HospitalInspections.org

.
Based on observations and staff interview during the Federal Recertification Survey, the facility failed to ensure that all interior wall finishes in exit access corridors in existing health care occupancies are a Class A or Class B Interior Wall and Ceiling Finish that were tested in accordance with NFPA 255, Standard Method of Test of Surface Burning Characteristics of Building Materials.

Findings:

On the morning and afternoon of 01/06/14, a plastic wall covering that was screwed into the lower portion of the exit access corridor walls was noted in the numerous areas of the hospital (e.g., 3rd Floor 3 South Unit, 2nd Floor 2 North and 2 South Units). These plastic panels were approximately 42-inches high and ran the entire length of the corridors they were used in.

On 01/06/14 at 10:54AM, interview with the Director of Plant Engineering revealed that the product was "Lexan" and that this product had a Class "C" rating. He stated that the hospital was already aware that this material was not permitted and had already started removing these panels from walls and rooms throughout the facility.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.3.2
.

.
Based on observations and interviews during the Federal Recertification Survey, the facility failed to ensure that corridor walls in non-sprinkler protected smoke compartments were continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and that they had a fire resistance rating of not less than ?-hour.

Findings:

On 01/10/14 at 11:22AM, a couple of unsealed cable penetrations were found in a 3rd Floor corridor wall (vicinity of Room 320).

On 01/10/14 at 11:25AM, an unsealed cable penetration was found in a 3rd Floor corridor wall (vicinity of the Staff Office near Room 328).

As per concurrent interviews with the facility's Director of Engineering, these penetrations would be sealed immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.6.2.1
.

.
Based on observations and staff interview during the Federal Recertification Survey, the facility failed to ensure that all door openings from hazardous areas were provided with approved hold-open devices that automatically closed all such doors in accordance with NFPA 101-2000 Life Safety Code Section 7.2.1.8.2.

Findings:

On 01/07/14 at 10:22AM, a portable fire extinguisher was found to have been improperly used as a door hold-open device on the door to the Lower Level "Cave" Medical Record Storage Room.

As per concurrent interviews with the facility's Corporate Life Safety Director and Director of Plant Engineering, the portable fire extinguisher should not have been used to hold this fire door open.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.2.1, 8.4.1.3, 7.2.1.8.2
.

.
Based on observations and interviews during the Federal Recertification Survey, the facility failed to ensure that smoke barrier walls were constructed to have at least a ?-hour fire resistance rating.

Findings:

On 01/06/14 at 11:24AM, a plumbing penetration and a duct penetration in a 3rd Floor smoke barrier (vicinity of the staff office near Room 328) were found to have been improperly sealed with a non-fire resistance rated material (e.g., joint compound).

On 01/06/14 at 8:33AM, an unsealed cable penetration and a few cable penetrations that were improperly sealed with a non-fire resistance rated material (e.g., joint compound were found in a 1st Floor smoke barrier (in the 1 North Unit near the "Large T Room").

On 01/07/14 at 8:31AM, an unsealed conduit was found to have been incorporated in the construction of a 1st Floor smoke barrier (above a set of cross-aisle doors in the Emergency Department (ED) Unit near Cardiac Trauma Rooms 16 & 17).

On 01/07/14 at 8:34AM, an approximately 3-inch by 3-inch hole was found in a 1st Floor smoke barrier (near the ED Unit Triage Area).

On 01/07/14 at 8:37AM, the top-of-wall assembly, two (2) cable penetrations, and several steel joist penetrations that were improperly sealed with a non-fire resistance rated material (e.g., joint compound found in a 1st Floor smoke barrier (near the ED Unit General Procedure Room 15).

On 01/06/14 at 8:46AM, an unsealed cable penetration, an unsealed conduit penetration, and an unsealed plumbing penetration were found in a 1st Floor smoke barrier (above a set of doors to a corridor in the ED Unit near Quiet Room 9 and OB/GYN Room 9).

As per concurrent interviews with the facility's Director of Plant Engineering, he will have all of these penetrations completely sealed with approved firestopping materials immediately. The above-mentioned examples were appropriately sealed during the survey but the facility shall conduct an inspection of all of the smoke barrier walls (including both sides of each wall) to ensure that all penetrations have been appropriately sealed.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.7.3, 8.3
.

.
Based on observations and staff interview during the Federal Recertification Survey, the facility failed to ensure that all door openings from hazardous areas were protected by self-closing, positive latching doors.

Findings:

On 01/07/14 at 9:51AM, the door to a Lower Level Chronic Dialysis Reuse Room that had been converted into a Storage Room was found to lack a self-closing device.

On 01/07/14 at 11:07AM, the door to a Lower Level Housekeeping Clean Linen Storage Room was found to lack a self-closing device and had a broken hinge.

On 01/07/14 at 11:30AM, the door to a Lower Level Office that had been converted into Storage Room (vicinity of the Sleep Studies Laboratory) was found to lack a self-closing device.

As per concurrent interviews with the facility's Director of Plant Engineering, he would have approved self-closing or automatic closing devices installed on all of the above-mentioned doors.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.2.1
.

.
Based observations and staff interview during the Federal Recertification Survey, the facility failed to ensure that all means of egress be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Findings:

On 01/07/14 at 11:40AM, a metal filing cabinet was found to be stored in an exit access aisle in the Lower Level Medical Records Office Suite. This filing cabinet partially obstructed access to the nearest exit because it reduced the clear width of the exit to approximately 24-inches. As per concurrent interview with the facility's Director of Plant Engineering, he will have the filing cabinet relocated as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.2.1, 19.2.3.3,7.1.10.1
.

.
Based on observation and staff interview during the Federal Recertification Survey, the facility failed to ensure that exit signs were lit and functional. This was noted on two (2) of four (4) floors.

Findings:

On 01/06/14 & 01/07/14 between 8:15AM - 2:00PM during the survey, exit signs were observed not lit and non-functional. Examples are:

1) One (1) exit sign in the vicinity of Mechanical Room 7 on 2N.

2) One (1) exit sign in the vicinity of the Emergency Exit Door within "The Cave" on the Lower Level.

In an interview on 01/07/14 at approximately 12:10PM, the Director of Plant Engineering stated that the exit signs will be fixed immediately.

42 CFR 482.41(b), 2000 NFPA 101: 7.10.1.4, 7.10.2, 7.10.5.1
.

.
Based on observation and staff interview during the Federal Recertification Survey, the facility was not protected throughout by an approved, supervised sprinkler system in that all required areas within the facility were not provided with automatic sprinkler coverage. This was noted in the 1st Floor Office Area within the Histology Laboratory.

Findings:

On 01/06/14 at approximately 2:30PM during the survey, the 1st Floor Office Area within the Histology Lab was observed not provided with sprinkler coverage.

In an interview on 01/06/14 at approximately 2:38PM, the Director of Plant Engineering stated that the office will be sprinklered as part of the Ambulatory Surgery Unit sprinkler project.

42 CFR 482.41(b)
.

.
Based on observation and staff interview during the Federal Recertification Survey, it was determined that the facility failed to maintain the automatic sprinkler system as required by NFPA 25, inspection, testing and maintenance of water-based fire protection systems.

Findings:

On 01/07/14 between 8:15AM - 11:30AM during the survey, the following was noted in the Lower Level of the Main Hospital. Examples are:

1) Approximately five (5) upright sprinkler heads were noted installed within 1-inch of the ceiling in the Main Computer Server Room.

2) An upright sprinkler head was installed instead of a pendant type sprinkler head in the Medical Records Room.

3) Pipes and bundles of wires were noted wire-tied to the sprinkler pipe in the Information Technology (IT) Closet adjacent to Elevator #3

In an interview on 01/09/14 at approximately 8:16AM, the Plant Operations Foreman stated that all of the sprinkler heads were changed and lowered.

42 CFR 482.41(b), NFPA 13, NFPA 25
.

.
Based on observation and staff interview during the Federal Recertification Survey, the facility failed to ensure that ashtrays of a safe design with center rests were provided in the outdoor smoking area on 1N.

Findings:

On 01/06/14 at approximately 1:12PM during the survey, ashtrays of a safe design with center rests were not provided in the outdoor smoking area on 1N. Three (3) ashtrays were provided, one (1) with a clam-shell design and the two (2) others were missing the clam-shell. These ashtrays were not configured to allow a resident to put down their cigarette securely as they were not provided with the center rests.

In an interview on 01/06/14 at approximately 1:12PM, the Director of Plant Engineering stated that he would order the ashtrays with a center rest immediately.

42 CFR 482.41(b)
.

.
Based on observation, staff interview, and record review during the Federal Recertification Survey, the facility failed to conduct the required monthly inspections of the range hood fire extinguishing system in the Kitchen and Cafe Rio.

Findings:

On 01/09/14 at approximately 8:45AM during the survey, the last documented range hood fire extinguishing system inspection was completed in August 2013 as noted by tags on the pull station and canisters in the Kitchen and Cafe Rio. There were no documented monthly range hood fire extinguishing system inspections noted since the service date.

In an interview on 01/09/14 at approximately 9:09AM, the Plant Operations Foreman stated that a monthly visual inspection is done during the monthly fire extinguisher inspection but not documented. He further stated that he will add the monthly range hood fire extinguishing system inspection to the Monthly Fire Extinguisher Log.

42 CFR 482.41(b), 2000 NFPA 101: 19.3.2.6, 9.2.3
1998 NFPA 96: 7.2.2.1
1998 NFPA 17A: 5.2.1
.

.
Based on observation and staff interview during the Federal Recertification Survey, the facility failed to ensure that the oxygen tanks (E tanks) were stored in accordance with the requirements of NFPA 99 as evidenced by nineteen (19) E tanks being stored outside of a dedicated Oxygen Storage Room within a single smoke compartment. This was noted in the Emergency Department (ED).

Findings:

On 01/07/14 at approximately 8:35AM during the survey, nineteen (19) E tanks were noted being stored outside of a dedicated Oxygen Storage Room within a single smoke compartment.

In an interview on 01/07/14 at approximately 8:35AM, the Director of Plant Engineering stated that there was no dedicated Oxygen Storage Room in the ED and he further stated that he will have the excess oxygen moved immediately.

42 CFR 482.41(b), 1999 NFPA 99: 8-3.1.11.2
.

.
1) Based on observation and staff interview during the Federal Recertification Survey, an exit sign in the vicinity of the West Exit Stair on the Lower Level of the Medical Office Building (M.O.B.) was not lit and non-functional.

Findings:

On 01/07/14 at approximately 12:10PM during the survey, an exit sign in the vicinity of the West Exit Stair on the Lower Level of the M.O.B. was observed not lit and non-functional.

In an interview on 01/07/14 at approximately 12:10PM, the Director of Plant Engineering stated that the exit sign would be fixed immediately.

42 CFR 482.41(b), 2000 NFPA 101: 7.10.1.4, 7.10.2, 7.10.5.1
10NYCRR, 405.24 (b), 711.2(a)(1)

2) Based on observation and staff interview during the Federal Recertification Survey, the top and bottom of the elevator shaft in the M.O.B was not provided with sprinkler coverage.

Findings:

On 01/09/14 at approximately 11:00AM during the survey, the top and bottom of the elevator shaft that serves two (2) elevators in the M.O.B was not provided with sprinkler coverage.

In an interview on 01/09/14 at approximately 11:05AM, the Director of Plant Engineering stated that the sprinkler heads would be added immediately.

42 CFR 482.41(b), 1999 NFPA 13: 5-13.6.1, 5-13.6.3

3) Based on observation and staff interview during the Federal Recertification Survey, it was determined that the facility failed to maintain the automatic sprinkler system as required by NFPA 25, inspection, testing and maintenance of water-based fire protection systems in that pendant type sprinkler heads were noted installed instead of upright sprinkler heads in the vicinity of Endoscopy in the Lower Level of the M.O.B.

Findings:

On 01/07/14 between 11:30AM - 2:00PM during the survey, the following was noted in the vicinity of Endoscopy in the Lower Level of the M.O.B:

a) Approximately six (6) pendant type sprinkler heads were installed instead of upright sprinkler heads in Mechanical Room 13.

b) Approximately two (2) pendant type sprinkler heads were installed instead of upright sprinkler heads in the Generator Room.

In an interview on 01/07/14 at approximately 11:55AM, the Director of Plant Engineering stated that he will have the sprinkler heads replaced immediately.

42 CFR 482.41(b), NFPA 25

4) Based on observations and staff interview during the Federal Recertification Survey, the facility failed to ensure that vertical penetrations between floors were sealed.

Findings:

On 01/07/14 at 12:01PM, six (6) vertical conduit penetrations of a floor/ceiling assembly in the Medical Office Building were found to have been sealed with a non-fire resistance rated material (e.g., joint compound).

As per concurrent interview with the facility's Director of Plant Engineering, these penetrations will be sealed with an approved firestopping material as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.1, 8.2.5

5) Based on observations and staff interview during the Federal Recertification Survey, the facility failed to ensure that smoke barrier walls were constructed to have at least a 1/2-hour fire resistance rating.

Findings:

On 01/07/14 at 11:45AM, a conduit penetration of a Lower Level smoke barrier wall in the Medical Office Building (vicinity of the Endoscopy Unit Waiting Room) was found to have been only partially sealed with firestopping.

As per concurrent interviews with the facility's Director of Plant Engineering, he will have this penetration completely sealed with approved firestopping materials immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.7.3, 8.3

6) Based on observations and staff interviews during the Federal Recertification Survey, the facility failed to ensure that the integrity of 2-hour fire resistance rated fire barrier walls that serve as part of exit passageways were maintained.

Findings:

a) On 01/07/14 at 9:00AM, wooden surfaces of a 90-minute rated cross-corridor fire door (vicinity of the entrance to the 1st Floor Radiology Area) were noted to be delaminated (i.e., in disrepair).

b) On 01/07/14 at 9:04AM, three (3) partially sealed pneumatic tube penetrations were found in a 2-hour fire resistance rated fire barrier wall (vicinity of 1st Floor Consultation Room).

As per concurrent interview with the facility's Director of Plant Engineering, he will have these penetrations sealed with approved firestopping materials immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.7.6, 7.2.6, 7.1.3.2, 8.2.3, 4.6.12
.

.
Based on observations and staff interview during the Federal Recertification Survey, the facility failed to ensure that the electrical wiring was installed in a neat and workman like manner or maintained in good repair. Specific reference is made to the following requirement: Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment.

Findings:

On 01/07/14 at 10:15AM, an unprotected opening due to a missing cover plate was found in an electrical junction box located above the suspended ceiling in the Lower Level Environmental Services Storage Room.

As per concurrent interview with the facility's Director of Plant Engineering, he will ensure that an approved cover plate is installed over this unprotected opening into the electrical box immediately.

On 01/07/14 at 10:21AM, an unprotected opening due to a missing cover plate was found in an electrical junction box that was mounted on a wall in the Lower Level "Cave" Medical Records Storage Room. In addition, an extension cord in this location was found to be improperly used to power a fan located in the adjacent Mail Room Area.

As per concurrent interview with the facility's Director of Plant Engineering, he will ensure that an approved cover plate is installed over this unprotected opening into the electrical box immediately. He also removed the extension cord from use.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 110-12 (a), Article 305
.

.
Based on observation and staff interview during the Federal Recertification Survey, Alcohol Based Hand Rub (ABHR) dispensers were observed installed: 1) over carpeting in a building that is not fully sprinklered, and 2) in a corridor over an electrical outlet.

Findings:

On 01/06/14 between 11:30AM - 2:00PM during the survey, the following was noted:

1) Two (2) ABHR dispensers were noted installed over carpeted areas in the 1st Floor Administration Office. Sprinkler coverage was not provided in the 1st Floor Administration Office.

2) One (1) ABHR dispenser was noted installed directly over an electrical outlet in a 2N corridor in the vicinity of Patient Room 230.

In an interview on 01/06/14 at approximately 11:50AM, the Director of Plant Engineering stated that he would remove the ABHR dispensers.

42 CFR 482.41(b)
10NYCRR, 405.24 (b), 711.2(a)(1)

.
Based on observations and staff interview during the Federal Recertification Survey, the facility failed to ensure that all interior wall finishes in exit access corridors in existing health care occupancies are a Class A or Class B Interior Wall and Ceiling Finish that were tested in accordance with NFPA 255, Standard Method of Test of Surface Burning Characteristics of Building Materials.

Findings:

On the morning and afternoon of 01/06/14, a plastic wall covering that was screwed into the lower portion of the exit access corridor walls was noted in the numerous areas of the hospital (e.g., 3rd Floor 3 South Unit, 2nd Floor 2 North and 2 South Units). These plastic panels were approximately 42-inches high and ran the entire length of the corridors they were used in.

On 01/06/14 at 10:54AM, interview with the Director of Plant Engineering revealed that the product was "Lexan" and that this product had a Class "C" rating. He stated that the hospital was already aware that this material was not permitted and had already started removing these panels from walls and rooms throughout the facility.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.3.2
.

.
Based on observations and interviews during the Federal Recertification Survey, the facility failed to ensure that corridor walls in non-sprinkler protected smoke compartments were continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and that they had a fire resistance rating of not less than ?-hour.

Findings:

On 01/10/14 at 11:22AM, a couple of unsealed cable penetrations were found in a 3rd Floor corridor wall (vicinity of Room 320).

On 01/10/14 at 11:25AM, an unsealed cable penetration was found in a 3rd Floor corridor wall (vicinity of the Staff Office near Room 328).

As per concurrent interviews with the facility's Director of Engineering, these penetrations would be sealed immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.6.2.1
.

.
Based on observations and staff interview during the Federal Recertification Survey, the facility failed to ensure that all door openings from hazardous areas were provided with approved hold-open devices that automatically closed all such doors in accordance with NFPA 101-2000 Life Safety Code Section 7.2.1.8.2.

Findings:

On 01/07/14 at 10:22AM, a portable fire extinguisher was found to have been improperly used as a door hold-open device on the door to the Lower Level "Cave" Medical Record Storage Room.

As per concurrent interviews with the facility's Corporate Life Safety Director and Director of Plant Engineering, the portable fire extinguisher should not have been used to hold this fire door open.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.2.1, 8.4.1.3, 7.2.1.8.2
.

.
Based on observations and interviews during the Federal Recertification Survey, the facility failed to ensure that smoke barrier walls were constructed to have at least a ?-hour fire resistance rating.

Findings:

On 01/06/14 at 11:24AM, a plumbing penetration and a duct penetration in a 3rd Floor smoke barrier (vicinity of the staff office near Room 328) were found to have been improperly sealed with a non-fire resistance rated material (e.g., joint compound).

On 01/06/14 at 8:33AM, an unsealed cable penetration and a few cable penetrations that were improperly sealed with a non-fire resistance rated material (e.g., joint compound were found in a 1st Floor smoke barrier (in the 1 North Unit near the "Large T Room").

On 01/07/14 at 8:31AM, an unsealed conduit was found to have been incorporated in the construction of a 1st Floor smoke barrier (above a set of cross-aisle doors in the Emergency Department (ED) Unit near Cardiac Trauma Rooms 16 & 17).

On 01/07/14 at 8:34AM, an approximately 3-inch by 3-inch hole was found in a 1st Floor smoke barrier (near the ED Unit Triage Area).

On 01/07/14 at 8:37AM, the top-of-wall assembly, two (2) cable penetrations, and several steel joist penetrations that were improperly sealed with a non-fire resistance rated material (e.g., joint compound found in a 1st Floor smoke barrier (near the ED Unit General Procedure Room 15).

On 01/06/14 at 8:46AM, an unsealed cable penetration, an unsealed conduit penetration, and an unsealed plumbing penetration were found in a 1st Floor smoke barrier (above a set of doors to a corridor in the ED Unit near Quiet Room 9 and OB/GYN Room 9).

As per concurrent interviews with the facility's Director of Plant Engineering, he will have all of these penetrations completely sealed with approved firestopping materials immediately. The above-mentioned examples were appropriately sealed during the survey but the facility shall conduct an inspection of all of the smoke barrier walls (including both sides of each wall) to ensure that all penetrations have been appropriately sealed.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.7.3, 8.3
.

.
Based on observations and staff interview during the Federal Recertification Survey, the facility failed to ensure that all door openings from hazardous areas were protected by self-closing, positive latching doors.

Findings:

On 01/07/14 at 9:51AM, the door to a Lower Level Chronic Dialysis Reuse Room that had been converted into a Storage Room was found to lack a self-closing device.

On 01/07/14 at 11:07AM, the door to a Lower Level Housekeeping Clean Linen Storage Room was found to lack a self-closing device and had a broken hinge.

On 01/07/14 at 11:30AM, the door to a Lower Level Office that had been converted into Storage Room (vicinity of the Sleep Studies Laboratory) was found to lack a self-closing device.

As per concurrent interviews with the facility's Director of Plant Engineering, he would have approved self-closing or automatic closing devices installed on all of the above-mentioned doors.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.2.1
.

.
Based observations and staff interview during the Federal Recertification Survey, the facility failed to ensure that all means of egress be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Findings:

On 01/07/14 at 11:40AM, a metal filing cabinet was found to be stored in an exit access aisle in the Lower Level Medical Records Office Suite. This filing cabinet partially obstructed access to the nearest exit because it reduced the clear width of the exit to approximately 24-inches. As per concurrent interview with the facility's Director of Plant Engineering, he will have the filing cabinet relocated as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.2.1, 19.2.3.3,7.1.10.1
.

.
Based on observation and staff interview during the Federal Recertification Survey, the facility failed to ensure that exit signs were lit and functional. This was noted on two (2) of four (4) floors.

Findings:

On 01/06/14 & 01/07/14 between 8:15AM - 2:00PM during the survey, exit signs were observed not lit and non-functional. Examples are:

1) One (1) exit sign in the vicinity of Mechanical Room 7 on 2N.

2) One (1) exit sign in the vicinity of the Emergency Exit Door within "The Cave" on the Lower Level.

In an interview on 01/07/14 at approximately 12:10PM, the Director of Plant Engineering stated that the exit signs will be fixed immediately.

42 CFR 482.41(b), 2000 NFPA 101: 7.10.1.4, 7.10.2, 7.10.5.1
.

.
Based on observation and staff interview during the Federal Recertification Survey, the facility was not protected throughout by an approved, supervised sprinkler system in that all required areas within the facility were not provided with automatic sprinkler coverage. This was noted in the 1st Floor Office Area within the Histology Laboratory.

Findings:

On 01/06/14 at approximately 2:30PM during the survey, the 1st Floor Office Area within the Histology Lab was observed not provided with sprinkler coverage.

In an interview on 01/06/14 at approximately 2:38PM, the Director of Plant Engineering stated that the office will be sprinklered as part of the Ambulatory Surgery Unit sprinkler project.

42 CFR 482.41(b)
.

.
Based on observation and staff interview during the Federal Recertification Survey, it was determined that the facility failed to maintain the automatic sprinkler system as required by NFPA 25, inspection, testing and maintenance of water-based fire protection systems.

Findings:

On 01/07/14 between 8:15AM - 11:30AM during the survey, the following was noted in the Lower Level of the Main Hospital. Examples are:

1) Approximately five (5) upright sprinkler heads were noted installed within 1-inch of the ceiling in the Main Computer Server Room.

2) An upright sprinkler head was installed instead of a pendant type sprinkler head in the Medical Records Room.

3) Pipes and bundles of wires were noted wire-tied to the sprinkler pipe in the Information Technology (IT) Closet adjacent to Elevator #3

In an interview on 01/09/14 at approximately 8:16AM, the Plant Operations Foreman stated that all of the sprinkler heads were changed and lowered.

42 CFR 482.41(b), NFPA 13, NFPA 25
.

.
Based on observation and staff interview during the Federal Recertification Survey, the facility failed to ensure that ashtrays of a safe design with center rests were provided in the outdoor smoking area on 1N.

Findings:

On 01/06/14 at approximately 1:12PM during the survey, ashtrays of a safe design with center rests were not provided in the outdoor smoking area on 1N. Three (3) ashtrays were provided, one (1) with a clam-shell design and the two (2) others were missing the clam-shell. These ashtrays were not configured to allow a resident to put down their cigarette securely as they were not provided with the center rests.

In an interview on 01/06/14 at approximately 1:12PM, the Director of Plant Engineering stated that he would order the ashtrays with a center rest immediately.

42 CFR 482.41(b)
.

.
Based on observation, staff interview, and record review during the Federal Recertification Survey, the facility failed to conduct the required monthly inspections of the range hood fire extinguishing system in the Kitchen and Cafe Rio.

Findings:

On 01/09/14 at approximately 8:45AM during the survey, the last documented range hood fire extinguishing system inspection was completed in August 2013 as noted by tags on the pull station and canisters in the Kitchen and Cafe Rio. There were no documented monthly range hood fire extinguishing system inspections noted since the service date.

In an interview on 01/09/14 at approximately 9:09AM, the Plant Operations Foreman stated that a monthly visual inspection is done during the monthly fire extinguisher inspection but not documented. He further stated that he will add the monthly range hood fire extinguishing system inspection to the Monthly Fire Extinguisher Log.

42 CFR 482.41(b), 2000 NFPA 101: 19.3.2.6, 9.2.3
1998 NFPA 96: 7.2.2.1
1998 NFPA 17A: 5.2.1
.

.
Based on observation and staff interview during the Federal Recertification Survey, the facility failed to ensure that the oxygen tanks (E tanks) were stored in accordance with the requirements of NFPA 99 as evidenced by nineteen (19) E tanks being stored outside of a dedicated Oxygen Storage Room within a single smoke compartment. This was noted in the Emergency Department (ED).

Findings:

On 01/07/14 at approximately 8:35AM during the survey, nineteen (19) E tanks were noted being stored outside of a dedicated Oxygen Storage Room within a single smoke compartment.

In an interview on 01/07/14 at approximately 8:35AM, the Director of Plant Engineering stated that there was no dedicated Oxygen Storage Room in the ED and he further stated that he will have the excess oxygen moved immediately.

42 CFR 482.41(b), 1999 NFPA 99: 8-3.1.11.2
.

.
1) Based on observation and staff interview during the Federal Recertification Survey, an exit sign in the vicinity of the West Exit Stair on the Lower Level of the Medical Office Building (M.O.B.) was not lit and non-functional.

Findings:

On 01/07/14 at approximately 12:10PM during the survey, an exit sign in the vicinity of the West Exit Stair on the Lower Level of the M.O.B. was observed not lit and non-functional.

In an interview on 01/07/14 at approximately 12:10PM, the Director of Plant Engineering stated that the exit sign would be fixed immediately.

42 CFR 482.41(b), 2000 NFPA 101: 7.10.1.4, 7.10.2, 7.10.5.1
10NYCRR, 405.24 (b), 711.2(a)(1)

2) Based on observation and staff interview during the Federal Recertification Survey, the top and bottom of the elevator shaft in the M.O.B was not provided with sprinkler coverage.

Findings:

On 01/09/14 at approximately 11:00AM during the survey, the top and bottom of the elevator shaft that serves two (2) elevators in the M.O.B was not provided with sprinkler coverage.

In an interview on 01/09/14 at approximately 11:05AM, the Director of Plant Engineering stated that the sprinkler heads would be added immediately.

42 CFR 482.41(b), 1999 NFPA 13: 5-13.6.1, 5-13.6.3

3) Based on observation and staff interview during the Federal Recertification Survey, it was determined that the facility failed to maintain the automatic sprinkler system as required by NFPA 25, inspection, testing and maintenance of water-based fire protection systems in that pendant type sprinkler heads were noted installed instead of upright sprinkler heads in the vicinity of Endoscopy in the Lower Level of the M.O.B.

Findings:

On 01/07/14 between 11:30AM - 2:00PM during the survey, the following was noted in the vicinity of Endoscopy in the Lower Level of the M.O.B:

a) Approximately six (6) pendant type sprinkler heads were installed instead of upright sprinkler heads in Mechanical Room 13.

b) Approximately two (2) pendant type sprinkler heads were installed instead of upright sprinkler heads in the Generator Room.

In an interview on 01/07/14 at approximately 11:55AM, the Director of Plant Engineering stated that he will have the sprinkler heads replaced immediately.

42 CFR 482.41(b), NFPA 25

4) Based on observations and staff interview during the Federal Recertification Survey, the facility failed to ensure that vertical penetrations between floors were sealed.

Findings:

On 01/07/14 at 12:01PM, six (6) vertical conduit penetrations of a floor/ceiling assembly in the Medical Office Building were found to have been sealed with a non-fire resistance rated material (e.g., joint compound).

As per concurrent interview with the facility's Director of Plant Engineering, these penetrations will be sealed with an approved firestopping material as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.1, 8.2.5

5) Based on observations and staff interview during the Federal Recertification Survey, the facility failed to ensure that smoke barrier walls were constructed to have at least a 1/2-hour fire resistance rating.

Findings:

On 01/07/14 at 11:45AM, a conduit penetration of a Lower Level smoke barrier wall in the Medical Office Building (vicinity of the Endoscopy Unit Waiting Room) was found to have been only partially sealed with firestopping.

As per concurrent interviews with the facility's Director of Plant Engineering, he will have this penetration completely sealed with approved firestopping materials immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.7.3, 8.3

6) Based on observations and staff interviews during the Federal Recertification Survey, the facility failed to ensure that the integrity of 2-hour fire resistance rated fire barrier walls that serve as part of exit passageways were maintained.

Findings:

a) On 01/07/14 at 9:00AM, wooden surfaces of a 90-minute rated cross-corridor fire door (vicinity of the entrance to the 1st Floor Radiology Area) were noted to be delaminated (i.e., in disrepair).

b) On 01/07/14 at 9:04AM, three (3) partially sealed pneumatic tube penetrations were found in a 2-hour fire resistance rated fire barrier wall (vicinity of 1st Floor Consultation Room).

As per concurrent interview with the facility's Director of Plant Engineering, he will have these penetrations sealed with approved firestopping materials immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.7.6, 7.2.6, 7.1.3.2, 8.2.3, 4.6.12
.

.
Based on observations and staff interview during the Federal Recertification Survey, the facility failed to ensure that the electrical wiring was installed in a neat and workman like manner or maintained in good repair. Specific reference is made to the following requirement: Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment.

Findings:

On 01/07/14 at 10:15AM, an unprotected opening due to a missing cover plate was found in an electrical junction box located above the suspended ceiling in the Lower Level Environmental Services Storage Room.

As per concurrent interview with the facility's Director of Plant Engineering, he will ensure that an approved cover plate is installed over this unprotected opening into the electrical box immediately.

On 01/07/14 at 10:21AM, an unprotected opening due to a missing cover plate was found in an electrical junction box that was mounted on a wall in the Lower Level "Cave" Medical Records Storage Room. In addition, an extension cord in this location was found to be improperly used to power a fan located in the adjacent Mail Room Area.

As per concurrent interview with the facility's Director of Plant Engineering, he will ensure that an approved cover plate is installed over this unprotected opening into the electrical box immediately. He also removed the extension cord from use.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 110-12 (a), Article 305
.