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Based on observations, the facility failed to maintain the smoke and fire resistance rating for 2-hour and 3-hour rated fire barrier walls in accordance with NFPA 101, 2000 Edition, Section 8.2.3.2.4.2. These deficiencies affect 5 of 21 smoke compartments.

Findings include:

First Floor:

- During an observation on 12/1/15 at 1:50 p.m., the 3-hour wall near the horizontal sliding fire door (HSFD) was reviewed. There were two penetrations above the ceiling tile where the HSFD closes.¹ One was at a sprinkler pipe, and the remaining was around an I beam.

- During an observation on 12/1/15 at 2:00 p.m., the 3 hour wall above the exit door near the conference room was reviewed. There was a penetration for a large black wire which was not properly sealed.¹

- During an observation on 12/1/15 at 2:30 p.m., the 2-hour wall between the Maria Dean center and the existing hospital was reviewed. There were two unsealed conduits, 1 inch and 1.5 inch in size, which contained wiring to control doors.¹

Second Floor:

- During an observation on 12/1/15 at 10:48 a.m., the 2-hour barrier outside the IT training room was inspected. There were two conduits not sealed on either side, and a penetration with two IT cables running through which was not sealed on either side. There was also a bank of electrical conduits which were not sealed on one side of the barrier.¹

- During an observation on 12/1/15 at 11:36 a.m., the 2-hour barrier in the old OB department near room 2328 and the boiler room entrance was inspected. There was one penetration around a pipe which was not sealed.¹

- During an observation on 12/1/15 at 12:09 p.m., the 2-hour barrier above the double doors near room 2972 was inspected. There were two 2.5" conduits not sealed or plugged to fill the rest of space in the conduit.¹

- During an observation on 12/1/15 at 12:15 p.m., the 2-hour barrier across from 2972 electrical room was inspected. There was a penetration around a conduit which was not sealed on either side.¹

¹ NFPA 101, 2000 Edition, Section 8.2.3.2.4.2; Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the fire barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on observations, the facility failed to ensure that all corridor walls in the sprinkled building could resist the passage of smoke in accordance with NFPA 101, 2000 Edition, Section 19.3.6.1. The deficiency affects 4 of 21 smoke compartments, two on each floor.

Findings include:

First Floor:

- During an observation on 11/30/15 at 1:45 p.m., the 1-hour corridor wall of the F- Mechanical room in Informational Technology (IT)/Finance was reviewed. There were penetrations in the west wall of this room which is a corridor wall.¹

Second Floor:

- During an observation on 12/1/15 at 12:23 p.m., the 1-hour corridor wall near room 2978 was inspected, there were two electrical conduits going into room 2978 from the corridor which were not sealed on the corridor side.¹

¹ NFPA 101, 2000 Edition, Section 19.3.6.1; Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5. (See also 19.2.5.9.)
Exception No. 1: Smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.3 shall be permitted to have spaces that are unlimited in size open to the corridor, provided that the following criteria are met:
(a) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas.
(b) The corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the smoke compartment in which the space is located is protected throughout by quick-response sprinklers.
(c) The open space is protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the entire space is arranged and located to allow direct supervision by the facility staff from a nurses ' station or similar space.
(d) The space does not obstruct access to required exits.

Based on observations, the facility failed to maintain a latching corridor door and to use acceptable hold open devices on a corridor door in accordance with NFPA 101, 2000 Edition, Sections 19.3.6.3.2, 19.3.6.3.3 and Annex Section A.19.3.6.3.3. This deficiency affects 2 of 21 smoke compartments.

Findings include:

- During an observation on 12/1/15 at 8:20 a.m., the corridor door to conference room 1584 was exercised. The south most door failed to latch.¹

- During an observation on 12/1/15 at 9:10 a.m., the corridor door to the Health Resource center was exercised. The door had a kick-down device installed on the door and could not be closed without first unlatching the kick-down device.²

¹ NFPA 101, 2000 Edition, Section 19.3.6.3.2, Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: Existing roller latches demonstrated to keep the door closed against a force of 5 lbf (22 N) shall be permitted to be kept in service.

² NFPA 101, 2000 Edition, Section 19.3.6.3.3, hold-open devices that release when the door is pushed or pulled shall be permitted. Annex A.19.3.6.3.3, doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

Based on observation, the facility failed to maintain vertical openings between floors in accordance with NFPA 101,2000 Edition, Section 18.3.1.1.¹ The deficiency affects 1 of 2 smoke compartments on first and second floors.

Findings included:

- During an observation on 12/1/15 at 10:40 a.m., room 1243 was reviewed. The room contains two vertical chases for communication wiring for upper floors. The conduit chases were not sealed between floors to maintain the two hour fire resistance rating between floors.

¹ NFPA 101, 2000 Edition, Section 18.3.1.1, Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least two hours connecting four stories or more. (One hour for single story building and sprinkled buildings up to three stories in height.)

Based on observations, the facility failed to maintain the two-hour fire protection of the self-closing doors used as a horizontal exit in accordance with NFPA 101, 2000 Edition, Section 8.2.3.2.1 and NFPA 80, 1999 Edition, Section 2-4.1.4. These deficiencies affect 10 of 21 smoke compartments.

Findings include:

First Floor:

- During an observation on 12/1/15 at 8:10 a.m., the set of 1.5 hour fire rated doors were reviewed for the mechanical room (1500) on smoke compartment 1-C. The set of doors had louvers through the leaf of each door reducing the doors to less than smoke resisting. The set of doors were not rated for the 2-hour barrier wall which they were installed in.¹

- During an observation on 12/1/15 at 1:15 p.m., The set of fire rated doors between the Maria Dean building and the Main Hospital were exercised. The 1.5 hour rated fire doors failed to latch when exercised on three different tries.¹ ²


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Second Floor:

- During an observation on 11/30/15 at 3:41 p.m., the 2-hour doors between rooms 2550 and 2548 in same day services was exercised. The west leaf was found to have no automatic locking latch system.¹ ²

- During an observation on 11/30/15 at 3:45 p.m., the east 2-hour doors were exercised in same day services. The north leaf does not latch on its own.¹ ²

- During an observation on 11/30/15 at 4:57 p.m., the 3-hour doors near phlebotomy were exercised. The south leaf did not latch on its own.¹ ²

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 8.2.3.2.1; Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire doors and Fire Windows.

² NFPA 80 Standard for Fire Doors and Fire Windows, 1999 Edition, Section 2-4.1.4; All closing mechanisms shall be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.

Based on observation, the facility failed to ensure that access to exits was marked by approved, readily visible signs properly denoting the way to the means of egress in accordance with NFPA 101, 2000 Edition, Section 7.10.1.4. The deficiency affects 1 of 4 exits.

Findings include:

- During an observation on 12/2/15 at 10:27 a.m., the corridor area in the north east corner of the building leading to the northeast exit door was lacking an exit sign. The exit was not readily identifiable from both directions in the corridor.

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 7.10.1.4, Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
Exception: Signs in exit access corridors in existing buildings shall not be required to meet the placement distance requirements.

Based on observations, the facility failed to maintain smoke barriers per NFPA 101, 2000 Edition, Section 8.3.6.1. These deficiencies affect 2 of 10 first floor smoke compartments.

Findings include:

- During an observation on 11/30/15 at 1:50 p.m., the F-Mechanical room in IT/Finance was reviewed. A conduit on the north wall of the room was not properly sealed to maintain the smoke barrier wall.¹

- During an observation on 11/30/15 at 3:40 p.m., the E-Mechanical room near the Medical Staff Conference room was reviewed. There was wiring in the north east corner of the smoke barrier wall which was not sealed, along with other penetrations which included a three inch by three inch cut out in the wall and a two inch by four inch cut out which were not sealed properly.¹

- During an observation on 12/1/15 at 8:50 a.m., the electrical room (1504) was reviewed. There were three penetrations in the west smoke barrier wall near the ceiling which were not sealed to maintain the fire resistance for smoke barriers.¹

¹ NFPA 101, 2000 Edition, Section 8.3.6.1; Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on observation, the facility failed to ensure that all doors in smoke barriers were able to resist the passage of smoke in accordance with NFPA 101, 2000 Edition, Section 8.3.4.1¹ and Annex A.8.3.4.1². The deficiency affected 1 of 10 main floor smoke compartments.

Findings include:

- During an observation on 12/1/15 at 10:05 a.m., the north facing doors to the elevator lobby were exercised. The right most leaf drug on the floor and failed to close at all.¹ ² The elevator lobby doors were in a smoke barrier for the smoke compartment.

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 8.3.4.1; Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

² NFPA 101, 2000 Edition, Annex A.8.3.4.1; The clearance for proper operation of smoke doors is defined as 1/8 in. (0.3 cm). For additional information on the installation of smoke-control door assemblies, see NFPA 105, Recommended Practice for the Installation of Smoke-Control Door Assemblies, 1999 Edition.

Based on observation, the facility failed to maintain the one-hour rated construction of hazardous areas in accordance with NFPA 101, 2000 Edition, Sections 8.4.1.2 and 8.2.3.2.4.2. The deficiency could affect one room in 1 of 2 smoke compartments.

Findings include:

First Floor:

- During an observation on 12/1/15 at 11:10 a.m., room 1293 (soiled linen room) was reviewed. The ceiling was not properly rated for a hazardous location, and the door to the room was not rated or self-closing.

NFPA 101, 2000 Edition, Section 8.4.1.2; In new construction, where protection is provided with automatic extinguishing systems without fire-resistive separation, the space protected shall be enclosed with smoke partitions in accordance with 8.2.4.

NFPA 101, 2000 Edition, Section 8.2.3.2.4.2; Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts and similar building service equipment that pass through fire barriers shall be protected as follows:

Based on observation, the facility failed to maintain clear pathways to the exit discharge in accordance with NFPA 101, 2000 Edition, Section 7.1.10.1¹ and CMS Policy S&C-10-18-LSC². The deficiency could affect 1 of 4 exits from the main level.

Findings include:

- During an observation on 12/1/15 at 11:20 a.m., the exit from Magnetic Resonance Imaging (MRI) to the loading dock was reviewed. There were carts blocking direct access to full instant use of the egress path in cases of emergency.

- During an observation on 12/3/15 at 6:30 a.m., the doors in the smoke barrier in the Diagnostic Imaging corridor were exercised during the testing of the fire alarm. The set of doors failed to release when tested causing an obstruction for all who would need to exit the interior spaces in case of emergency.

¹ NFPA 101, 2000 Edition, Section 7.1.10.1; Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Annex .7.1.10.1; A proper means of egress allows unobstructed travel at all times. Any type of barrier including, but not limited to, the accumulations of snow and ice in those climates subject to such accumulations is an impediment to free movement in the means of egress.

Based on record review, the facility failed to hold fire drills at a minimum of quarterly on each shift per NFPA 101, 2000 Edition, Section 19.7.1.2. This deficiency could affect 21 of 21 smoke compartments.

Findings include:

Review of facility documents regarding fire drills reflected fire drills were not completed for the night shift in the first quarter of 2015.¹

¹ NFPA 101, 2000 Edition, Section 19.7.1.2; Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Based on observation, the facility failed to install the fire alarm system with all its components per NFPA 72, National Fire Alarm Code, 1999 Edition, Section 2-8.2.2. This deficiency could affect 2 of 8 smoke compartments in the patient tower.

Findings include:

- During an observation on 12/3/15 at 6:23 a.m., the building separation between the patient towers and the main hospital on the second floor was inspected. There was not a manual pull station for the fire alarm within 5 feet of the horizontal exit on the patient tower side of the 3-hour doors.¹

¹ NFPA 72, National Fire Alarm Code, 1999 Edition, Section 2-8.2.2; Manual fire alarm boxes shall be located within 5 ft (1.5 m) of the exit doorway opening at each exit on each floor.

Based on record review and interview, the facility failed to conduct load voltage tests on the batteries of the fire alarm control panel (FACP) semi-annually, as required per NFPA 72, 1999 Edition, Table 7-3.2. The deficiency affects 21 of 21 smoke compartments.

Findings include:

Review of the alarm system test records reflected the annual maintenance of the panel was conducted on 6/19/15, and reflected the load voltage testing had been done on the sealed lead-acid batteries of the panel. There was no evidence the sealed-lead acid batteries have been voltage tested six-months prior to the annual alarm test.¹

During an interview on 8/10/15 at 11:15 a.m., staff member A, director of facilities, stated they were not aware of the semiannual testing requirement.

¹ NFPA 72 National Fire Alarm Code, 1999 Edition, Table 7.3.2 (6)(d)(3), requires sealed lead-acid type batteries to have a "Load Voltage Test" upon initial installation and then semiannually thereafter.

Based on observations, the facility failed to provide a complete sprinkler system free of obstructions for complete sprinkler pattern coverage in accordance with NFPA 13, 1999 Edition, Sections 5-6.5.2.1 and 5-6.5.3.1. The deficiency affects 1 of 10 first floor smoke compartments.

Findings include:

- During an observation on 12/1/15 at 9:40 a.m., Mechanical room A in the professional wing was reviewed. The room had air handler units greater than 48 inches in width which were not sprinkled above and below the ducting.³

¹ NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-6.5.2.1, Continuous or noncontinuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that prevent the pattern from fully developing shall comply with this section. Regardless of the rules of this section, solid continuous obstructions shall meet the requirements of 5-6.5.1.2.

² NFPA 13 Standard for Installation of Sprinkler Systems, 1999 Edition, Section 5-6.5.3.1; Sprinklers shall be installed under fixed obstructions over 4 ft (1.2 m) wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors.
Exception: Obstructions that are not fixed in place, such as conference tables.

Based on observation, the facility failed to maintain the sprinkler system in accordance to NFPA 13, 1999 Edition, Section 5-5.5.3. This deficiency affects 1 room in 1 of 2 smoke compartments.

- During an observation on 12/1/15 at 11:00 a.m., room 1268 was reviewed. The privacy curtain for the room did not have mesh at the top to allow full sprinkler coverage for the lone sprinkler head.

NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-5.5.3; Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. (457 mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 5-5.5.3.

Based on observations, the facility failed to place portable fire extinguishers at proper heights per NFPA 10, Section 1-6.10 and failed to inspect all portable fire extinguishers at least every 30 days in accordance with NFPA 10, 1998 Edition, Section 4-3.1. These deficiencies affect two fire extinguishers.

Findings include:

- During an observation on 12/2/15 at 10:15 a.m., the portable fire extinguisher located in diagnostic imaging was mounted above 60 inches.¹


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- During an observation on 12/2/15 at 10:18 a.m., the fire extinguisher in the fire equipment room was found to be missing the initials for monthly inspections for October and November of 2015.²

¹ NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition, Section 1-6.10; 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. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 31/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

² NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition, Section 4-3.1 Frequency; Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.

Based on observation and interview, the facility failed to maintain the means of egress free of all obstruction for instant use in accordance with NFPA 101, 2000 Edition, Section 7.1.10.1 and Annex A.7.1.10.1. These deficiencies affect 1 of 9 exits and 2 of 10 first floor smoke compartments.

Findings include:

- During an observation on 11/30/15, the exit corridor near facilities leading toward the boiler room was reviewed. There were stored items in the corridor including, pallets of delivered supplies, building supplies, lighting, and combustible materials. The isle toward the exit was not free and clear for proper means of egress which allows unobstructed travel at all times.¹

¹ NFPA 101, 2000 Edition, Section 7.1.10.1; Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Annex Section A.7.1.10.1; A proper means of egress allows unobstructed travel at all times. Any type of barrier including, but not limited to, the accumulations of snow and ice in those climates subject to such accumulations is an impediment to free movement in the means of egress.

Based on observation, the facility failed to store a nitrous oxide compressed gas cylinder in accordance with the standards of NFPA 99, 1999 Edition, Section 4-3.5.2.1.¹ This deficiency affects the second floor.

Findings include:

During an observation on 12/2/15 at 8:10 a.m., procedure room 2020 was observed. The nitrous cylinder was not secured to prevent it from tipping over.¹

¹ NFPA 99 Standard for Health Care Facilities, 1999 Edition, Section 4-3.5.2.1, Gases in Cylinders and Liquefied Gases in Containers - Level 1, (a) Handling of Gases; requires administrative authorities shall provide regulations to ensure that standards for safe practice in the specifications for cylinders; marking of cylinders, regulators, and valves; and cylinder connections have been met by vendors of cylinders containing compressed gases supplied to the facility. (b) Special Precautions - Oxygen Cylinders and Manifolds. Great care shall be exercised in handling oxygen to prevent contact of oxygen under pressure with oils, greases, organic lubricants, rubber, or other materials of an organic nature. The following regulations, based on those of the CGA Pamphlet G-4, Oxygen, shall be observed: 27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Based on observations, interview and record review, the facility failed to ensure that the piped medical gas system met the standards of NFPA 99, 1999 Edition, Section 4-3.5.4.2. These deficiencies affect 2 of 21 first and second floor smoke compartments.

Findings include:

First Floor:

- During an observation on 11/30/15 at 4:28 p.m., the shut off valve for the med gas in room 1704 was reviewed. The shut off valve was labeled incorrectly and did not reflect that it was now room 1704.¹

- During an observation on 11/30/15 at 4:32 p.m., the shut off valve for the med gas in room 1742 of Neuropsychiatry was reviewed. The cover for the control valve was not labeled to reflect the room number that was controlled by the shut of valve.¹

Second Floor:

- During an observation on 11/30/15 at 4:30 p.m., OR 3 and OR 4 were inspected. The gas shutoffs outside the rooms were not labeled to which room was controlled by the shutoff valve.¹

¹ NFPA 99 Health Care Facilities, 1999 Edition, Section 4-3.5.4.2; The shutoff valves described in 4-3.1.2.3, 4-3.1.2.3(m), and 4-3.1.2.3(n) shall be labeled to reflect the rooms that are controlled by such valves. Labeling shall be kept current from initial construction through acceptance. Valves shall be labeled in substance as follows:
CAUTION:
(NAME OF MEDICAL GAS) VALVE DO NOT CLOSE EXCEPT IN EMERGENCY THIS VALVE CONTROLS SUPPLY TO . . . .

Based on observation, record review, and staff interviews, all of the anesthetizing locations were not held above 35% humidity per NFPA 99, Section 5-4.1.1. This deficiency could affect 5 of 7 operating rooms.

Finding include:

During an interview on 12/2/15 at 11:25 a.m., staff member A stated operating rooms (ORs) 5, 6, and 7 are humidified and the humidifiers are set at 25%. He stated the facility does not have a categorical waiver to allow the humidity to be below 35%.

In the same interview, it was discovered operating rooms 1, 2, 3, and 4 are not humidified. Rooms 2 and 3 are not used for anything but storage. ORs 1 and 4 are not humidified.¹

During an observation of the facility's automatic monitoring system, the humidity was recorded to be hovering slightly above or below 25% in ORs 5, 6, and 7. The automated system was recording humidity levels of 9 or 10% in ORs 1 and 4. This appeared to be in error, as a local humidity device in the OR read the humidity to be 30%.¹

In an interview on 12/2/15 at 2:00 p.m., staff member B stated the humidities have been running around 30% on the reports she gets. Staff member B, stated all the ORs are used interchangeably, there are no special surgeries in the ORs with no humidification. She also stated, she was not aware of CMS humidity requirements, and that with the categorical waiver, humidity could be as low as 20%.²

¹ NFPA 99 Standard for Health Care Facilities, 1999 Edition, Section 5-4.1.1*; The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

² CMS S&C-13-25-LSC and ASC: Relative Humidity (RH): Waiver of Life Safety Code (LSC) Anesthetizing Location Requirements; Discussion of Ambulatory Surgical Center (ASC) Operation Room Requirements, Issued April 29, 2013.

Based on observation, the facility failed to ensure interior walls were constructed and finished to be noncombustible in accordance with NFPA 101, Life Safety Code, 2000 Edition, Section 18.1.6.3. The deficiency could affect 1 of 2 smoke compartments on the third floor of the patient tower.

Findings include:

Second Floor:

- During an observation on 12/1/15 at 1:15 p.m., the third floor of the patient tower was inspected. The corridor wall outside room 2164 had a one foot by two feet cutout of the 1-hour separated interior wall.¹

¹ In accordance with NFPA 101 and Section 19.1.6.3; all interior walls and partitions in buildings of Type I or Type II construction shall be of noncombustible or limited-combustible materials.
Exception*: Listed, fire-retardant-treated wood studs shall be permitted within non-load bearing 1-hour fire-rated partitions. Further, Annex A.19.1.6.3 Exception states that there is a finish capacity in a 1-hour fire-rated partition that would be expected to prevent the generation of smoke and gases from fire retardant-treated wood studs for an extended time during fire exposure. This Code does not intend to permit the use of fire-retardant wood studs and partitions of only 20-minute fire resistance.

Based on observation, the facility failed to ensure that smoke dampers, interconnected to the facility fire alarm system, closed upon testing per NFPA 72, 1999 Edition, Section 3-9.5.2. This deficiency could effect 2 of 2 smoke compartments on the second floor of the patient towers.

Findings include:

Second Floor:

- During an observation on 12/1/15 at 1:23 p.m., the damper over the double doors in the west corridor on the second floor of the patient towers was inspected. Upon being tested by removal of the air line from the damper, it failed to close.¹

¹ NFPA 72 National Fire Alarm Code®, 1999 Edition, Section 3-9.5.2; If connected to the fire alarm system serving the protected premises, all detection devices used to cause the operation of HVAC (Heating, Ventilation, and Air-Conditioning) systems smoke dampers, fire dampers, fan control, smoke doors, and fire doors shall be monitored for integrity in accordance with 1-5.8.

Based on observation, the facility failed to maintain the electrical system and/or its components in accordance with the Centers for Medicare and Medicaid Services (CMS) Policy S&C-14-46-LSC and NFPA 70, 1999 Edition. These deficiencies affected the second floor.

Findings include:

- During an observation on 12/2/15 at 7:15 a.m., room 2216 was inspected. A floor heater was plugged into a power strip.¹

- During an observation on 12/2/15 at 7:25 a.m., room 2070 was inspected. A refrigerator was plugged into a power strip.¹

- During an observation on 12/2/15 at 7:40 a.m., the Audiology 2-E office was inspected. A white extension cord was found in-use.²

- During an observation on 12/2/15 at 7:50 a.m., room 2050 was inspected. A white extension cord was found in-use.²

- During an observation on 12/2/15 at 8:02 a.m., room 2038 was inspected. A multi-plug adaptor was found in-use.²

- During an observation on 12/2/15 at 8:07 a.m., the 2-A nurse's station was inspected. A white extension cord was found in-use.²

- During an observation on 12/2/15 at 8:20 a.m., room 2156 was inspected. A yellow extension cord was found which supplied power to a camera which had been installed. The extension cord was still in-use for the camera.²

¹ CMS Survey & Certification Policy S&C-14-46-LSC Categorical Waiver for Power Strips Use in Patient Care Areas, Issued 9/26/14.

² NFPA 70 National Electrical Code, 1999 Edition, Article 305-2(b); All Wiring Installations (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.
(b) Approval. Temporary wiring methods shall be acceptable only if approved based on the conditions of use and any special requirements of the temporary installation.

Based on observations, the facility failed to ensure that alcohol-based hand rub (ABHR) dispensers were not installed directly over or adjacent to an ignition source per CMS Survey & Certification Policy S&C-05-33. This deficiency affects 2 of 11 second floor smoke compartments.

Findings include:

- During an observation on 12/1/15 at 7:15 a.m., the dialysis reception area was inspected. There was an ABHR (Alcohol-Based Hand Rub) dispenser positioned over a wall outlet.¹

- During an observation on 12/1/15 at 7:58 a.m., the nutrition conference room was inspected. The ABHR dispenser was within an inch of the light switch.¹

¹ CMS interpretations under Survey & Certification (S&C)-05-33 policy issued on June 9, 2005, states ABHR dispensers shall meet the NFPA amendment to the 2000 Life Safety Code regarding the installation of ABHR dispensers in exit corridors and on interior walls. The Certification Bureau enforces that ABHR dispensers be offset by at least one inch and not mounted directly above any electrical source.