Based on observation and record review, the provider failed to ensure two conforming exits were provided from the basement level of the building. Findings include:

1. Observation at 11:30 a.m. on 2/14/12 revealed the basement housekeeping room was only provided with one egress route that discharged onto the ground floor of the building. Further observation and review of previous survey data indicated the provider had installed a sprinkler in the basement area in front of the elevator and in the stairs leading to the main level. Heat detection had also been replaced with smoke detection to add an additional level of safety for that condition.

The building meets the FSES. Please mark an "F" in the completion date column to indicate correction of the deficiencies identified in K000.

Based on observation and record review, the provider failed to maintain a protected path of egress from the basement to the exterior of the building. Findings include:

1. Observation at 11:30 a.m. on 2/14/12 revealed the continuous path of escape protection from other parts of the building was not provided from the basement to the exterior of the building. The door from the basement housekeeping storage room discharged onto the ground floor. Further observation and record review indicated the provider had installed sprinklers in the basement area in front of the elevator and in the stairs leading to the main level. The heat detection had also been replaced with smoke detection that gave that condition an additional level of fire safety.

The building meets the FSES. Please mark an "F" in the completion date column to indicate correction of the deficiencies identified in K000.

Based on observation and record review, the provider failed to maintain conforming exit stairs in the west stair enclosure, northeast stair enclosure, and the northwest stair enclosure. Findings include:

1. Observation at 1:00 p.m. on 2/14/12 revealed the doors entering the west stair enclosures and the northeast stair enclosure restricted the width of the landing to less than 22 inches. The clearance varied from 7 1/2 inches to 17 inches on several floors. Review of previous survey data revealed those restrictions had existed since the stairs were constructed in 1973.

2. Observation at 1:30 p.m. on 2/14/12 revealed three of the five stair enclosures only had handrails on one side of the stairs. Record review of previous survey data indicated the single handrails were provided when the stair enclosures were constructed in 1973.

3. Observation at 2:00 p.m. on 2/14/12 revealed the handrail/guardrail height in the northeast stair enclosure measured 29 inches in height. Record review of previous survey data identified the handrail/guardrail was the original rail when the stair enclosure was constructed in 1946.

4. Observation at 2:30 p.m. on 2/14/12 revealed the door width on the northwest stair enclosure was less than 29 inches. Record review of previous survey data identified that door width had existed since the stair enclosure was constructed in 1946.

5. The items identified in 1 through 4 above meet the FSES. Please mark an "F" in the completion date column to indicate correction of the deficiencies identified in K000.

A. Based on observation and interview, the provider failed to maintain similar levels for the path of egress on both sides of one randomly observed exit door (SW-10). The exterior side of that exit door had a three inch step-down when exiting the building. Findings include:

1. Observation at 3:30 p.m. on 2/14/12 revealed the exit door SW-10 did not have similar level surfaces on both sides of the door. The exterior side of that exit door had a six inch step-down when exiting the building. Interview with the safety officer at the time of the observation confirmed that finding.



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B. Based on observation and interview, the provider failed to ensure one randomly observed exit door (main entrance) was readily accessible at all times.That exit did not meet the requirements of 7.2.1.9.1 of the Life Safety Code. Findings include:

1. Observation at 11:20 a.m. on 2/14/12 revealed the interior door at the main entrance was a power operated horizontal sliding door. Further observation at that same time revealed the two leaves of that door slid into pockets concealing them when the door was fully opened. Section 7.2.1.9.1 of the Life Safety Code states "The door shall be designed and installed so that when a force is applied to the door on the side from which egress is made, it shall be capable of swinging from any position to the full use of the required width of the opening in which it is installed." That door was not capable of providing the full opening width from any position other than fully open or fully closed. That condition would present an impediment to egress from the building in an emergency situation. Interview with the plant operations manager at the time of the observation confirmed that condition. He stated that door had been in-place for approximately 15 years in the same configuration.

Based on observation and record review, the provider failed to install swinging doors for seven randomly observed sets of exit access doors. Examination (exam) rooms 3, 4, 5 were sliding doors that were not equipped with a breakaway feature. Doors 1-E-13, 1-E-13A, 1-E-15, and 1-E-15A were sliding doors that were not equipped with a breakaway feature. Exit access doors and exit doors used by health care occupants must be swinging doors and must be at least 32 inches in clear width. Findings include:

1. Observations at 4:15 p.m. on 2/14/12 revealed the exam rooms 3, 4, 5 had sliding doors that were not equipped with a breakaway feature. Doors 1-E-13, 1-E-13A, 1-E-15, and 1-E-15A were sliding doors that were not equipped with a breakaway feature. Interview with the safety officer at the time of the observations confirmed those findings.

Based on observation, testing, and interview, the provider failed to maintain 90 minute horizontal exit doors in operating condition. One randomly observed horizontal exit door at the separation between Building 01 and the tunnel in the basement did not latch when closed with the closer. Findings include:

1. Observation and testing at 9:10 a.m. on 2/15/12 revealed the north leaf of the 90 minute horizontal exit door (T-6) at the exit for the electrical/mechanical room in the basement into the tunnel corridor did not latch when closed with the closer. Those doors were in the two hour fire-resistive wall between building 01 and the tunnel. Testing the door several times with the plant operations manager revealed the door pulled into the frame, but the latch would not engage. Further observation revealed the door was covered with a horizontally sliding gate. That gate did not allow for that door leaf to completely close and latch. Interview with the plant operations manager at the time of the observation and testing confirmed that finding. He further stated the gate would be removed as soon as possible.

Based on observation and interview, the provider failed to maintain an appropriate light fixture at one randomly observed exit stair location (SWS-1-4A). The enclosed exterior stair landing did not have a light fixture. Findings include:

1. Observation at 1:45 p.m. on 2/14/12 revealed the enclosed exterior stair landing SWS-1-4A was not equipped with a light fixture. There was also no emergency lighting in the stair landing. Interview with the director of plant operations at the time of the observation revealed the concrete structure was louvered to allow ambient light to enter the landing enclosure. He had considered that adequate.

Based on observation, interview, and document review, the provider failed to furnish exit signs to ensure the path of egress to exits were identified in the southwest building material handling area and in surgery. Findings include:

1. Observation at 3:00 p.m. on 2/14/12 revealed no illuminated exit sign was visible to indicate the paths of egress from the materials area in the southwest building. The south exit from surgery also did not have a lit exit sign to indicate the path of egress. Interview with the safety officer at the time of the observation confirmed that finding. Review of the facility evacuation plan showed the areas identified were in the designated paths of egress from those areas.

Based on observation and interview, the provider failed to properly maintain the fire alarm system. The fire alarm strobes did not function during the fire drill. The audible fire alarm made an initial double-sound followed by a voice announcement then ceased. Findings include:

1. Observation at 10:00 a.m. on 2/15/12 during the fire drill revealed the strobes on the fire alarm system on the fourth floor south building did not function. Interview with the director of plant operations and the safety officer at the time of the observation confirmed that finding. Further interview revealed the strobes were not functioning in the smoke compartments on the second and third floors of building 2 (south building). They commented the strobes had worked two weeks prior on the 2/15/12 fire drill date when another fire drill had been held and were not sure why they did not work.

2. Observation at 10:00 a.m. on 2/15/12 during the fire drill revealed when the manual fire alarm pull station was activated, two audible tones sounded momentarily followed by a recorded voice announcement, then all audible announcement automatically ceased. The audible alarm should have been at least ten decibels louder than the ambient noise level for the area. The alarm sound level should be measured 5 feet above the floor and last for at least 60 seconds. Reducing or eliminating the audible alarm can only be approved by the authority having jurisdiction (South Dakota Department of Health, Office of Licensure and Certification) under approved circumstances (critical patient care areas with working strobes, for example). Interview with the director of plant operations at the time of the fire drill revealed he considered the fire alarm strobe lights to be the alarm annunciation after the initial audible tones and recorded voice announcement.

A. Based on observation and interview, the provider failed to maintain proper separation of hazardous areas in the physical plant (Building 12.13). Storage room PP15 had flammable liquids kept in the room without one hour fire-rated separation to the adjacent maintenance area in the physical plant. Storage room PP07 did not have the correct door-closing assembly. The boiler room separation walls had unsealed openings around pipe penetrations of the fire-rated separation wall to the stair enclosure and the control room area. Two exit doors PP01 and PP02 had stepdowns at the exit thresholds. Findings include:

1. Observation at 4:30 p.m. on 2/13/12 revealed storage room PP15 was over 100 square feet in area and was not separated from the adjacent maintenance repair area by one hour fire-rated construction. PP15 had five gallons of xylene, five gallons of mineral spirits, bottles of laquer thinner, and denatured alcohol stored on shelving in the room. There was a two foot by four foot air transfer opening in the concrete masonry unit (cmu) wall between the storage room and the maintenance repair area that was not equipped with fire dampers.

2. Observation at 4:35 p.m. on 2/13/12 revealed the door separating storage room PP15 from the maintenance repair area of the physical plant was a non-rated metal door. Further observation and testing revealed the door closer would not pull the door far enough into the jamb to allow the striker to engage the strike plate and latch.

3. Observation at 4:40 p.m. on 2/13/12 revealed the storage room PP07 was over 100 square feet and was adjacent to PP5 west exit from the generator room. The door PP07 was equipped with spring hinges that were not fire-rated assemblies. Testing of the door revealed the spring hinges would not pull the door into the jamb so the striker would engage the strike plate and latch.

4. Observation at 4:45 p.m. on 2/13/12 revealed the stair enclosure from the power plant to the tunnel had unsealed openings around pipe penetrations from the boiler room. additionally there were unsealed openings around pipe penetrations in the wall separating the boiler room from the control room area.

5. Observation at 4:50 p.m. on 2/13/12 revealed the PP01 exit door had exterior landings that had a six inch stepdown at the threshold instead of the required same level on each side of the threshold.

6. Interview with the director of plant operations at the times of the observations confirmed those findings.



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B. Based on observation and interview, the provider failed to maintain stair enclosures between floors (ground floor and secondy story) enclosed with construction having a fire-resistance rating of at least one hour for one randomly observed stair (Building 12.3 - 201 S. Lloyd St. Suite E104). Findings include:

1. Observation at 2:30 on 2/14/12 revealed the door to the north stair enclosure from suite E101 was a rated door. That door however was not automatically latching into the door frame under the power of a door closer. That door is required to be automatically closing in order to maintain its fire rating. Interview with the plant operations manager at the time of the observation confirmed that condition. He stated he was unaware that door was not equipped with a door closer.

C. Based on observation and interview, the provider failed to maintain stair enclosures between floors enclosed with construction having a fire-resistance rating of at least one hour for one randomly observed stair (Building 12.7 - 201 S. Lloyd St. Suite W140). Findings include:

1. Observation at 2:10 on 2/14/12 revealed the door to the north-west stair enclosure from the corridor for suite W140 was not properly latching into the door frame under the power of the doors closer. That door is required to latch into its fame automatically to retain the required one-hour fire separation from the stair enclosure. Interview with the plant operations manager at the time of the observation confirmed that condition. He stated he was unaware that door was not operating properly.

D. Based on observation and interview, the provider failed to ensure all exits were in accordance with section 7.2.1.5 of the Life Safety Code accessible at all times. Two randomly observed exit doors (both main entrance vestibule doors for Building 12.8 - Worthmore clinic 1206 S Main St.) had keyed deadbolts installed. Findings include:

1. Observation at 10:15 a.m. on 2/14/12 revealed both of the main entrance vestibule doors to the clinic had keyed deadbolts installed in them. Further observation at that same time revealed those doors did not have required signage posted on or adjacent to the door stating "THIS DOOR TO REMAIN UNLOCKED WHEN THE BUILDING IS OCCUPIED" per section 7.2.1.5 of the Life Safety Code. Interview with the plant operations manager at the time of the observation revealed he was unaware of that condition.

E. Based on observation and interview, the provider failed to ensure exits were readily accessible at all times. One randomly observed exit doors (Building 12.1 - 201 S Lloyd St. Suite 102, main entrance) had a door kick-down installed. Findings include:

1. Observation at 2:30 p.m. on 2/14/12 revealed the main entrance door to suite E102 had a kick-down as a holding device installed on the bottom of the door. That kick-down device could become wedged and prevent that door from opening in the event of an emergency. That exit door was shared between suite E101 and E102. Interview with the plant operations manager at the time of the observation revealed he was unaware of that condition.

F. Based on observation and interview, the provider failed to ensure exits were readily accessible at all times. One randomly observed exit doors (Building 12.2 - 201 S Lloyd St. Suite 102, main entrance) had a door kick-down installed. Findings include:

1. Observation at 2:30 p.m. on 2/14/12 revealed the main entrance door had a kick-down as holding device installed on the bottom of the door. That kick-down device could become wedged and prevent that door from opening in the event of an emergency. That exit door was shared between suite E101 and E102. Interview with the plant operations manager at the time of the observation revealed he was unaware of that condition.

G. Based on observation and interview, the provider failed to maintain similar levels for the path of egress on both sides of one randomly observed exit door (west exit to alley for Building 12.9 - Worthmore clinic 1206 S Main St.). The exterior side of that exit door had a six inch step-down when exiting the building. Findings include:

1. Observation at 10:42 a.m. on 2/14/12 revealed the west exit door from the building to the alley did not have similar level surfaces on both sides of the door. The exterior side of that exit door had a six inch step-down when exiting the building. Interview with the plant operations manager at the time of the observation confirmed that finding.

H. Based on observation and interview, the provider failed to maintain similar levels for the path of egress on both sides of three randomly observed exit doors (PP-1, PP-2, and PP-5 for Building 12.12 - Physical Plant). The exterior side of those exit doors had a six inch step-down when exiting the building. Findings include:

1. Observation at 4:42 p.m. on 2/13/12 revealed exit door PP-1 did not have similar level surfaces on both sides of the door. The exterior side of that exit door had a six inch step-down when exiting the building. Interview with the plant operations manager at the time of the observation confirmed that finding. He stated he believed almost all exits from that building had the same condition.

2. Observation at 4:45 p.m. on 2/13/12 revealed exit door PP-2 did not have similar level surfaces on both sides of the door. The exterior side of that exit door had a six inch step-down when exiting the building. Interview with the plant operations manager at the time of the observation confirmed that finding. He stated he believed almost all exits from that building had the same condition.

3. Observation at 8:45 a.m. on 2/15/12 revealed exit door PP-5 did not have similar level surfaces on both sides of the door. The exterior side of that exit door had a six inch step-down when exiting the building. Interview with the plant operations manager at the time of the observation confirmed that finding. He stated he believed almost all exits from that building had the same condition.

I. Based on observation and interview, the provider failed to maintain emergency lighting of at least one and a half hours in duration. One randomly observed emergency light (in the corridor outside of building 12.4 - 201 S Lloyd St. suite E105) did not work. Findings include:

1. Observation at 2:47 p.m. on 2/14/12 revealed the battery powered emergency light in the corridor outside of suite E105 was not functioning under the power of its backup battery. That emergency light would be necessary to provide lighting for the path of egress for the occupants of suite E105 in the event of a loss of power. Interview with the plant operations manager at the time of observation confirmed that finding. He revealed he did not have documentation for monthly testing of that emergency light or the annual 90 minute functional test. He further stated that building was a leased building and most of the maintenance was provided by the building owner.

J. Based on observation and interview, the provider failed to maintain emergency lighting of at least one and one-half hours in duration (Building 12.9 - Groton clinic 8 E. Hwy 12). Findings include:

1. Observation at 9:27 a.m. on 2/14/12 revealed the building was equipped with battery operated emergency lights. When asked for documentation showing the battery powered emergency lights had received monthly testing and an annual 90 minute functional test the provider could not furnish documentation. Interview with the plant operations manager at the time of observation confirmed that finding. He revealed he did not have documentation for monthly testing of that emergency light or the annual 90 minute functional test.

K. Based on observation and interview, the provider failed to provide emergency lighting of at least one and a half hours in duration. One randomly observed emergency light (at the generators in the physical plant building - building 12.13) did not work. Findings include:

1. Observation at 8:48 a.m. on 2/15/12 revealed the battery powered emergency light for the generators was not functioning under the power of its backup battery. That emergency light would be necessary to provide lighting for the generators in the event of a loss of power and generator failure. Interview with the plant operations manager at the time of observation confirmed that finding. He revealed he did not have documentation for monthly testing of that emergency light or the annual 90 minute functional test. He further stated that emergency light had been recently installed and had not made it into the preventative maintenance plan.


L. Based on observation and interview, the provider failed to provide emergency lighting of at least one and a half hours in duration. One randomly observed emergency light (Building 12.14 - 105 S. State St.) did not work. Findings include:

1. Observation at 10:28 a.m. on 2/15/12 revealed the battery powered emergency light for the transfer switch in the electrical room would not provide emergency lighting under the power of its backup battery. That emergency light would be necessary to provide lighting for the transfer switch in the event of a loss of power and generator or transfer switch failure. That emergency light was not equipped with any lamps or lamp housings. Interview with the plant operations manager at the time of observation confirmed that finding. He also revealed he did not have documentation for monthly testing of that emergency light or the annual 90 minute functional test. He further stated he was unaware that emergency light was not provided with lamp housings or lamps.


M. Based on observation and interview, the provider failed to maintain emergency lighting of at least one and a half hours in duration. One randomly observed combination exit sign/emergency light (Building 12.5 - at the entrance of 201 S Lloyd St. suite E201) did not work. Findings include:

1. Observation and testing at 2:52 p.m. on 2/14/12 revealed the battery powered combination emergency light and exit sign at the main entrance to the suite E202 was not functioning under the power of its backup battery. That eemergency light would be necessary to light the path of egress for the occupants of suite E201 in the event of a loss of power. Interview with the plant operations manager at the time of observation confirmed that finding. He revealed he did not have documentation for monthly testing of that emeregency light or the annual 90 minute functional test.
N. Based on observation and interview, the provider failed to maintain emergency lighting of at least one and a half hours in duration. One randomly observed emergency light (in the corridor of 201 S Lloyd St. suite E202 - Building 12.6) was not in a proper working condition. Findings include:

1. Observation at 2:52 p.m. on 2/14/12 revealed the battery powered emergency light in the corridor between exam rooms two and three in suite E202 only had one of two lamps functioning under the power of its backup battery. That emergency light would be necessary to provide lighting for the path of egress for the occupants of suite E202 in the event of a loss of power. Interview with the plant operations manager at the time of observation confirmed that finding. He revealed he did not have documentation for monthly testing of that emergency light or the annual 90 minute functional test.
O. Based on observation and interview, the provider failed to maintain emergency lighting of at least one and a half hours in duration. One randomly observed emergency light (in the corridor of 201 S Lloyd St. suite E202 - Building 12.6) did not work. Findings include:

1. Observation at 2:56 p.m. on 2/14/12 revealed the battery powered emergency light in the corridor outside of the doctor's office in suite E202 was not functioning under the power of its backup battery. That emergency light would be necessary to provide lighting for the path of egress for the occupants of suite E202 in the event of a loss of power. Interview with the plant operations manager at the time of observation confirmed that finding. He revealed he did not have documentation for monthly testing of that emergency light or the annual 90 minute functional test.


P. Based on observation and interview, the provider failed to maintain emergency lighting of at least one and one-half hours in duration. One randomly observed exit (in the corridor of 201 S Lloyd St. Between suite E201 and E202 - Building 12.5 and Building 12.6) was not provided with emergency lighting. Findings include:

1. Observation at 2:58 p.m. on 2/14/12 revealed the exit for the back of suite E202 passed through a shared corridor with suite E201. That corridor was separated from either suite by a door at either end. That corridor was also separated from the exit stairwell by a self-closing door. When all three doors were closed (their default positions) that corridor was left in complete darkness. A battery powered emergency light is required to provide lighting in that area in the event of power loss. That emergency light was required to provide lighting for the path of egress for the occupants of suite E201 and suite E202. Interview with the plant operations manager at the time of observation confirmed that finding. He agreed an emergency light needed to be installed in that location to provide egress lighting for the occupant of both suite E201 and E202.


Q. Based on observation and interview, the provider failed to provide emergency lighting of at least one and a half hours in duration. One randomly observed combination emergency light/exit sign (at the entrance of 201 S Lloyd St. suite E201 - Building 12.5) did not work. Findings include:

1. Observation at 2:52 p.m. on 2/14/12 revealed the combination battery powered emergency light and exit sign at the main entrance to the suite E202 was not functioning under the power of its backup battery. That emergency light would be necessary to provide lighting for the path of egress for the occupants of suite E201 in the event of a loss of power. Interview with the plant operations manager at the time of observation confirmed that finding. He revealed he did not have documentation for monthly testing of that emergency light or the annual 90 minute functional test.


R. Based on observation and interview, the provider failed to maintain exit sign lighting of at least one and one-half hours in duration (Building 12.9 - Groton clinic 8 E. Hwy 12). Findings include:

1. Observation at 9:27 a.m. on 2/14/12 revealed the building was equipped with battery operated exit signs. When asked for documentation showing the battery powered exit signs had received monthly testing and an annual 90 minute functional test the provider could not furnish documentation. Interview with the plant operations manager at the time of observation confirmed that finding. He revealed he did not have documentation for monthly testing of that emergency light or the annual 90 minute functional test.

S. Based on observation and interview, the provider failed to provide exit signs in all locations required in a path of egress. One randomly observed location requiring an exit sign (back exit of Building 12.4 - 201 S Lloyd St. suite E105) was not equipped with an exit sign. Findings include:

1. Observation at 2:47 p.m. on 2/14/12 revealed exit signage led occupants to the back corridor of the suite. Further observation revealed once an occupant had traveled to the back corridor the exit was not obvious, and there was no signage indicating where the exit was. Interview with the plant operations manager at the time of observation confirmed that finding.

T. Based on observation, testing, and interview, the provider failed to provide lilluminated exit signs of at least one and a half hours in duration. One randomly observed combination exit sign/emergency light (Building 12.5 - at the entrance of 201 S Lloyd St. suite E201) did not work. Findings include:

1. Observation and testing at 2:52 p.m. on 2/14/12 revealed the battery powered combination emergency light and exit sign at the main entrance to the suite E202 was not functioning under the power of its backup battery. That exit sign would be necessary to show the path of egress for the occupants of suite E201 in the event of a loss of power. Interview with the plant operations manager at the time of observation confirmed that finding. He revealed he did not have documentation for monthly testing of that exit sign or the annual 90 minute functional test.

U. Based on observation, testing, and interview, the provider failed to maintain illuminated exit signs of at least one and one-half hours in duration. One randomly observed exit sign (Building 12.7 - at the entrance to the lobby of 201 S Lloyd St. suite W140) did not work. Findings include:

1. Observation and testing at 2:10 p.m. on 2/14/12 revealed the battery backup exit sign at the entrance to the lobby of suite W140 was not functioning under the power of its backup battery. That exit sign would be necessary to show the path of egress for the occupants of suite W140 in the event of a loss of power. Further observation revealed that exit sign had the rocker switch for testing the functionality of the batteries painted over. When the seal of the paint was broken and the switch to test the batteries was activated the sign went dark. Interview with the nursing staff revealed that suite had been repainted in late October or early November 2011, the paint on the signs test switch was from that time frame. Interview with the plant operations manager at the time of observation confirmed those findings. He revealed he did not have documentation for monthly testing of that exit sign or the annual 90 minute functional test.


V. Based on observation and interview, the provider failed to perform monthly checks of fire extinguishers in accordance with NFPA 10. Monthly checks had not been performed on two of two fire extinguishers (Building 12.9 - Groton clinic 8 E. Hwy 12) since the annual inspection in may 2011. Findings include:

1. Random observation at 9:32 a.m. on 2/14/12 revealed the fire extinguisher in the entrance vestibule did not have proof of monthly inspections having been performed since the annual inspection in May 2011 (did not have monthly maintenance checks written on the fire extinguisher tag). Further observation at that same time revealed the same condition existed for the fire extinguisher by the back exit for the clinic. Interview with the plant operations manager at the time of the observation confirmed those findings. He indicated he was unaware those extinguishers had not been receiving their monthly inspections.

W. Based on observation and interview, the provider failed to perform monthly checks of fire extinguishers in accordance with NFPA 10. Comprehensive monthly checks had not been performed on two randomly checked fire extinguishers (In the north corridor and by the stairs to the basement, for Building 12.8 - Worthmore clinic 1206 S Main St.). Findings include:

1. Observation at 10:24 a.m. revealed the fire extinguisher in the north corridor did not have monthly maintenance checks written on the fire extinguisher tag since December 2011. Further observation of the extinguisher by the basement stairs at 10:34 a.m. revealed it had its inspection for January 2012, but no record was available for any month in 2011. The building was initially occupied by the provider in July 2011. Interview with plant operations manager at the time of the observation confirmed that finding. He indicated he was unaware why that extinguisher was not receiving proper inspection and maintenance.

X. Based on observation and interview, the provider failed to perform monthly checks of fire extinguishers in accordance with NFPA 10. Comprehensive monthly checks had not been performed on one randomly checked fire extinguisher (elevator room for building 12.14 - 105 S. State St.). Findings include:

1. Observation at 10:20 a.m. on 2/15/12 revealed one of the fire extinguishers did not have monthly maintenance checks written on the fire extinguisher tag. The extinguisher in the elevator room had not had monthly inspections performed since the annual inspection in September 2009. Interview with plant operations manager at the time of the observation confirmed that finding. He indicated he was unaware why that extinguisher was not receiving proper inspection and maintenance.

Y. Based on observation and interview, the provider failed to ensure one randomly observed fire extinguisher (by exit to stair B in Building 12.4 - 201 S Lloyd St. suite E105) was mounted in accordance with NFPA 10 Standards for Portable Fire Extinguishers (see attached: NFPA 10 Standards for Portable Fire Extinguishers). Findings include:

1. Observation at 2:52 p.m. on 2/14/12 revealed one fire extinguisher mounted by the back exit from suite E105 to stair B was mounted on the wall 65 inches above the finished floor. That height was greater than the 60 inch maximum allowed by NFPA 10. Interview with the plant operations manager at the time of the observation confirmed that finding. He indicated he was unaware of the maximum height requirement for fire extinguishers. He further indicated he would have that extinguisher relocated as soon as possible.

Based on observation and interview, the provider failed to maintain one-hour fire resistive construction for the oxygen transfilling room 3-S-03. There was an unsealed opening around the exhaust duct penetration of the east wall. Findings include:

1. Observation at 2:00 p.m. revealed the liquid oxygen transfilling room 3-S-03 had an unsealed opening around the exhaust duct penetration of the east wall. The opening must be sealed with an approved intumescing firestop material (such as red fire caulk). Interview with the safety officer at the time of the observation revealed city officials had approved the liquid oxygen room construction approximately six months prior to the survey.

Based on observation and interview, the provider failed to furnish a cover on one randomly observed electrical fixture in the ceiling above the CT machine. Findings include:

1. Observation at 4:00 p.m. on 2/14/12 revealed an open electrical socket for a ceiling incandescent light above the CT table. Interview with the safety officer at the time of the observation revealed the light was directly over the patient's head and was unpleasant to have the light on during the procedure. She stated the lamp had been removed and was no longer used/needed and they could have the fixture removed.

Based on observation, testing, and interview, the provider failed to ensure one of five elevators (elevator A)met the requirements of the facility's manual procedure for recall during a fire event. The elevators must meet the requirements of ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators. Findings include:

1. Observation and testing beginning with the fire drill at 10:00 a.m. and ending at 10:58 a.m. on 2/15/12 revealed the provider had a procedure for shutting down the elevator operation during a fire event. Observation and testing of that procedure with the director of plant operations and the staff person responsible for shutting down the elevator on the second floor revealed the car for elevator A would not stop from normal operation when the key was used to disable the car's movement. Interview with the director of plant operations at the time of the testing confirmed that finding. He stated he was unaware that elevator car was not functioning according to their procedure. He further stated he had not received a report of any problems with that elevator car during the facility's last fire drill.