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Based on observation and staff interview, the facility failed to ensure the fire rated door of the occupancy separation closed to a latching position. This had the potential to affect all patients receiving services at the facility. The facility census was four.

Findings include:

Observation of the fire rated double doors between the facility and the nursing home completed on 03/06/18 revealed the doors were fire rated for 1 1/2 hours. When tested, the right door failed to close to a latching position.

This finding was verified in an interview by Staff Z at the time of the observation.

Based on observations and interview, the facility failed to ensure suites were separated from the remainder of the building in accordance with Edition 2012 of NFPA 101, Life Safety Code, Sections 19.3.6.5.2. This had the potential to affect all patients in the facility. The facility census was four.

Findings include:

On 03/06/18, during a tour of the facility with facility Staff Z, the following was observed:

1. At 12:00 PM, the reception desk enclosure for radiology was provided with two windows, one to the corridor and one to the waiting room. Each window had a four inch diameter speaking hole and a 13 inch by 4.75 inch slot open to the exit corridor in the adjacent smoke compartment.

2. At 12:27 PM, the reception desk enclosure for cardiology was provided with a 47.5 inch by 17.5 inch sliding glass window open to the exit corridor in the adjacent smoke compartment.

Interview with facility Staff Z verified the above findings at the time of the discovery.

39.2.1.1 All means of egress shall be in accordance with Chapter 7 and this chapter.

7.7 Discharge from Exits.
7.7.1* Exit Termination. Exits shall terminate directly, at a public way or at an exterior exit discharge, unless otherwise provided in 7.7.1.2 through 7.7.1.4.
7.7.1.1 Yards, courts, open spaces, or other portions of the exit discharge shall be of the required width and size to provide all occupants with a safe access to a public way.

Based on observation and staff interview, the facility failed to ensure surfaces leading to public ways were safe. This had the potential to affect all patients in the facility. The facility census was four.

Findings include:

Tour of the building completed on 03/07/18 revealed an identified exit egress that lead to an exit beside the Audiology space. After going through the identified exit door three two foot by two foot walking stones were noted. When stepping off of the walking stones there was approximately 75 feet of snow covered grass to get to another hard packed surface.

This finding was verified in an interview by Staff Z at the time of the observation.

Based on observation and staff interview, the facility failed to ensure exit signs were present directing patients toward the exits. This had the potential to affect all patients receiving services at the facility. The facility census was four.

Findings include:

During tour of the facility on 03/05/18, a central stairwell was noted. When exiting the stairwell on the first floor no exit sign was noted. The exits were not obvious at the stair well exit due to being three directions that a person could go and only two of the directions were actual exits.

This finding was verified in an interview by Staff Z at the time of the observation.

38617

Based on observation and staff interview, the facility failed to maintain vertical openings between floors in accordance with Edition 2012 of NFPA 101, Life Safety Code, Section 19.3.1.7. This had the potential to affect all patients in the facility. The facility census was four.

Findings include:

1. Observation above the drop ceiling in the equipment room located behind the CPR training room completed on 03/05/18 revealed a two foot by two foot chase in the Southeast corner with two foot of space between where the chase stopped and the deck above.

This finding was verified in an interview by staff Z at the time of the observation.

2. On 03/06/18 at 8:53 AM during a tour of the facility with facility Staff Z, observation revealed the perimeter of the PVC pipe penetrating the gypsum board at the top of the chase-way, which terminated in the interstitial space above the ceiling tiles in the storage room adjacent to OR1, was not fire-caulked. This condition left up to a 1/2 inch gap between the perimeter of the PVC pipe and the cut edge of the gypsum board.

Interview with facility Staff Z verified this finding at the time of discovery.

38617

Based on observation and staff interview, the facility failed to ensure protection from hazardous areas in accordance with NFPA 101 - 2012 Edition 19.3.2. and 8.7. This had the potential to affect all patients in the facility. The facility census was four.

Findings include:

1. Observation above the drop ceiling beside the North stairwell "4" door completed on 03/05/18 revealed a 1 1/2 inch by 3/4 inch penetration located in the South wall of the "shell" storage room beside the stairwell, where the wall met the two hour fire rated wall and at the deck above.

This finding was verified in an interview by Staff Z at the time of the observation.

2. Observation above the drop ceiling in the corridor above the double doors across from the CPR training room completed on 03/05/18 revealed a 1 1/2 inch round hole in the west fire rated wall of the decontamination room.

This was verified in an interview by Staff Z at the time of the observation.

3. Observation of the wall in the electrical closet located in the corridor to the south of storage room of the cardiac suite completed on 03/06/18 revealed an eight inch section of a seam not sealed with a fire rated material.

This finding was verified in an interview by Staff Z at the time of the observation.

4. On 03/06/18 at 9:13 AM during a tour of the facility with facility Staff Z, observation revealed the 3-hour fire-resistant-rated fire door in the physician's lounge shower room to gain access to the smoke damper contained within the adjacent hazardous area, was not provided with a self-closing device.

Interview with facility Staff Z verified this finding at the time of discovery.

Based on observation and interview, the facility failed to ensure a cooking facility was closed to the corridor in accordance with Edition 2012 of NFPA 101, Life Safety Code, Sections 9.2.3, 19.3.2.5.5, 19.3.6.3.2(2), 19.3.7.8(1) and 19.2.2.2.7. This had the potential to affect all patients in the facility. The facility census was four.

Findings include:

On 03/06/18 at 11:14 AM during a tour of the facility with facility Staff Z, observation revealed the exit corridor door off the southeast corner of the kitchen was not provided with an automatic-closing device and was held open by a friction device.

Interview with facility Staff Z verified this finding at the time of discovery.

Based on staff interview and record review, the facility failed to maintain and test fire alarm interfaced equipment in accordance with the test methods described in Edition 2010 of NFPA 72, National Fire Alarm and Signaling Code, Section 14.2.6.2 and Table 14.4.2.2. This had the potential to affect all patients in the facility. The facility census was four.

Findings include:

On 03/07/18 at 2:30 PM during the review of monthly fire alarm test result records with facility Staff Z, there was no evidence to show the signal was received by the supervising station within 90 seconds of fire alarm actuation during the months of April 2017, June 2017, July 2017, September 2017, December 2017 and January 2018.

Interview with facility Staff Z verified this finding at the time of discovery.

Based on observation and interview, the facility failed to ensure all wet gauges were inspected monthly and all dry gauges were inspected weekly in accordance with Edition 2012 of NFPA 101, Life Safety Code, Sections 9.7.5, 9.7.7 and 9.7.8, and Edition 2011 of NFPA 25, Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, Sections 13.2 and 4.3. This had the potential to affect all patients in the facility. The facility census was four.

Findings include:

On 03/07/18 at 11:15 AM during a review of life safety records provided by facility Staff Z, there was no evidence to show the facility was performing weekly inspections of the gauges on the dry sprinkler systems or monthly inspections of the gauges on the wet sprinkler system. Furthermore, the facility was unable to provide such records upon request.

Interview with facility Staff Z verified this finding at the time of discovery.

Based on observations and interview, the facility failed to ensure openings in smoke barriers did not exceed 80 square inches per room in accordance with Edition 2012 of NFPA 101, Life Safety Code, Sections 19.3.6.5.2. This had the potential to affect all patients in the facility. The facility census was four.

Findings include:

On 03/06/18 during a tour of the facility with facility Staff Z, the following was observed:

1. At 12:00 PM, the reception desk enclosure for radiology was provided with two windows, one to the corridor and one to the waiting room. Each window had a 4 inch diameter speaking hole and a 13 inch by 4.75 inch slot open to the exit corridor in the adjacent smoke compartment. The total area of these window openings were in excess of 148 square inches; and

2. At 12:27 PM, the reception desk enclosure for cardiology was provided with a 47.5 inch by 17.5 inch sliding glass window open to the exit corridor in the adjacent smoke compartment. The total area of this window opening was in excess of 830 square inches.

Interview with facility Staff Z verified the above findings at the time of discovery.

Based on schematic review, observation, and staff interview, the facility failed to ensure the identified one hour fire rated smoke barrier penetrations were sealed with a fire rated material. This had the potential to affect all patients receiving services at the facility. The facility census was four.

Findings include:

Observation above the drop ceiling in the outpatient procedure room behind the double elevators on the 2nd floor completed on 03/05/18 revealed a 1/2 inch conduit with four red data cables passing through located in the South wall of the room open on the end and a four inch by four inch gypsum board patch not sealed with a fire rated material at the seams.

These findings were verified in an interview by Staff Z at the time of the observation.

Observation above the drop ceiling in the corridor between the registration area and the elevator equipment room completed on 03/06/18 revealed a three foot section without the fire rated incandescent paint covering the non-rated material sealing the wall at the deck above to the right of the double door.

This finding was verified in an interview by Staff Z at the time of the observation.

Observation of the wall in the electrical closet located in the corridor to the south of storage room of the cardiac suite completed on 03/06/18 revealed an eight inch section of a seam not sealed with a fire rated material.

This finding was verified in an interview by Staff Z at the time of the observation.

Based on interview and observation, the facility failed to ensure staff were aware of where the medical gas zone valve shut offs were in the Post Anesthesia Care Unit (PACU) area. This had the potential to affect all patients receiving services at the facility. The facility census was four.

Findings include:

During tour of the PACU completed on 03/16/18 at 9:47 AM, Four staff were asked where the medical gas shut offs were for the PACU. Three staff stated that they did not know where they were and one staff was unable to locate the medical gas shut offs.

NFPA 99, 2012

5.1.4.8.7.2 Zone valves shall be so arranged that shutting off the supply of gas to any one operating room or anesthetizing location will not affect the others.

Based on observation, policy review and staff interview, the facility failed to ensure zone valves were arranged as to where shutting the supply of gas to any one operating room would not affect the other operating room. This had the potential to affect all patients receiving services at the facility. The facility census was four.

Findings include:

During tour of the endoscope procedure rooms completed on 03/05/18 revealed one zone valve shut off located in the corridor south of the endoscope procedure rooms. The label identified it as the medical gas shut offs for endo rooms 1 and 2. Staff Z verified in an interview that the shut offs turned the medical gas and vaccum off to both endoscope rooms. Each endoscope room was noted to have an anesthesia cart. Lines from the medical air and vacuum ports were noted to run to the anesthesia cart and vacuum equipment.

Interview with Staff Y completed on 03/07/18 at 1:58 PM revealed the endoscope rooms were considered minor procedure rooms. A policy was provided demonstrating what procedures were to be performed in the endoscope rooms titled "Guidelines for Procedures Performed Under Local Anesthesia or Conscious sedation".

Review of the policy titled "Guidelines for Procedures Performed Under Local Anesthesia or Conscious Sedation" completed on 03/08/18 revealed "Physicians, assisted by one or two caregivers (one scrub, if necessary, and one circulating nurse) may utilize the Minor Procedure Room OR Surgical Suites to perform inpatient and outpatient minor surgical procedures/therapies under local anesthesia or IV conscious sedation administered by the OR RN."