HospitalInspections.org

Based on observation and staff interview, the facility failed to ensure that doors to ancillary areas are capable of resisting the passage of smoke. This deficient practice would not prevent the spread of fire and smoke products from entering the corridor and affects 16 patients and all occupants in 2 of 8 smoke zones on the 1st floor. There are 16 smoke zones on 5 floors/levels total. This facility has a capacity of 25 and a census of 10 patients.

Findings Include:

During the tour conducted on 8/1/13, between 9:00 A.M. and 4:30 P.M., and 8/5/13, between 10:00 A.M. and 3:00 P.M., the following is observed:

1.) At 11:10 A.M. on 8/5/13 it is discovered that there are 2 wedges holding open corridor doors near the Pain Clinic.
2.) At 11:42 A.M. on 8/5/13 it is discovered that the south leaf does not fully close on the double smoke barrier doors near the Emergency Waiting area.

The Chief Operations Officer and Director of Buildings and Grounds are aware of these findings.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3.

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other spaces. The area of deficient practice would provide a path for smoke and fire to travel into adjoining void spaces above corridor ceiling assemblies, affecting 0 patients and all occupants in 1 of 8 smoke zones on the 1st floor. There are 16 smoke zones on 5 floors/levels total. This facility has a capacity of 25 and a census of 10 patients.

Findings Include:

During the tour conducted on 8/1/13, between 9:00 A.M. and 4:30 P.M., and 8/5/13, between 10:00 A.M. and 3:00 P.M., the following is observed:

1.) At 11:30 A.M. on 8/5/13 it is discovered that there are unsealed penetrations of the barrier wall in the upper southwest corner of the East Link Mechanical room.
2.) At 11:35 A.M. on 8/5/13 it is discovered that there are unsealed penetrations around conduit in the upper southwest corner of the East Link Data Closet.

The Chief Operations Officer and Director of Buildings and Grounds are aware of these findings.

NFPA Standard: Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1 hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42. 2000 NFPA 101, 8.4.1.

Based on observation and staff interview, the facility failed to provide a means of egress that is maintained free of all obstructions or impediments to a full instant use in case of fire or other emergency. The deficient practice would prevent residents and staff from exiting without impediments through one of 2 exits, affecting 0 patients and all occupants in 1 of 8 smoke zones on the 1st floor. There are 16 smoke zones on 5 floors/levels total. This facility has a capacity of 25 and a census of 10 patients.

Findings Include:

During the tour conducted on 8/1/13, between 9:00 A.M. and 4:30 P.M., and 8/5/13, between 10:00 A.M. and 3:00 P.M., the following is observed:

1.) At 2:25 P.M. on 8/5/13 it is discovered that there is a flush-mounted surface bolt in use on the south exit doors of the Surgery Suite.

The Chief Operations Officer and Director of Buildings and Grounds are aware of these finding.

NFPA Standard: 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. 2000 NFPA 101, 7.1.10.1.

Based on records review and observation the facility failed to provide emergency lighting as required. This deficient practice could result in critical areas being left without illumination during a disruption of normal power or in the event of an emergency, affecting all 25 patients and occupants in 16 of 16 smoke zones on 5 floors/levels. This facility has a capacity of 25 and a census of 10 patients.

Findings Include:

During the tour conducted on 8/1/13, between 9:00 A.M. and 4:30 P.M., and 8/5/13, between 10:00 A.M. and 3:00 P.M., the following is observed:

1.) At 10:09 A.M. on 8/1/13 it is discovered that there is no documentation of emergency light testing on a monthly basis since March 2013.
2.) At 12:09 P.M. on 8/5/13 it is discovered that the emergency lighting is controlled by manual switches in the Northeast and Southeast Patient wings Designated Storm Shelters.
3.) At 12:20 P.M. on 8/5/13 it is discovered that there is no emergency lighting provided for the Central Nurses Station Medication Preparation room.

The Chief Operations Officer and Director of Buildings and Grounds are aware of these findings.

NFPA Standard: A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 and 1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 2000 NFPA 101, 7.9.3 and 7.10.9

Based on observation and staff interview, the facility failed to provide illuminated exit signs marking the exit paths. The deficient practice may prevent the occupants of the building to be directed to the exit path and delay egress affecting 0 patients and all occupants in 1 of 4 smoke zones in the Basement. There are 16 smoke zones on 5 floors/levels total. This facility has a capacity of 25 and a census of 10 patients.

Findings Include:

During the tour conducted on 8/1/13, between 9:00 A.M. and 4:30 P.M., and 8/5/13, between 10:00 A.M. and 3:00 P.M., the following is observed:

1.) At 11:24 A.M. on 8/1/13 it is discovered that the exit sign is not illuminated near the Rehabilitation Waiting area exit door.

The Chief Operations Officer and Director of Buildings and Grounds are aware of these finding.

NFPA Standard: Means of egress shall have signs in accordance with Section 7.10.
Exception: Where the path of egress travel is obvious, signs shall not be required in one-story buildings with an occupant load of fewer than 30 persons. 2000 NFPA 101, 19.2.10.1.

Based on observation and staff interview, the facility fails to assure that a fire alarm system with approved components, devices or equipment is installed according to NFPA 72, National Fire Alarm Code, to provide effective warning of fire in any part of the building. The deficient practice of improperly installing manual fire alarm boxes will delay the initiation of the fire alarm system via these devices. This deficient practice affects 0 patients and all occupants in 1 of 8 smoke zones on the 1st floor. There are 16 smoke zones on 5 floors/levels total. This facility has a capacity of 25 and a census of 10 patients.

Findings Include:

During the tour conducted on 8/1/13, between 9:00 A.M. and 4:30 P.M., and 8/5/13, between 10:00 A.M. and 3:00 P.M., the following is observed:

1.) At 1:28 P.M. on 8/5/13 it is discovered that there is no manual pull station at the E.R. Walk-in Entrance, which is marked as a designated exit.

The Chief Operations Officer and Director of Buildings and Grounds are aware of these finding.

NFPA Standard: A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, and NFPA 72. 2000 NFPA 101 section 9.6.1.4.

Based on record review and staff interviews, the facility failed to assure that the sprinkler system is maintained and tested in accordance with the NFPA 13 and NFPA 25. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting all 25 patients and occupants in 16 of 16 smoke zones on 5 floors/levels. This facility has a capacity of 25 and a census of 10 patients.

Findings Include:

During the tour conducted on 8/1/13, between 9:00 A.M. and 4:30 P.M., and 8/5/13, between 10:00 A.M. and 3:00 P.M., the following is observed:

1.) At 10:35 A.M. on 8/1/13 it is discovered that there is no documentation of quarterly sprinkler testing being performed for the last 5 quarters.
2.) At 11:27 A.M. on 8/1/13 it is discovered that there is a missing escutcheon ring for a sprinkler head in the Occupational Therapy room.
3.) At 11:30 A.M. on 8/1/13 it is discovered that there are sprinkler heads with dust and/or debris obstructing sprinkler heads throughout the basement Rehabilitation area.
4.) At 11:19 A.M. on 8/5/13 it is discovered that there are missing escutcheon rings for all sprinkler heads throughout the Medical Records Storeroom.

The Chief Operations Officer and Director of Buildings and Grounds are aware of these findings.

NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. 1999 NFPA 13, 12.1.

Based on staff interview and record review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice may prevent the emergency power supply from being available at the time of a power loss, affecting all 25 patients and occupants in 16 of 16 smoke zones on 5 floors. This facility has a capacity of 25 and a census of 10 patients.

Findings Include:

During the tour conducted on 8/1/13, between 9:00 A.M. and 4:30 P.M., the following is observed:

1.) At approximately 10:23 A.M. it is discovered that there is no documentation of monthly generator testing being performed since 10/22/12. Upon further record review, it is also discovered that on the facilities Emergency Generator Inspection Form provided for October 2012, it is documented on 10/22/12 that " ran and generator broken they took off line on 10-23-12. " Also on the same October 2012 Inspection Form it is documented that "Central brought rental generator in and hook(ed) up" on 10/23/12. The Surveyor then interviewed the Director of Building and Grounds as to the current status of the emergency generator and the Director stated that the broken generator was removed and a rental was used until a permanent replacement was brought in and installed. At the time of records review and interview there is no documentation of the new generator installation and/or testing available since October 2012. The Facility cares for patients on life support and the generator supports all life support equipment, emergency power and lighting throughout the facility. The Surveyor then proceeded to contact his Immediate Supervisor, [Chief of Fire Prevention Division] for the KSFMO, in Topeka, KS, and subsequently, with the C.M.S. Regional Office Representative. At approximately 11:55 A.M. it was declared by C.M.S. representatives that the facility was under an Immediate Jeopardy condition. Immediately the Surveyor held an emergency meeting with accompanying staff, including the CEO and Director of Buildings and Grounds, as well as the 2 present KDHE Health Facility Surveyors and informed them of the Immediate Jeopardy status declaration. The facility staff proceeded to make contact with the contractors, generator rental company and generator service company to begin acquiring all available documentation. At approximately 1:00 P.M. an invoice from Central Power Systems and Services of Salina KS documenting the rental and use of a generator between 10/23/12 at 12:00pm and 11/8/12 at 6:59 A.M. was provided to the Surveyor and at approximately 2:00 P.M. Central Power Systems and Services of Salina KS contacted the facility and informed them that a generator technician was in route to the facility to perform a Load bank test on the generator and ensure that it is in compliance with applicable NFPA 110 Standards for Emergency and Standby Power Equipment. At approximately 7:00 P.M. the Generator technician contacted the Surveyor via telephone and informed him that the generator testing was complete and functioned as required and documentation of this was provided to the surveyor by email at 9:20 P.M. and forwarded to his Immediate Supervisor, [Chief of Fire Prevention Division] for the KSFMO, in Topeka, KS, and subsequently, with the C.M.S. Regional Office Representative. The records of testing and inspection were reviewed and accepted as satisfactory and the condition of Immediate Jeopardy is ABATED.

The CEO and Director of Buildings and Grounds are aware of these findings.

NFPA Standard: Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10 second interval specified in 3 4.1.1.8 and 3 4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
(b) Inspection and Testing.
1.* Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
2. Test Conditions. The scheduled test under load conditions shall include a complete simulated cold start and automatic and manual transfer of all essential electrical system loads.
3. Test Personnel. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures. 1999 NFPA 99 3.4.4.1.

Based on observation and staff interview, the facility did not ensure that electrical wiring and equipment is installed and maintained in accordance with NFPA 70, National Electrical Code. This deficient practice does not ensure prevention of an electrical fire or electric shock hazard, affecting 0 patients and all occupants in 1 of 4 smoke zones in the Basement and 1 of 8 smoke zones on the First floor. There are 16 smoke zones on 5 floors/levels total. This facility has a capacity of 25 and a census of 10 patients.

Findings Include:

During the tour conducted on 8/1/13, between 9:00 A.M. and 4:30 P.M., and 8/5/13, between 10:00 A.M. and 3:00 P.M., the following is observed:

1.) At 11:15 A.M. on 8/1/13 it is discovered that there are 2 extension cords being used as permanent wiring in the Laundry area.
2.) At 11:34 A.M. on 8/1/13 it is discovered that there is an extension cord powering treadmills in the Basement Stress Testing area.
3.) At 10:58 A.M. on 8/5/13 it is discovered that there are 2 outlets not GFCI protected in the Dishwashing area and near the Central Hand washing Sink area in the Kitchen.
4.) At 11:06 A.M. on 8/5/13 it is discovered that there is a surge protector being powered by another surge protector in the Pain Clinic Conference 2 room.

The Chief Operations Officer and Director of Buildings and Grounds are aware of these findings.

NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8.

Based on observation and staff interview, the facility failed to ensure that doors to ancillary areas are capable of resisting the passage of smoke. This deficient practice would not prevent the spread of fire and smoke products from entering the corridor and affects 16 patients and all occupants in 2 of 8 smoke zones on the 1st floor. There are 16 smoke zones on 5 floors/levels total. This facility has a capacity of 25 and a census of 10 patients.

Findings Include:

During the tour conducted on 8/1/13, between 9:00 A.M. and 4:30 P.M., and 8/5/13, between 10:00 A.M. and 3:00 P.M., the following is observed:

1.) At 11:10 A.M. on 8/5/13 it is discovered that there are 2 wedges holding open corridor doors near the Pain Clinic.
2.) At 11:42 A.M. on 8/5/13 it is discovered that the south leaf does not fully close on the double smoke barrier doors near the Emergency Waiting area.

The Chief Operations Officer and Director of Buildings and Grounds are aware of these findings.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3.

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other spaces. The area of deficient practice would provide a path for smoke and fire to travel into adjoining void spaces above corridor ceiling assemblies, affecting 0 patients and all occupants in 1 of 8 smoke zones on the 1st floor. There are 16 smoke zones on 5 floors/levels total. This facility has a capacity of 25 and a census of 10 patients.

Findings Include:

During the tour conducted on 8/1/13, between 9:00 A.M. and 4:30 P.M., and 8/5/13, between 10:00 A.M. and 3:00 P.M., the following is observed:

1.) At 11:30 A.M. on 8/5/13 it is discovered that there are unsealed penetrations of the barrier wall in the upper southwest corner of the East Link Mechanical room.
2.) At 11:35 A.M. on 8/5/13 it is discovered that there are unsealed penetrations around conduit in the upper southwest corner of the East Link Data Closet.

The Chief Operations Officer and Director of Buildings and Grounds are aware of these findings.

NFPA Standard: Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1 hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42. 2000 NFPA 101, 8.4.1.

Based on observation and staff interview, the facility failed to provide a means of egress that is maintained free of all obstructions or impediments to a full instant use in case of fire or other emergency. The deficient practice would prevent residents and staff from exiting without impediments through one of 2 exits, affecting 0 patients and all occupants in 1 of 8 smoke zones on the 1st floor. There are 16 smoke zones on 5 floors/levels total. This facility has a capacity of 25 and a census of 10 patients.

Findings Include:

During the tour conducted on 8/1/13, between 9:00 A.M. and 4:30 P.M., and 8/5/13, between 10:00 A.M. and 3:00 P.M., the following is observed:

1.) At 2:25 P.M. on 8/5/13 it is discovered that there is a flush-mounted surface bolt in use on the south exit doors of the Surgery Suite.

The Chief Operations Officer and Director of Buildings and Grounds are aware of these finding.

NFPA Standard: 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. 2000 NFPA 101, 7.1.10.1.

Based on records review and observation the facility failed to provide emergency lighting as required. This deficient practice could result in critical areas being left without illumination during a disruption of normal power or in the event of an emergency, affecting all 25 patients and occupants in 16 of 16 smoke zones on 5 floors/levels. This facility has a capacity of 25 and a census of 10 patients.

Findings Include:

During the tour conducted on 8/1/13, between 9:00 A.M. and 4:30 P.M., and 8/5/13, between 10:00 A.M. and 3:00 P.M., the following is observed:

1.) At 10:09 A.M. on 8/1/13 it is discovered that there is no documentation of emergency light testing on a monthly basis since March 2013.
2.) At 12:09 P.M. on 8/5/13 it is discovered that the emergency lighting is controlled by manual switches in the Northeast and Southeast Patient wings Designated Storm Shelters.
3.) At 12:20 P.M. on 8/5/13 it is discovered that there is no emergency lighting provided for the Central Nurses Station Medication Preparation room.

The Chief Operations Officer and Director of Buildings and Grounds are aware of these findings.

NFPA Standard: A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 and 1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 2000 NFPA 101, 7.9.3 and 7.10.9

Based on observation and staff interview, the facility failed to provide illuminated exit signs marking the exit paths. The deficient practice may prevent the occupants of the building to be directed to the exit path and delay egress affecting 0 patients and all occupants in 1 of 4 smoke zones in the Basement. There are 16 smoke zones on 5 floors/levels total. This facility has a capacity of 25 and a census of 10 patients.

Findings Include:

During the tour conducted on 8/1/13, between 9:00 A.M. and 4:30 P.M., and 8/5/13, between 10:00 A.M. and 3:00 P.M., the following is observed:

1.) At 11:24 A.M. on 8/1/13 it is discovered that the exit sign is not illuminated near the Rehabilitation Waiting area exit door.

The Chief Operations Officer and Director of Buildings and Grounds are aware of these finding.

NFPA Standard: Means of egress shall have signs in accordance with Section 7.10.
Exception: Where the path of egress travel is obvious, signs shall not be required in one-story buildings with an occupant load of fewer than 30 persons. 2000 NFPA 101, 19.2.10.1.

Based on observation and staff interview, the facility fails to assure that a fire alarm system with approved components, devices or equipment is installed according to NFPA 72, National Fire Alarm Code, to provide effective warning of fire in any part of the building. The deficient practice of improperly installing manual fire alarm boxes will delay the initiation of the fire alarm system via these devices. This deficient practice affects 0 patients and all occupants in 1 of 8 smoke zones on the 1st floor. There are 16 smoke zones on 5 floors/levels total. This facility has a capacity of 25 and a census of 10 patients.

Findings Include:

During the tour conducted on 8/1/13, between 9:00 A.M. and 4:30 P.M., and 8/5/13, between 10:00 A.M. and 3:00 P.M., the following is observed:

1.) At 1:28 P.M. on 8/5/13 it is discovered that there is no manual pull station at the E.R. Walk-in Entrance, which is marked as a designated exit.

The Chief Operations Officer and Director of Buildings and Grounds are aware of these finding.

NFPA Standard: A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, and NFPA 72. 2000 NFPA 101 section 9.6.1.4.

Based on record review and staff interviews, the facility failed to assure that the sprinkler system is maintained and tested in accordance with the NFPA 13 and NFPA 25. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting all 25 patients and occupants in 16 of 16 smoke zones on 5 floors/levels. This facility has a capacity of 25 and a census of 10 patients.

Findings Include:

During the tour conducted on 8/1/13, between 9:00 A.M. and 4:30 P.M., and 8/5/13, between 10:00 A.M. and 3:00 P.M., the following is observed:

1.) At 10:35 A.M. on 8/1/13 it is discovered that there is no documentation of quarterly sprinkler testing being performed for the last 5 quarters.
2.) At 11:27 A.M. on 8/1/13 it is discovered that there is a missing escutcheon ring for a sprinkler head in the Occupational Therapy room.
3.) At 11:30 A.M. on 8/1/13 it is discovered that there are sprinkler heads with dust and/or debris obstructing sprinkler heads throughout the basement Rehabilitation area.
4.) At 11:19 A.M. on 8/5/13 it is discovered that there are missing escutcheon rings for all sprinkler heads throughout the Medical Records Storeroom.

The Chief Operations Officer and Director of Buildings and Grounds are aware of these findings.

NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. 1999 NFPA 13, 12.1.

Based on staff interview and record review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice may prevent the emergency power supply from being available at the time of a power loss, affecting all 25 patients and occupants in 16 of 16 smoke zones on 5 floors. This facility has a capacity of 25 and a census of 10 patients.

Findings Include:

During the tour conducted on 8/1/13, between 9:00 A.M. and 4:30 P.M., the following is observed:

1.) At approximately 10:23 A.M. it is discovered that there is no documentation of monthly generator testing being performed since 10/22/12. Upon further record review, it is also discovered that on the facilities Emergency Generator Inspection Form provided for October 2012, it is documented on 10/22/12 that " ran and generator broken they took off line on 10-23-12. " Also on the same October 2012 Inspection Form it is documented that "Central brought rental generator in and hook(ed) up" on 10/23/12. The Surveyor then interviewed the Director of Building and Grounds as to the current status of the emergency generator and the Director stated that the broken generator was removed and a rental was used until a permanent replacement was brought in and installed. At the time of records review and interview there is no documentation of the new generator installation and/or testing available since October 2012. The Facility cares for patients on life support and the generator supports all life support equipment, emergency power and lighting throughout the facility. The Surveyor then proceeded to contact his Immediate Supervisor, [Chief of Fire Prevention Division] for the KSFMO, in Topeka, KS, and subsequently, with the C.M.S. Regional Office Representative. At approximately 11:55 A.M. it was declared by C.M.S. representatives that the facility was under an Immediate Jeopardy condition. Immediately the Surveyor held an emergency meeting with accompanying staff, including the CEO and Director of Buildings and Grounds, as well as the 2 present KDHE Health Facility Surveyors and informed them of the Immediate Jeopardy status declaration. The facility staff proceeded to make contact with the contractors, generator rental company and generator service company to begin acquiring all available documentation. At approximately 1:00 P.M. an invoice from Central Power Systems and Services of Salina KS documenting the rental and use of a generator between 10/23/12 at 12:00pm and 11/8/12 at 6:59 A.M. was provided to the Surveyor and at approximately 2:00 P.M. Central Power Systems and Services of Salina KS contacted the facility and informed them that a generator technician was in route to the facility to perform a Load bank test on the generator and ensure that it is in compliance with applicable NFPA 110 Standards for Emergency and Standby Power Equipment. At approximately 7:00 P.M. the Generator technician contacted the Surveyor via telephone and informed him that the generator testing was complete and functioned as required and documentation of this was provided to the surveyor by email at 9:20 P.M. and forwarded to his Immediate Supervisor, [Chief of Fire Prevention Division] for the KSFMO, in Topeka, KS, and subsequently, with the C.M.S. Regional Office Representative. The records of testing and inspection were reviewed and accepted as satisfactory and the condition of Immediate Jeopardy is ABATED.

The CEO and Director of Buildings and Grounds are aware of these findings.

NFPA Standard: Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10 second interval specified in 3 4.1.1.8 and 3 4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
(b) Inspection and Testing.
1.* Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
2. Test Conditions. The scheduled test under load conditions shall include a complete simulated cold start and automatic and manual transfer of all essential electrical system loads.
3. Test Personnel. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures. 1999 NFPA 99 3.4.4.1.

Based on observation and staff interview, the facility did not ensure that electrical wiring and equipment is installed and maintained in accordance with NFPA 70, National Electrical Code. This deficient practice does not ensure prevention of an electrical fire or electric shock hazard, affecting 0 patients and all occupants in 1 of 4 smoke zones in the Basement and 1 of 8 smoke zones on the First floor. There are 16 smoke zones on 5 floors/levels total. This facility has a capacity of 25 and a census of 10 patients.

Findings Include:

During the tour conducted on 8/1/13, between 9:00 A.M. and 4:30 P.M., and 8/5/13, between 10:00 A.M. and 3:00 P.M., the following is observed:

1.) At 11:15 A.M. on 8/1/13 it is discovered that there are 2 extension cords being used as permanent wiring in the Laundry area.
2.) At 11:34 A.M. on 8/1/13 it is discovered that there is an extension cord powering treadmills in the Basement Stress Testing area.
3.) At 10:58 A.M. on 8/5/13 it is discovered that there are 2 outlets not GFCI protected in the Dishwashing area and near the Central Hand washing Sink area in the Kitchen.
4.) At 11:06 A.M. on 8/5/13 it is discovered that there is a surge protector being powered by another surge protector in the Pain Clinic Conference 2 room.

The Chief Operations Officer and Director of Buildings and Grounds are aware of these findings.

NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8.