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Based on observation and staff interview, the facility failed to maintain the integrity of the building construction, providing a 1 hour separation, by failing to ensure that penetrations in walls and ceilings are sealed with fire rated material. This deficient practice could result in the spread of fire and/or smoke to other areas of the facility, and affected 5 of 23 smoke compartments. A smoke compartment is a space within the building enclosed by smoke barriers on all sides, including the top and the bottom, for the purpose of containing smoke or fire, in the event of a fire.

Findings:

During a tour of the facility, the following penetrations were observed at the following times and locations:
a)On 10/04/10 at 10:57 a.m., there was a junction box cover missing on the west wall, above electrical panel EILH6/00283, in the roof fan room.
b)On 10/04/10 at 10:59 a.m., there was a ceiling tile missing, in the maintenance office, on the roof.
c)On 10/04/10 at 11:34 a.m., there was an approximately 1 inch unsealed penetration in the north wall, next to the thermostat control box, in Room H569.
d)On 10/04/10 at 11:47 a.m., there was an approximately 1/2 inch penetration in the east wall in Room A526.
e)On 10/04/10 at 11:50 a.m., there were sixteen approximately 2 inch unsealed conduit pipes in Room A-525.
f)On 10/04/10 at 1:40 p.m., there was an approximately 3 inch unsealed conduit pipe penetration in Room A-118.
g)On 10/06/10 at 2:20 p.m., there was an approximately 6 inch unsealed conduit pipe in the north wall, in the fan control room, B level.
h)On 10/06/10 at 3:40 p.m., there was an approximately 10 inch unsealed penetration in the corridor wall located by Room C-C04.

Facility Staff V1 acknowledged the findings at the time of the survey.

Based on observation and interview, the facility failed to maintain corridor doors free from obstructions to closing and latching. This was evidenced by corridor doors that failed to close and latch, by corridor doors that were obstructed, and by doors that failed to resist the passage of smoke. This could result in the spread of smoke or fire in the event of a fire, and affected 9 of 23 smoke compartments. A smoke compartment is a space within the building enclosed by smoke barriers on all sides, including the top and the bottom, for the purpose of containing smoke or fire, in the event of a fire.

Findings:During a tour of the facility, on 10/04/10, the following deficiencies were observed at the following times and locations:
a) At 10:45 a.m., the double corridor door to the roof welding room failed to latch.b) At 11:09 a.m., the corridor door to Room H-525, was obstructed by a bed. The door could not be closed.
c) At 11:15 a.m., the corridor door to Room H-525 failed to latch.
d) At 11:18 a.m., the corridor door to Room H-527 was obstructed by a gurney. The door could not be closed.
e) At 11:23 a.m., the corridor door to Room H-538 required more than 5 lbs. to open and close.
f) At 11:24 a.m., the door to Room 443 was obstructed by a bed.
g) At 11:27 a.m., the door to Room H-459 failed to positive latch. The door was equipped with a self-closing device.
h) At 11:32 a.m., the double corridor doors at nursing station B, 5th floor, failed to close and latch.
i) At 11:45 a.m., the emergency exit door located by Room A-531 failed to latch. The latching mechanism was observed stuffed with paper.
j) At 12:00 p.m., the door in Room 330 was obstructed by a chair.
k) At 1:23 p.m., corridor door H-114A was obstructed by a built-in cabinet and shelving.
l) At 1:24 p.m., the door in Room H-263 failed to positive latch. The door was equipped with a self-closing device.
m) At 1:30 p.m., the door to the activities storage room, 1st floor, Room H-116B, could not be opened to full capacity due to storage behind the door.
n) At 1:38 p.m., corridor door H-122 was observed held open by a kickstand door hold.
o) At 1:45 p.m., the pass through door located in Room A-120 leading into room A-121 was obstructed by a bookshelf.
p) At 2:30 p.m., 4 unsealed dime sized penetrations were observed in the door, and 3 unsealed dime sized penetrations were observed in the door frame, of the dietary men's locker room door. A self-closing device had been removed from the door.

Facility Staff V1 acknowledged the findings at the time of the survey.

Based on observation and interview, the facility failed to provide hold open devices for cross-corridor doors, and failed to maintain the doors that automatically close upon activation of the fire alarm system. This was evidenced by doors that were not equipped with magnetic hold open devices that were connected to the fire alarm system, and by doors that failed to automatically close upon activation of the fire alarm sytem. This could result in the failure to contain a fire in a smoke compartment, and affected 3 of 23 smoke compartments. A smoke compartment is a space within the building enclosed by smoke barriers on all sides, including the top and the bottom, for the purpose of containing smoke or fire, in the event of a fire.



Findings:

During at tour of the facility, the following deficiencies were observed at the following times and locations:
a)On 10/04/10 at 11:10 a.m., the cross-corridor separation doors, located by room H-524, were held open by kickstand hold open devices.
b) On 10/04/10 at 11:32 a.m., the cross corridor doors, on the 3rd floor by Room H328, were held open by kickstand hold open devices.
c) On 10/04/1, at 11:35 a.m., the cross corridor doors, on the 3rd floor by Room H322, were held open by kickstand hold open devices.
d) On 10/06/10 at 1:17 p.m., the fire doors to the welding room on the roof were held open by magnetic devices. When the fire alarm was activated, the right leaf door failed to positive latch.
e) On 10/06/10 at 1:27 p.m., the fire doors in nurse station 5D, on the 5th floor, were held open by magnetic devices. When the fire alarm was activated, the right leaf door was obstructed from closing by a cart.

Facility Staff V1 acknowledged the findings at the time of the survey.

Based on observation, record review, and staff interviews, the facility failed to maintain the smoke barrier walls with a one hour fire resistance rating in accordance with Section 8.3. This was evidenced by unsealed penetrations in the smoke barrier walls. This could result in the spread of smoke or fire from one smoke compartment to another in the event of a fire, and affected 3 of 23 smoke compartments. A smoke compartment is a space within the building enclosed by smoke barriers on all sides, including the top and the bottom, for the purpose of containing smoke or fire, in the event of a fire.

Findings:
During a tour of the facility on 10/04/10, the fire smoke barrier walls were observed at the following times and locations:
a) At 1:00 p.m., the 1st floor Center for Health fire smoke barrier wall was observed. The smoke compartment wall, running the length of the admitting offices, was observed. There were three approximately 2 foot wide by 2 foot long square penetrations observed in the wall, approximately 6 feet apart. Cables, wires and flexible conduit pipes were observed passing through the three penetrations. At 10:55 a.m., building plans for the 1st floor Center for Health smoke barrier walls and compartments were requested. At 1:20 p.m., the building plans dated "1967", were reviewed. The building plans showed the corridor as a smoke compartment, and the corridor walls extend fully to the ceiling. At 1:05 p.m., an interview was conducted with staff member V1. Staff member V1 stated the three approximately 2 foot wide by 2 foot long square penetrations were used as a plenum to circulate air in that smoke compartment. A plenum is a compartment or chamber to which one or more air ducts are connected and that forms part of the air distribution system.

On 10/05/10 at 4:06 p.m., an interview was conducted with staff member V1. The staff member confirmed that the Center for Health is part of the hospital's license.

b)At 1:10 p.m., an approximately 3/4 inch unsealed conduit pipe was observed in the smoke barrier wall located by Room H-114.
c) At 1:40 p.m., two approximately 1/2 inch unsealed conduit pipes were observed in the smoke barrier wall, in the First floor ancillary building, by Room H-123.

Staff member V1 acknowleged the penetrations in the smoke barrier walls.

Based on observation, the facility failed to maintain the cross-corridor doors. This was evidenced by cross corridor doors that failed to close and latch. This could result in the spread of smoke or fire from one compartment to another in the event of a fire, and affected all patients and staff in 6 of 23 smoke compartments. A smoke compartment is a space within the building enclosed by smoke barriers on all sides, including the top and the bottom, for the purpose of containing smoke or fire, in the event of a fire.



Findings:

During a tour of the facility, the following cross-corridor fire doors were observed deficient at the following times and locations:
a) On 10/04/10, at 11:04 a.m., the cross-corridor fire doors located by Room C-120, 1st floor, failed to latch.
b) On 10/04/10, at 1:07 p.m., the cross-corridor fire doors located by Room H-114, 1st floor, failed to latch.
c) On 10/04/10, at 1:40 p.m., the cross-corridor fire doors located by Room H-123, 1st floor of the ancillary building, failed to latch.

Based on observation and interview, the facility failed to maintain the exit access readily accessible at all times. This was evidenced by two emergency exit doors that were obstructed by the storage of items. This affected 2 of 23 smoke compartments, and could result in a delay of egress in the event of an emergency evacuation. A smoke compartment is a space within the building enclosed by smoke barriers on all sides, including the top and the bottom, for the purpose of containing smoke or fire, in the event of a fire.



Findings:

During a tour of the facility with staff on 10/4/10, the emergency exit doors were observed.

1. At 11:53 a.m., the exit door in the outpatient surgery, on the 3rd floor in the north hallway by Room A-321, was obstructed by six pieces of medical equipment.
2. At 2 p.m., the exit door that was across from C-C18, in the C level, was obstructed by six 64 gallon bins.

Facility Staff V1 acknowledged the findings at the time of the survey.

Based on observation, the facility failed to maintain, test and inspect battery powered emergency lighting located in Operating rooms 1, 2, 3 and the OR cysto room, in accordance with 7.9.2.4 and 7.9.3. This was evidenced by the
failure to provide documentation of the monthly inspections, and the annual test, of the battery operated emergency lights in the Operating Rooms and the OR cysto room. This could result in a loss of lighting in the event of a loss of power in the facility.

7.9.2.4 Battery-operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition. Batteries used in such lights or units shall be approved for their intended use and shall comply with NFPA 70, National Electrical Code®.
7.9.3 Periodic Testing of Emergency Lighting Equipment. 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
11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During a tour of the facility on 10/04/10, emergency battery powered light fixtures were observed in Operating Rooms 1, 2, 3 and in the cysto room.

On 10/06/10 during record review at 11:30 a.m., documentation was requested for the monthly inspection and the annual test of the battery operated emergency lights. The facility failed to provide documentation for the monthly 30 second test, and the 1 1/2 hour annual test of the battery operated emergency lighting. At 11:35 a.m. in an interview with staff member V2, staff member V2 stated they do not conduct a test on the battery operated lighting located in the operating rooms.

Based on record review and staff interview, the facility failed to conduct semi-annual disaster drills. This was evidenced by the failure to conduct disaster drills twice a year at 6 month intervals, that included all staff, providing training to ensure staff have knowledge of what to do if a disaster should occur. This could result in staff not being familiar with emergency procedures in the event of a fire or other emergency, and affected all patients and staff.

NFPA 99, 1999 edition
11-5.3.9 Drills
Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both.

Findings:

During record review with staff on 10/5/10, the disaster drills records were reviewed.

At 2:30 p.m., the facility failed to conduct simulated disaster drills that included all staff members on duty. The facility conducted two disaster drills in a 12 month period, 8 months apart. Disaster drills were conducted on 9/28/09, and on 5/6/10.

During an interview with staff at 2:45 p.m., staff member U3 stated that they were responsible for conducting the facility's disaster drills. They stated that they have been in this current position for approximately 3 weeks.

Based on observation, staff interview and record review, the facility failed to conduct and/or document simulated fire drills, one per shift per quarter, and ensure staff was familiar with the facility's fire and disaster policy and procedures. This was evidenced by incomplete documentation for 12 of 12 fire drills provided, and by 2 of 5 staff that when interviewed were not familiar with the facility's fire/disaster procedures. This could result in staff not being familiar with emergency fire procedures, and affected all patients and staff.

Findings:

During a tour of the facility and record review on 10/04/10 through 10/06/10, the following deficiencies were observed:

a) On 10/05/10 at 2:00 p.m., the documentation provided for fire drills did not include a sign in sheet for all departments/staff members on duty when the fire drill was conducted. The facility documented drills on four different type of forms. Each of the drills was missing a sign in sheet, department list, and shifts on duty during the fire drills conducted. Sign in sheets, fire drill forms, and information requested on the fire drills forms was incomplete and/or missing for the first, second and third quarters of 2010, and the 4th quarter of 2009, for all shifts and departments.

During an interview with staff at 2:45 p.m., staff member U3 stated was aware that the forms were incomplete.

b) On 10/04/10, at 2:32 p.m., dietary staff member V2 was interviewed and was asked to explain the facility's fire and disaster procedures. Staff member V4 did not know the fire procedures. Staff member V4 was asked what they would do if a fire occurred on the dietary stove, and staff member V4 did not know how to activate the ANSEL suppression system, and was not able to locate a manual fire alarm pull station. The ansel supression system is part of the kitchen fire alarm system, and has an activation handle which is pulled to activate the supression system in the event of a fire in the kitchen cooking area.

c) During fire alarm testing on 10/06/10, 4 staff members were being interviewed. At 1:38 p.m., 1 of 4 staff members interviewed did not know the facility's fire and disaster procedures. When staff on the 5th floor of ICU were asked what they would do in the event of a fire, 1 staff was unable to explain the fire procedures.

Based on observation, testing, record review, and staff interview, the facility failed to maintain, inspect and certify all fire alarm system devices. This was evidenced by the failure to ensure certified and qualified personnel inspected, tested and certified all fire alarm devices, by failing to provide complete records of testing and certification of the fire alarm system devices, and by the failure of the fire alarm control panel to re-set after activation of a device. This affected 23 of 23 smoke compartments, and could result in a delay in notification in the event of a fire. A smoke compartment is a space within the building enclosed by smoke barriers on all sides, including the top and the bottom, for the purpose of containing smoke or fire, in the event of a fire.

NFPA 72, 7-1.2.2 Service personnel shall be qualified and experienced in the inspection, testing, and maintenance of fire alarm systems.
Examples of qualified personnel shall be permitted to include, but shall not be limited to, individuals with the following qualifications:
(1) Factory trained and certified
(2) National Institute for Certification in Engineering Technologies fire alarm certified
(3) International Municipal Signal Association fire alarm certified
(4) Certified by a state or local authority
(5) Trained and qualified personnel employed by an organization listed by a national testing laboratory for the servicing of fire alarm systems

NFPA 90A, 1999 edition, 3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.
NFPA 90A, 1999 edition, 3-4.5.1 All fire dampers and ceiling dampers shall close automatically, and they shall remain closed upon the operation of a listed fusible link or other approved heat-actuated device located where readily affected by an abnormal rise of temperature in the air duct.
NFPA 90A, 1999 edition, 5-1 General.
NFPA 90A, 1999 edition, 5-1.1* An acceptance test shall be performed to determine that the protective measures required in this standard function when needed in order to restrict the spread of fire and smoke.
NFPA 90A, 1999 edition, 5-1.2 Records shall be maintained on acceptance test results and shall be available for inspection.

Findings:

During record review, and fire alarm system testing the following deficiencies were observed at the following times and locations:a) On 10/05/10 at 1:15 p.m., the facility failed to provide documentation from a certified fire alarm vendor for the testing and certification of the facility's fire smoke dampers. At 1:18 p.m., an interview was conducted with staff member V2. Staff member V2 stated that the facility does the fire smoke damper inspections in house. Staff member V2 was asked if the designated staff member is a certified fire alarm technician. Staff member V2 stated the staff member responsible for the testing is not certified.
b) On 10/05/10 at 1:59 p.m., the facility failed to provide documentation from a certified fire alarm vendor for the annual testing and certification for the cookson fire fly roll down doors located in the following areas: emergency room, PBX station, in-patient pharmacy, nursing station 3E, mental health cashier window, surgery reception window, 5th floor nursing station B, and the cancer center. An interview was conducted with staff member V2. Staff member V2 stated the facility conducts the testing in-house, and the staff member who is responsible for testing the cookson fire fly doors is not a certified fire alarm technician.
c) On 10/06/10 from 1:17 p.m., through 3:54 p.m., the fire alarm system was tested. 26 devices were activated. Of the 26 devices activated, 24 devices caused the fire alarm system control panel to malfunction. The fire alarm system silenced and/or rest itself after approximately 3 - 4 audible rings for 24 devices activated. At 1:58 p.m., staff member designated to reset the fire alarm control panel stated "I am not re-setting the fire alarm system, it seems to be silencing itself".
The following devices were tested, and after 3 - 4 audile rings, the fire alarm system stopped working:
1)Sprinkler water flow, #38-53, hospital roof.
2)Manual pull station #38-24, hospital roof.
3)Manual pull station #18-60, 5th. floor south exit.
4)Smoke detector, #24-9, 5th. floor by room 566.
5)Sprinkler water flow, #36-30, 5th. floor ancillary building.
6)Manual pull station, #36-29, 5th. floor ICU.
7)Sprinkler system water flow tamper alarm, #36-31, hospital roof.
8)Sprinkler water flow, #37-37, 4th. floor ancillary building.
9)Smoke detector, #37-15, 4th. floor ancillary lobby.
10)Manual pull station, #43-42, 4th. floor south exit.
11)Smoke detector, #31-19, 3rd. floor by laundry room.
12)Manual pull station, #32-1, 3rd. floor east stairwell.
13)Smoke detector, #29-30, 2nd. floor by x-ray room 2.
14)Manual pull station, #6-31, 2nd. floor east hallway.
15)Manual pull station, #1-56, 1st. floor by room 102.
16)Smoke detector, #2-40, 1st floor ancillary building, entrance/lab.
17)Smoke detector, #12-18, B level by room B21.
18)Tamper switch, #12-60, B level.
19)Manual pull station, #13-4, C level by mens bathroom.
20)Sprinkler water flow, #12-59, B level.
21)Manual pull station, #11-52, A level kitchen foyer.
22)Sprinkler system tamper, #1-16, doctors parking lot.
23)Sprinkle water flow, #1-13, 1st floor hospital/doctor parking lot.
24)Sprinkler tamper, #38-54, hospital roof.

Based on document review and interview, the facility failed to ensure all fire alarm devices are tested annually, as evidenced by an incomplete documentation for the annual fire alarm system testing/certification. This affected 23 of 23 smoke compartments, and could result in a malfunction of the fire alarm system. A smoke compartment is a space within the building enclosed by smoke barriers on all sides, including the top and the bottom, for the purpose of containing smoke or fire, in the event of a fire.

NFPA 72, 7-3.2*, Testing. Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual.
Table 7-3.2, #3 shall apply.
3. Engine-Driven Generator - Central Station Facilities and Fire Alarm Systems shall be tested monthly.
Table 7-3.2, Testing Frequencies
1. Control Equipment-Building system connected to supervising station.
(a) functions Annually
(b) Fuses Annually
(c) Interfaced equipment Annually
(d) Lamps and LEDs Annually
(e) Primary (Main)power supply Annually
(f) Transformers Annually

Findings:

During record review on 10/5/10, at 9:43 a.m., the annual fire alarm system report was reviewed. The facility failed to complete 100% of the annual fire alarm system testing. The fire alarm system report showed 90% completed. The facility has 1,248 fire alarm devices (excluding fire smoke dampers). The sprinkler system water flow, in quarter 3, was not tested to complete 100% of the 2009 annual fire alarm certification.

During an interview with staff at 9:45 a.m., staff member U1 stated they were not aware that the water flow was not tested at 100%. Staff explained that they had asked the vendor to come out earlier in the year to test all devices to ensure the facility was 100% completed.

Based on observation and interview, the facility failed to ensure smoke detectors were maintained. This was evidenced by smoke detection devices that were obstructed by storage of items under the device. This affected all patients and staff members in 3 of 23 smoke compartments. A smoke compartment is a space within the building enclosed by smoke barriers on all sides, including the top and the bottom, for the purpose of containing smoke or fire, in the event of a fire.



Findings:During a tour of the facility, the following smoke detectors were observed obstructed at the following times and locations:
a) On 10/04/10 at 11:10 a.m., the smoke detector located in H-516 was observed obstructed. Pillows and blankets were observed obstructing and covering the smoke detector.

b) On 10/04/10 at 1:35 p.m., the smoke detector located in room H-121, was observed obstructed. Items stored in the closet were stored to the ceiling, obstructing the smoke detector.

c) On 10/04/10, at 2:40 p.m., the smoke detector located in the dietary utility closet was observed obstructed. Catering supplies and dishes were observed stacked to the ceiling, touching the base of the smoke detector.

Facility Staff V1 acknowledged the findings at the time of the survey.

Based on observation, record review, interview, and testing of the sprinkler system, the facility failed to maintain the sprinkler system in reliable operating condition. This was evidenced by sprinkler head escutcheon rings that were not maintained flush with the ceiling, by the failure of the Inspector's Test Valve to activate the fire alarm system, and by incomplete records for testing and maintaining the automatic sprinkler system. This affected all patients and staff in 23 of 23 smoke comparments, and could result in a failure of the automatic sprinkler system. A smoke compartment is a space within the building enclosed by smoke barriers on all sides, including the top and the bottom, for the purpose of containing smoke or fire, in the event of a fire.



NFPA 25, table 2-1:
Summary of Sprinkler System Inspection, Testing, and Maintenance. Sprinkler system devices are to be tested quarterly to ensure system remains in a reliable operating condition.
Gauges (dry, preaction deluge systems) Inspection Weekly/monthly 2-2.4.2
Control valves Inspection Weekly/monthly Table 9-1
Alarm devices Inspection Quarterly 2-2.6
Gauges (wet pipe systems) Inspection Monthly 2-2.4.1
Hydraulic nameplate Inspection Quarterly 2-2.7
Buildings Inspection Annually (prior to freezing weather) 2-2.5
Hanger/seismic bracing Inspection Annually 2-2.3
Pipe and fittings Inspection Annually 2-2.2
Sprinklers Inspection Annually 2-2.1.1
Spare sprinklers Inspection Annually 2-2.1.3
Fire department connections Inspection Table 9-1
Valves (all types) Inspection Table 9-1
Alarm devices Test Quarterly 2-3.3
Main drain Test Annually Table 9-1
Antifreeze solution Test Annually 2-3.4
Gauges Test 5 years 2-3.2
Sprinklers - extra-high temp. Test 5 years 2-3.1.1 Exception No. 3
Sprinklers - fast response Test At 20 years and every 10 years thereafter
2-3.1.1 Exception No. 2
Sprinklers Test At 50 years and every 10 years thereafter 2-3.1.1
Valves (all types) Maintenance Annually or as needed Table 9-1
Obstruction investigation Maintenance 5 years or as needed Chapter 10

NFPA 72: 2-6 Sprinkler Waterflow Alarm-Initiating Devices. 2-6.1 The provisions of Section 2-6 shall apply to services that initiate an alarm indicating a flow of water in a sprinkler system. 2-6.2* Initiation of the alarm signal shall occur within 90 seconds of waterflow at the alarm-initiating device when flow occurs that is equal to or greater than that from a single sprinkler of the smallest orifice size installed in the system. Movement of water due to waste, surges, or variable pressure shall not be indicated.


Findings:During a tour of the facility, and testing of the sprinkler system, the following deficiencies were observed at the following times and locations:
a)On 10/04/10, at 10:43 a.m., 18 inches was not maintained between the items stored under the sprinkler header, located in room A-531.
b) On 10/04/10, at 11:46 a.m., 1 of 1 escutcheon rings in the waiting room by A-334, on the 3rd floor of physical therapy, was hanging down from the ceiling. There was an approximately ¼ inch penetration in the ceiling.
c) On 10/04/10, at 11:50 a.m., 1 of 1 escutcheon rings next to treatment room 3, on the 3rd floor of physical therapy, was hanging down from the ceiling. There was an approximately ¼ inch penetration in the ceiling.
d) On 10/04/10, at 11:51 a.m., 2 of 4 escutcheon rings in the speech therapy, on the 3rd floor, was hanging down from the ceiling. There was an approximately 1/4 inch penetration in the ceiling.
e)On 10/04/10, at 11:56 a.m., a 1/2 inch gap was observed around 1 of 2 sprinkler head escutcheon plates located in room A-513.
f)On 10/04/10, at 1:59 p.m., a 1/2 inch gap was observed around 2 of 3 sprinkler head escutcheon plates located in room A-108.
g) During document review with staff, on 10/5/10, at 2:20 p.m., " Fire Alarms & Sprinkler System: Quarterly Test, " records were reviewed. The facility failed to provide documentation for a sprinkler system test conducted for quarter 3. The documentation dated 7/2/10, for the 3rd quarter, was incomplete.
During an interview, at 2:48 p.m., staff member U2 stated the third quarter sprinkler test was not conducted, and the documentation was left blank because the testing was not conducted for that quarter.
h)On 10/06/10, at 1:37 p.m., the sprinkler system inspectors test valve located in the 5th floor stairwell, ICU, failed to activate the fire alarm system within 90 seconds of opening the valve. 200 seconds passed, and the fire alarm system did not activate.
i)On 10/06/10, at 2:00 p.m., the facility failed to provide documentation for the annual sprinkler system testing and certification.

Facility Staff V1 acknowledged the findings at the time of the survey.

Based on observation and interview, the facility failed to maintain the portable fire extinguishers. This was evidenced by portable fire extinguishers that were not mounted at proper heights, identification/location signs that were not provided for the portable fire extinguishers, and by a portable fire extinguisher that was missing the monthly checks of the extinguisher. This could result in a delay in locating and utilizing the portable fire extinguishers in the event of a fire, and affected all patients and staff in 23 of 23 smoke compartments. A smoke compartment is a space within the building enclosed by smoke barriers on all sides, including the top and the bottom, for the purpose of containing smoke or fire, in the event of a fire.



NFPA 10, 1998 Edition.
1-6.6* Fire extinguishers shall not be obstructed or obscured from view.
Exception: In large rooms, and in certain locations where visual obstruction cannot be completely avoided, means all be provided to indicate the location.
1-6.12 Fire extinguishers mounted in cabinets or wall recesses shall be placed so that the fire extinguisher operating instructions face outward. The location of such fire extinguishers shall be marked conspicuously. (See 1-6.6.)
Exception: In large rooms, and in certain locations where visual obstruction cannot be completely avoided, means all be provided to indicate the location.
1-6.7* Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer ' s instructions. Wheeled-type fire extinguishers shall be located in a designated location.
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 3 1/2 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).
1-6.12 Fire extinguishers mounted in cabinets or wall recesses shall be placed so that the fire extinguisher operating instructions face outward. The location of such fire extinguishers shall be marked conspicuously. (See 1-6.6.)


Findings:

During a tour of the facility, on 10/04/10, the following deficiencies were observed at the following times and locations:
a) At 11:06 a.m., the facility failed to provide a fire extinguisher identification sign for the fire extinguisher located by nursing station 5A.
b) At 11:17 a.m., a recessed portable ABC fire extinguisher across from Room A-418, on the 4th floor, was missing an identification sign
c)At11:25 a.m., the facility failed to provide a fire extinguisher identification sign for the fire extinguisher located by nursing station 5D.
d)At 11:30 a.m., the facility failed to provide a fire extinguisher identification sign for the fire extinguisher located by room H-575.
e)At 11:39 a.m., the facility failed to provide a fire extinguisher identification sign for the fire extinguisher located by H-525.
f)At 11:42 a.m., the facility failed to provide a fire extinguisher identification sign for the fire extinguisher located by A-531.
g) At 11:50 a.m., a recessed portable ABC fire extinguisher by Room H-319, on the 3rd floor, was missing an identification sign.
h) At 11:54, a recessed portable ABC fire extinguisher by Room A-332, on the 3rd floor, was missing an identification sign.
I)At 11:57 a.m., the facility failed to provide a fire extinguisher identification sign for the fire extinguisher located by room 8, ICU.
j) At 1:10 p.m., a recessed portable ABC fire extinguisher by Room A-219, on the 2nd floor, was missing an identification sign.
k) At 1:15 p.m., a recessed portable ABC fire extinguisher by Room A-200, on the 2nd floor, was missing an identification sign.
l)At 1:15 p.m., the facility failed to provide a fire extinguisher identification sign for the fire extinguisher located by H-132.
m)At 1:22 p.m., the facility failed to provide a fire extinguisher identification sign for the fire extinguisher located by room H-109.
n)At 1:22 p.m., the fire extinguisher located by room H-109, was observed undercharged, and the fire extinguisher was not signed off for the months of June, July and September 2010. Staff acknowledged that the documentation was missing for the monthly checks for the portable fire extinguishers.
o)At 1:25 p.m., the facility failed to provide a fire extinguisher identification sign for the fire extinguisher located by room H-116.
p)At 1:48 p.m., the facility failed to provide a fire extinguisher identification sign for the fire extinguisher located by room A-105.
q)At 1:54 p.m., the facility failed to provide a fire extinguisher identification sign for the fire extinguisher located by lab room A-109 and A-116.
r)At 2:40 p.m., the #2 "K" class fire extinguisher located in the dietary department was observed mounted higher than 5 feet above the ground.
s)At 2:45 p.m., the facility failed to provide a fire extinguisher identification sign for the fire extinguisher located by room H-123.

Facility Staff V1 acknowledged the failures to maintain the provide fire extinguishers at the time of the survey.

Based on observation and interview, the facility failed to ensure duct work for the heating, ventilation and air conditioning system is maintained in accordance with Section 9.2, NFPA 90A, and the manufacturer's specifications. This was evidenced by a penetration in the duct work. This could result in the spread of smoke or fire in the event of a fire, and affected all patients and staff in 1 of 23 smoke compartments. A smoke compartment is a space within the building enclosed by smoke barriers on all sides, including the top and the bottom, for the purpose of containing smoke or fire, in the event of a fire.

NFPA 90A, 5.4.7
Maintenance
At least every 4 years, the following maintenance shall be performed:
(1) Fusible links (where applicable) shall be removed.
(2) All dampers shall be operated to verify that they close fully.
(3) The latch, if provided, shall be checked.
(4) Moving parts shall be lubricated as necessary.

Findings:During a tour of the facility on 10/04/10, at 10:54 a.m., an approximately 6 inch by 6 inch piece of cardboard was taped to the duct work with duct tape. The cardboard was removed, and there was an approximately 5 inch by 5 inch penetration in the metal duct work.

Facility Staff V1 acknowledged the findings at the time of the survey.

Based on observation and interview, the facility failed to maintain the kitchen hood system and devices, which included the ansel supression system, kitchen hood system, and kitchen hood system automatic sprinkler system devices. This was evidenced by the failure to maintain the kitchen hood system sprinkler caps, and by the failure to provide complete documentation of conducting the semi-annual cleaning of the kitchen hood. This affected one of 23 smoke compartments, and could result in an increased risk of fire. A smoke compartment is a space within the building enclosed by smoke barriers on all sides, including the top and the bottom, for the purpose of containing smoke or fire, in the event of a fire.

NFPA 96, 11.2


Findings:

1. During a tour of the facility, on 10/04/10, at 2:45 p.m., 3 of 8 red blow off caps to the hood system's automatic sprinkler heads were observed detached. The red blow off caps are part of kitchen hood supression system devices.


2. During record review with Staff V2, on 10/5/10, the kitchen records were requested. At 10:45 a.m., the facility failed to provide documentation for two semi-annual cleaning of the kitchen range hood. The range hood was cleaned on 9/15/10. The previous cleaning was done on 10/28/09.

Based on observation and staff interview, the facility failed to enure that portable space heaters used in staff offices do not exceed 212 degrees Farenheit (F). This was evidenced by the use of two electrical space heaters without documentation that they did not exceed 212 degrees F. This could result in an increased risk of fire, and affected all staff and patients in 1 of 23 smoke compartments. A smoke compartment is a space within the building enclosed by smoke barriers on all sides, including the top and the bottom, for the purpose of containing smoke or fire, in the event of a fire.



Findings:During a tour of the facility, on 10/04/10, the following deficiencies were observed:

a) At 1:50 p.m., a portable space heater was observed in Room A-117. Engineering staff was unable to determine if the space heater met the regulatory requirements.
b) At 1:55 p.m., a portable space heater was observed in Room A-120. Engineering staff was unable to determine if the space heater met the regulatory requirements.

Based on observation and staff interview, the facility failed to maintain the corridors to full width. This was evidenced by the storage of items in the exit corridors. This could result in a delay in evacuation, and affected all patients and staff in 2 of 23 smoke compartments. A smoke compartment is a space within the building enclosed by smoke barriers on all sides, including the top and the bottom, for the purpose of containing smoke or fire, in the event of a fire.



Findings:

During a tour of the facility, the following items were observed stored in the corridors at the following times and locations:
a) On 10/04/10 at 11:55 a.m., and on 10/06/10, at 1:20 p.m., two supply carts and a portable x-ray machine were observed stored in the corridor located outside of Room A-513, ICU.
b) On 10/06/10 at 1:50 p.m., and 3:30 p.m., a portable x-ray machine, three x-ray carts, and a book cart were observed stored in the corridor, in the X-ray department by Room A-206.

Facility Staff V1 acknowledged the findings at the time of the survey.

Based on observation and interview, the facility failed to maintain the oxygen storage. This was evidenced by failing to properly store oxygen cylinders in designated room free from combustible materials, failing to secure the cylinders, and failing to ensure electrical light switch plates are not less than five feet above the floor. This affected 3 of 23 smoke compartments, and result in damage to a cylinder. A smoke compartment is a space within the building enclosed by smoke barriers on all sides, including the top and the bottom, for the purpose of containing smoke or fire, in the event of a fire.


NFPA 99, 4-3.1.1.1 Cylinder and Container Management. Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

4-3.5.2.1 (27) freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

4-3.1.1.2 (7) Combustible materials, such as paper, cardboard, plastics, and fabric shall not be stored or kept near supply system cylinders and/or manifolds containing oxygen or nitrous oxide. Racks for cylinder storage shall be permitted to be wooden construction. Wrappers shall be removed prior to storage.

4-3.1.1.2 (4) Electric wall fixtures, switches and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor, as a precaution against their physical damage.

Findings:

During a tour of the facility with staff on 10/4/10, the oxygen rooms were observed.

1. At 11:55 a.m., 12 "E"-type size oxygen tanks were observed stored in the outpatient surgery in Room A-318, on the 3rd floor. The room contained cleaning supplies, and the electrical light switch was mounted at approximately 56 inches from the floor.
2. At 1:14 p.m., one " H " -type size oxygen tank was observed stored next to Room A-202, on the 2nd floor, and the electrical light switch was 56 inches from the floor.
3. At 2:03 p.m., two CO2 tanks were freestanding on the ground in Room C-C12, by the loading dock in C level.
4. At 2:30 p.m., one " D " -type size oxygen tank was observed stored unsecured on the ground, in the exterior medical gas storage area.

Facility Staff V1 acknowledged the findings at the time of the survey.

Based on record review and staff interview, the facility failed to ensure humidity levels for the operating rooms 1, 2 and 3, and the cysto room, were maintained equal or greater than 35%. This was evidenced by humidity levels that were not maintained equal or greater than 35%. This could result in an increased risk of fire, and affected all patients and staff in the operating rooms and the cystology room.

Findings:

During record review, on 10/05/10, at 2:50 p.m., the following operating rooms fell below the required 35% humidity:
1. Operating Room 1 documentation provided showed the humidity fell below 35%, 80 days out of 365 days:
a) The humidity documented for 10/05/09 was 31%.
b) The humidity documented for 10/06/09 was 30%.
c) The humidity documented for 10/07/10 was 31%.
d) The humidity documented for 10/25/09 was 33%.
e) The humidity documented for 10/27/09 was 26%.
f) The humidity documented for 10/28/09 was 19%.
g) The humidity documented for 10/29/09 was 26%.
h) The humidity documented for 11/12/09 was 34%.
i) The humidity documented for 11/13/09 was 33%.
j) The humidity documented for 11/17/09 was 30%.
k) The humidity documented for 11/15/09 was 32%.
l) The humidity documented for 11/16/09 was 34%.
m) The humidity documented for 11/23/09 was 32%.
n) The humidity documented for 11/24/09 was 33%.
o) The humidity documented for 11/27/09 was 31%.
p) The humidity documented for 11/28/09 was 17%.
q) The humidity documented for 11/29/09 was 18%.
r) The humidity documented for 11/30/09 was 27%.
s) The humidity documented for 12/03/09 was 34%.
t) The humidity documented for 12/04/09 was 32%.
u) The humidity documented for 12/05/09 was 18%.
v) The humidity documented for 12/06/09 was 20%.
w) The humidity documented for 12/07/09 was 27%.
x) The humidity documented for 12/08/09 was 25%.
y) The humidity documented for 12/09/09 was 20%.
z) The humidity documented for 12/10/09 was 21%.
aa) The humidity documented for 12/21/09 was 33%.
bb) The humidity documented for 12/22/09 was 27%.
cc) The humidity documented for 12/23/09 was 22%.
dd) The humidity documented for 12/03/09 was 34%.
ee) The humidity documented for 12/04/09 was 32%.
ff) The humidity documented for 12/05/09 was 18%.
gg) The humidity documented for 12/06/09 was 27%.
hh) The humidity documented for 12/08/09 was 25%.
ii) The humidity documented for 12/09/09 was 20%.
jj) The humidity documented for 12/10/09 was 21%.
kk) The humidity documented for 12/21/09 was 33%.
ll) The humidity documented for 12/22/09 was 27%.
mm) The humidity documented for 12/23/09 was 22%.
nn) The humidity documented for 12/24/09 was 33%.
oo) The humidity documented for 12/25/09 was 30%.
pp) The humidity documented for 2/22/10 was 33%.
qq) The humidity documented for 3/05/10 was 33%.
rr) The humidity documented for 3/06/10 was 28%.
ss) The humidity documented for 3/08/10 was 28%.
tt) The humidity documented for 3/09/10 was 26%.
uu) The humidity documented for 3/10/10 was 31%.
vv) The humidity documented for 3/11/10 was 31%.
ww) The humidity documented for 3/13/10 was 20%.
xx) The humidity documented for 3/14/10 was 23%.
yy) The humidity documented for 3/18/10 was 22%.
zz) The humidity documented for 3/19/10 was 21%.
aaa) The humidity documented for 3/20/10 was 30%.
bbb) The humidity documented for 3/23/10 was 25%.
ccc) The humidity documented for 3/27/10 was 28%.
ddd) The humidity documented for 3/28/10 was 27%.
eee) The humidity documented for 3/30/10 was 31%.
fff) The humidity documented for 3/31/10 was 31%.
ggg) The humidity documented for 4/01/10 was 26%.
hhh) The humidity documented for 4/02/10 was 34%.
iii) The humidity documented for 4/03/10 was 32%.
jjj) The humidity documented for 4/05/10 was 32%.
kkk) The humidity documented for 4/06/10 was 30%.
lll) The humidity documented for 4/07/10 was 34%.
mmm) The humidity documented for 4/09/10 was 29%.
nnn) The humidity documented for 4/15/10 was 34%.
ooo) The humidity documented for 4/25/10 was 32%.
ppp) The humidity documented for 4/26/10 was 28%.
qqq) The humidity documented for 4/30/10 was 26%.
rrr) The humidity documented for 5/02/10 was 27%.
sss) The humidity documented for 5/04/10 was 30%.
ttt) The humidity documented for 5/05/10 was 29%.
uuu) The humidity documented for 5/06/10 was 16%.
vvv) The humidity documented for 5/07/10 was 30%.
www) The humidity documented for 5/08/10 was 31%.
xxx) The humidity documented for 5/21/10 was 32%.
yyy) The humidity documented for 5/22/10 was 31%.
zzz) The humidity documented for 5/29/10 was 29%.
aaaa) The humidity documented for 6/11/10 was 34%.
bbbb) The humidity documented for 8/25/10 was 33%.


2. Operating Room 2 documentation provided showed the humidity fell below 35%, 52 days out of 365 days:
a) The humidity documented for 10/05/09 was 31%.
b) The humidity documented for 10/06/09 was 30%.
c) The humidity documented for 10/07/09 was 31%.
d) The humidity documented for 10/27/09 was 25%.
e) The humidity documented for 10/28/09 was 21%.
f) The humidity documented for 10/29/09 was 28%.
g) The humidity documented for 11/12/09 was 33%.
h) The humidity documented for 11/13/09 was 32%.
i) The humidity documented for 11/15/09 was 31%.
j) The humidity documented for 11/16/09 was 33%.
k) The humidity documented for 11/23/09 was 34%.
l) The humidity documented for 11/28/09 was 21%.
m) The humidity documented for 11/29/09 was 23%.
n) The humidity documented for 11/30/09 was 32%.
o) The humidity documented for 12/04/09 was 33%.
p) The humidity documented for 12/05/09 was 19%.
q) The humidity documented for 12/06/09 was 20%.
r) The humidity documented for 12/07/09 was 24%.
s) The humidity documented for 12/08/09 was 24%.
t) The humidity documented for 12/09/09 was 22%.
u) The humidity documented for 12/10/09 was 24%.
v) The humidity documented for 12/22/09 was 27%.
w) The humidity documented for 12/23/09 was 23%.
x) The humidity documented for 12/25/09 was 32%.
y) The humidity documented for 3/08/10 was 33%.
z) The humidity documented for 3/09/10 was 25%.
aa) The humidity documented for 3/10/10 was 29%.
bb) The humidity documented for 3/11/10 was 32%.
cc) The humidity documented for 3/13/10 was 21%.
dd) The humidity documented for 3/14/10 was 25%.
ee) The humidity documented for 3/18/10 was 22%.
ff) The humidity documented for 3/19/10 was 21%.
gg) The humidity documented for 3/20/10 was 31%.
hh) The humidity documented for 3/23/10 was 32%.
ii) The humidity documented for 3/27/10 was 31%.
jj) The humidity documented for 3/28/10 was 30%.
kk) The humidity documented for 3/30/10 was 34%.
ll) The humidity documented for 3/31/10 was 34%.
mm) The humidity documented for 4/01/10 was 29%.
nn) The humidity documented for 4/06/10 was 34%.
oo) The humidity documented for 4/09/10 was 26%.
pp) The humidity documented for 4/25/10 was 32%.
qq) The humidity documented for 4/26/10 was 29%.
rr) The humidity documented for 4/30/10 was 27%.
ss) The humidity documented for 5/02/10 was 28%.
tt) The humidity documented for 5/04/10 was 31%.
uu) The humidity documented for 5/05/10 was 30%.
vv) The humidity documented for 5/06/10 was 19%.
ww) The humidity documented for 5/07/10 was 30%.
xx) The humidity documented for 5/08/10 was 31%.
yy) The humidity documented for 5/22/10 was 32%.
zz) The humidity documented for 5/29/10 was 33%.


3. Operating Room 3 documentation provided showed the humidity fell below 35% 47 days out of 365 days:
a) The humidity documented for 10/06/09 was 33%.
b) The humidity documented for 10/07/09 was 33%.
c) The humidity documented for 10/27/09 was 23%.
d) The humidity documented for 10/28/09 was 19%.
e) The humidity documented for 10/29/09 was 24%.
f) The humidity documented for 11/13/09 was 33%.
g) The humidity documented for 11/15/09 was 31%.
h) The humidity documented for 11/16/09 was 34%.
i) The humidity documented for 11/23/09 was 31%.
j) The humidity documented for 11/24/09 was 31%.
k) The humidity documented for 11/28/09 was 20%.
l) The humidity documented for 11/29/09 was 22%.
m) The humidity documented for 11/30/09 was 32%.
n) The humidity documented for 12/05/09 was 18%.
o) The humidity documented for 12/06/09 was 20%.
p) The humidity documented for 12/07/09 was 25%.
q) The humidity documented for 12/08/09 was 23%.
r) The humidity documented for 12/09/09 was 21%.
s) The humidity documented for 12/10/09 was 21%.
t) The humidity documented for 12/22/09 was 26%.
u) The humidity documented for 12/23/09 was 22%.
v) The humidity documented for 12/24/09 was 34%.
w) The humidity documented for 12/25/09 was 30%.
x) The humidity documented for 12/26/09 was 33%.
y) The humidity documented for 3/08/10 was 34%.
z) The humidity documented for 3/09/10 was 26%.
aa) The humidity documented for 3/10/10 was 32%.
bb) The humidity documented for 3/13/10 was 24%.
cc) The humidity documented for 3/14/10 was 27%.
dd) The humidity documented for 3/18/10 was 23%.
ee) The humidity documented for 3/19/10 was 23%.
ff) The humidity documented for 3/20/10 was 34%.
gg) The humidity documented for 3/23/10 was 28%.
hh) The humidity documented for 3/27/10 was 32%.
ii) The humidity documented for 3/28/10 was 32%.
jj) The humidity documented for 4/01/10 was 31%.
kk) The humidity documented for 4/03/10 was 34%.
ll) The humidity documented for 4/09/10 was 30%.
mm) The humidity documented for 4/25/10 was 34%.
nn) The humidity documented for 4/26/10 was 29%.
oo) The humidity documented for 4/30/10 was 29%.
pp) The humidity documented for 5/02/10 was 30%.
qq) The humidity documented for 5/05/10 was 32%.
rr) The humidity documented for 5/06/10 was 18%.
ss) The humidity documented for 5/07/10 was 30%.
tt) The humidity documented for 5/08/10 was 31%.
uu) The humidity documented for 5/29/10 was 30%.


4. Cystology Room documentation provided showed the humidity fell below 35%, 38 days out of 365 days:
a) The humidity documented for 10/06/09 was 32%.
b) The humidity documented for 10/07/09 was 34%
c) The humidity documented for 10/27/09 was 27%.
d) The humidity documented for 10/28/09 was 22%.
e) The humidity documented for 10/29/09 was 28%.
f) The humidity documented for 11/28/09 was 21%.
g) The humidity documented for 11/29/09 was 22%.
h) The humidity documented for 11/30/09 was 30%.
i) The humidity documented for 12/05/09 was 23%.
j) The humidity documented for 12/06/09 was 24%.
k) The humidity documented for 12/07/09 was 28%.
l) The humidity documented for 12/08/09 was 27%.
m) The humidity documented for 12/09/09 was 23%.
n) The humidity documented for 12/10/09 was 24%.
o) The humidity documented for 12/22/09 was 30%.
p) The humidity documented for 12/23/09 was 26%.
q) The humidity documented for 12/25/09 was 34%.
r) The humidity documented for 3/09/10 was 31%.
s) The humidity documented for 3/10/10 was 34%.
t) The humidity documented for 3/13/10 was 26%.
u) The humidity documented for 3/14/10 was 29%.
v) The humidity documented for 3/18/10 was 25%.
w) The humidity documented for 3/19/10 was 24%.
x) The humidity documented for 3/20/10 was 33%.
y) The humidity documented for 3/23/10 was 29%.
z) The humidity documented for 3/27/10 was 34%.
aa) The humidity documented for 3/28/10 was 34%.
bb) The humidity documented for 4/01/10 was 34%.
cc) The humidity documented for 4/08/10 was 31%.
dd) The humidity documented for 4/25/10 was 33%.
ee) The humidity documented for 4/26/10 was 29%.
ff) The humidity documented for 4/30/10 was 30%.
gg) The humidity documented for 5/02/10 was 31%.
hh) The humidity documented for 5/05/10 was 33%.
ii) The humidity documented for 5/06/10 was 21%.
jj) The humidity documented for 5/07/10 was 30%.
kk) The humidity documented for 5/08/10 was 31%.
ll) The humidity documented for 9/06/10 was 33%.

0n 10/05/10 at 4:00 p.m., an interview was conducted with staff members V2 and V3. Both staff members stated that the facility does not have a way to control the humidity levels in the Operating rooms and cystology room. Staff stated that several years ago the facility disconnected the system that was originally installed to control the humidity levels in the operating rooms.

Based on document review and interview, the facility failed to provide complete records for weekly inspections of the emergency generator. This was evidenced by incomplete records for 13 of 40 weekly generator inspections. This could result in a failure of the emergency generator in the event of a loss of power, and affected all patients and staff in the facility.


Findings:

During record review, on 10/05/10, at 3:00 p.m., the following records for the weekly inspections for the emergency generator were incomplete:
a) f) The facility failed to provide documentation for the week of 10/18/09 - 10/24/09.
b) The facility failed to provide documentation for the week of 10/11/09 - 10/17/09.
c) The facility failed to provide documentation for the week of 10/04/09 - 10/17/09.
d) The facility failed to provide documentation for the week of 11/22/09 - 11/28/09.
e) The facility failed to provide documentation for the week of 11/15/09 - 11/21/09.
f) The facility failed to provide documentation for the week of 11/08/09 - 11/14/09.
g) The facility failed to provide documentation for the week of 11/01/09 - 11/07/09.
h) The facility failed to provide documentation for the week of 10/25/09 - 10/31/09.
i) The facility failed to provide documentation for the week of 12/20/09 - 12/26/09.
j) The facility failed to provide documentation for the week of 4/25/10 - 5/01/10.
k) The facility failed to provide documentation for the week of 9/19/10 - 9/25/10.
l) The facility failed to provide documentation for the week of 9/12/10 - 9/18/10.
m) The facility failed to provide documentation for the week of 9/05/10 - 9/11/10.

Staff acknowledged that the documentation was missing for the weekly inspections of the emergency generator.




.

Based on observation, interview and record review, the facility failed to maintain the electrical utilities and connections in accordance with NFPA 70, NFPA 99, and the National Electrical Code (NEC). This was evidenced by the use of extension cords, by failing to maintain the electrical panels, and by failing to provide complete records of testing and maintaining the electrical outlets. This could result in an increased risk of an electrical fire, and affected all patients and staff in 23 of 23 smoke compartments. A smoke compartment is a space within the building enclosed by smoke barriers on all sides, including the top and the bottom, for the purpose of containing smoke or fire, in the event of a fire.

NFPA 70, 400-8 1999 edition, Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceiling, or floors.
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces

NFPA 70, article 240-4 1999 edition, Protection of Flexible Cords and Fixture Wires.
Flexible cord, including tinsel cord and extension cords, and fixtures wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixtures wire shall be protected against overcurrent in accordance with its ampacity as specified in table 402-5. Supplementary overcurrent protection, as in section 240-10, shall be permitted to be an acceptable mean cor providing this protection.
(b) Supply cord of listed appliance or portable lamps. Where flexible cord or tinsel cord is approved for and used with specific listed appliance or portable lamp, it shall be permitted to be supplied by a branch circuit of Article 210.
Also, HCFA transmittal notice 22-99, prohibits the use of extension cords without overcurrent protection (surge protectors).

NEC 70: 110-22: Connecting means required by this code for motors and or appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is clearly evident. The marking shall be of sufficient durability to withstand the environment involved.

NEC 70: 400-8 1999 edition, Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceiling, or floors.
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces

NFPA 99, 3-3.3.3 Receptacle Testing in Patient Care Areas.
(a) The physical integrity of each receptacle shall be confirmed by visual
inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be
verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle
shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle
(except locking-type receptacles) shall be not less than 115 grams (4 ounces).

7-6.2.1.2 Testing Intervals.
(a) The facility shall establish policies and protocols for the type of test and intervals of testing for each appliance. (b) All appliances used in patient care areas shall be tested in accordance with 7-5.1.3 or 7-5.2.2.1 before being put into

NFPA 99, 3-3.4.3.1 General - A record shall be maintained of the tests required by this chapter and associated repairs or modifications. At a minimum, this record shall contain the dates, the rooms or areas tested, and an indication of which items have met or have failed to meet the performance requirements of this chapter.

Findings:

During a tour of the facility, on 10/04/10 through 10/07/10, the following deficiencies were observed at the following times and locations:
a) On 10/04/10, at 10:55 a.m., an extension cord was observed plugged into a telephone/server "glenqyre" machine, located in the fan room, on the roof.
b) On 10/04/10, at 11:28 a.m., electrical panel #0218, located by Room 544, had electrical breakers 4, 16, and 22 listed as spare breakers. The breakers were not capped off or turned to the off position.
c) On 10/04/10, at 1:16 p.m., there was a surge protector was plugged into a surge protector, in Room H-138.
d) On 10/04/10, at 1:20 p.m., electrical panel #PNL3041, located in Room H-112, had electrical breakers 35. 37, 39, 41, and 42 listed as spare breakers. The breakers were not capped off or turned to the off position.
e) On 10/04/10, at 1:22 p.m., electrical panel #PNL3042, located in Room H-112, had electrical breakers 17, 19, 21, 25, 27, 33, and 35 listed as spare breakers. The breakers were not capped off or turned to the off position.
f) On 10/04/10, at 1:25 p.m., there was a surge protector plugged into a surge protector, in Room H-116A.
g) On 10/04/10, at 1:32 p.m., a 6 plug outlet adaptor was observed in the activities storage room, located next to Room H-116A.
h) On 10/04/10, at 1:35 p.m., a surge protector was plugged into a surge protector, in Room A-121.
i) On 10/06/10, at 10:26 a.m., the facility failed to provide semi-annual receptacle testing for wet location outlets located in the morgue, kitchen and cystology room.

Facility Staff V1 acknowledged the findings at the time of the survey.

Based on observation and staff interview, the facility failed to maintain the integrity of the building construction, providing a 1 hour separation, by failing to ensure that penetrations in walls and ceilings are sealed with fire rated material. This deficient practice could result in the spread of fire and/or smoke to other areas of the facility, and affected 5 of 23 smoke compartments. A smoke compartment is a space within the building enclosed by smoke barriers on all sides, including the top and the bottom, for the purpose of containing smoke or fire, in the event of a fire.

Findings:

During a tour of the facility, the following penetrations were observed at the following times and locations:
a)On 10/04/10 at 10:57 a.m., there was a junction box cover missing on the west wall, above electrical panel EILH6/00283, in the roof fan room.
b)On 10/04/10 at 10:59 a.m., there was a ceiling tile missing, in the maintenance office, on the roof.
c)On 10/04/10 at 11:34 a.m., there was an approximately 1 inch unsealed penetration in the north wall, next to the thermostat control box, in Room H569.
d)On 10/04/10 at 11:47 a.m., there was an approximately 1/2 inch penetration in the east wall in Room A526.
e)On 10/04/10 at 11:50 a.m., there were sixteen approximately 2 inch unsealed conduit pipes in Room A-525.
f)On 10/04/10 at 1:40 p.m., there was an approximately 3 inch unsealed conduit pipe penetration in Room A-118.
g)On 10/06/10 at 2:20 p.m., there was an approximately 6 inch unsealed conduit pipe in the north wall, in the fan control room, B level.
h)On 10/06/10 at 3:40 p.m., there was an approximately 10 inch unsealed penetration in the corridor wall located by Room C-C04.

Facility Staff V1 acknowledged the findings at the time of the survey.

Based on observation and interview, the facility failed to maintain corridor doors free from obstructions to closing and latching. This was evidenced by corridor doors that failed to close and latch, by corridor doors that were obstructed, and by doors that failed to resist the passage of smoke. This could result in the spread of smoke or fire in the event of a fire, and affected 9 of 23 smoke compartments. A smoke compartment is a space within the building enclosed by smoke barriers on all sides, including the top and the bottom, for the purpose of containing smoke or fire, in the event of a fire.

Findings:During a tour of the facility, on 10/04/10, the following deficiencies were observed at the following times and locations:
a) At 10:45 a.m., the double corridor door to the roof welding room failed to latch.b) At 11:09 a.m., the corridor door to Room H-525, was obstructed by a bed. The door could not be closed.
c) At 11:15 a.m., the corridor door to Room H-525 failed to latch.
d) At 11:18 a.m., the corridor door to Room H-527 was obstructed by a gurney. The door could not be closed.
e) At 11:23 a.m., the corridor door to Room H-538 required more than 5 lbs. to open and close.
f) At 11:24 a.m., the door to Room 443 was obstructed by a bed.
g) At 11:27 a.m., the door to Room H-459 failed to positive latch. The door was equipped with a self-closing device.
h) At 11:32 a.m., the double corridor doors at nursing station B, 5th floor, failed to close and latch.
i) At 11:45 a.m., the emergency exit door located by Room A-531 failed to latch. The latching mechanism was observed stuffed with paper.
j) At 12:00 p.m., the door in Room 330 was obstructed by a chair.
k) At 1:23 p.m., corridor door H-114A was obstructed by a built-in cabinet and shelving.
l) At 1:24 p.m., the door in Room H-263 failed to positive latch. The door was equipped with a self-closing device.
m) At 1:30 p.m., the door to the activities storage room, 1st floor, Room H-116B, could not be opened to full capacity due to storage behind the door.
n) At 1:38 p.m., corridor door H-122 was observed held open by a kickstand door hold.
o) At 1:45 p.m., the pass through door located in Room A-120 leading into room A-121 was obstructed by a bookshelf.
p) At 2:30 p.m., 4 unsealed dime sized penetrations were observed in the door, and 3 unsealed dime sized penetrations were observed in the door frame, of the dietary men's locker room door. A self-closing device had been removed from the door.

Facility Staff V1 acknowledged the findings at the time of the survey.

Based on observation and interview, the facility failed to provide hold open devices for cross-corridor doors, and failed to maintain the doors that automatically close upon activation of the fire alarm system. This was evidenced by doors that were not equipped with magnetic hold open devices that were connected to the fire alarm system, and by doors that failed to automatically close upon activation of the fire alarm sytem. This could result in the failure to contain a fire in a smoke compartment, and affected 3 of 23 smoke compartments. A smoke compartment is a space within the building enclosed by smoke barriers on all sides, including the top and the bottom, for the purpose of containing smoke or fire, in the event of a fire.



Findings:

During at tour of the facility, the following deficiencies were observed at the following times and locations:
a)On 10/04/10 at 11:10 a.m., the cross-corridor separation doors, located by room H-524, were held open by kickstand hold open devices.
b) On 10/04/10 at 11:32 a.m., the cross corridor doors, on the 3rd floor by Room H328, were held open by kickstand hold open devices.
c) On 10/04/1, at 11:35 a.m., the cross corridor doors, on the 3rd floor by Room H322, were held open by kickstand hold open devices.
d) On 10/06/10 at 1:17 p.m., the fire doors to the welding room on the roof were held open by magnetic devices. When the fire alarm was activated, the right leaf door failed to positive latch.
e) On 10/06/10 at 1:27 p.m., the fire doors in nurse station 5D, on the 5th floor, were held open by magnetic devices. When the fire alarm was activated, the right leaf door was obstructed from closing by a cart.

Facility Staff V1 acknowledged the findings at the time of the survey.

Based on observation, record review, and staff interviews, the facility failed to maintain the smoke barrier walls with a one hour fire resistance rating in accordance with Section 8.3. This was evidenced by unsealed penetrations in the smoke barrier walls. This could result in the spread of smoke or fire from one smoke compartment to another in the event of a fire, and affected 3 of 23 smoke compartments. A smoke compartment is a space within the building enclosed by smoke barriers on all sides, including the top and the bottom, for the purpose of containing smoke or fire, in the event of a fire.

Findings:
During a tour of the facility on 10/04/10, the fire smoke barrier walls were observed at the following times and locations:
a) At 1:00 p.m., the 1st floor Center for Health fire smoke barrier wall was observed. The smoke compartment wall, running the length of the admitting offices, was observed. There were three approximately 2 foot wide by 2 foot long square penetrations observed in the wall, approximately 6 feet apart. Cables, wires and flexible conduit pipes were observed passing through the three penetrations. At 10:55 a.m., building plans for the 1st floor Center for Health smoke barrier walls and compartments were requested. At 1:20 p.m., the building plans dated "1967", were reviewed. The building plans showed the corridor as a smoke compartment, and the corridor walls extend fully to the ceiling. At 1:05 p.m., an interview was conducted with staff member V1. Staff member V1 stated the three approximately 2 foot wide by 2 foot long square penetrations were used as a plenum to circulate air in that smoke compartment. A plenum is a compartment or chamber to which one or more air ducts are connected and that forms part of the air distribution system.

On 10/05/10 at 4:06 p.m., an interview was conducted with staff member V1. The staff member confirmed that the Center for Health is part of the hospital's license.

b)At 1:10 p.m., an approximately 3/4 inch unsealed conduit pipe was observed in the smoke barrier wall located by Room H-114.
c) At 1:40 p.m., two approximately 1/2 inch unsealed conduit pipes were observed in the smoke barrier wall, in the First floor ancillary building, by Room H-123.

Staff member V1 acknowleged the penetrations in the smoke barrier walls.

Based on observation, the facility failed to maintain the cross-corridor doors. This was evidenced by cross corridor doors that failed to close and latch. This could result in the spread of smoke or fire from one compartment to another in the event of a fire, and affected all patients and staff in 6 of 23 smoke compartments. A smoke compartment is a space within the building enclosed by smoke barriers on all sides, including the top and the bottom, for the purpose of containing smoke or fire, in the event of a fire.



Findings:

During a tour of the facility, the following cross-corridor fire doors were observed deficient at the following times and locations:
a) On 10/04/10, at 11:04 a.m., the cross-corridor fire doors located by Room C-120, 1st floor, failed to latch.
b) On 10/04/10, at 1:07 p.m., the cross-corridor fire doors located by Room H-114, 1st floor, failed to latch.
c) On 10/04/10, at 1:40 p.m., the cross-corridor fire doors located by Room H-123, 1st floor of the ancillary building, failed to latch.

Based on observation and interview, the facility failed to maintain the exit access readily accessible at all times. This was evidenced by two emergency exit doors that were obstructed by the storage of items. This affected 2 of 23 smoke compartments, and could result in a delay of egress in the event of an emergency evacuation. A smoke compartment is a space within the building enclosed by smoke barriers on all sides, including the top and the bottom, for the purpose of containing smoke or fire, in the event of a fire.



Findings:

During a tour of the facility with staff on 10/4/10, the emergency exit doors were observed.

1. At 11:53 a.m., the exit door in the outpatient surgery, on the 3rd floor in the north hallway by Room A-321, was obstructed by six pieces of medical equipment.
2. At 2 p.m., the exit door that was across from C-C18, in the C level, was obstructed by six 64 gallon bins.

Facility Staff V1 acknowledged the findings at the time of the survey.

Based on observation, the facility failed to maintain, test and inspect battery powered emergency lighting located in Operating rooms 1, 2, 3 and the OR cysto room, in accordance with 7.9.2.4 and 7.9.3. This was evidenced by the
failure to provide documentation of the monthly inspections, and the annual test, of the battery operated emergency lights in the Operating Rooms and the OR cysto room. This could result in a loss of lighting in the event of a loss of power in the facility.

7.9.2.4 Battery-operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition. Batteries used in such lights or units shall be approved for their intended use and shall comply with NFPA 70, National Electrical Code®.
7.9.3 Periodic Testing of Emergency Lighting Equipment. 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
11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During a tour of the facility on 10/04/10, emergency battery powered light fixtures were observed in Operating Rooms 1, 2, 3 and in the cysto room.

On 10/06/10 during record review at 11:30 a.m., documentation was requested for the monthly inspection and the annual test of the battery operated emergency lights. The facility failed to provide documentation for the monthly 30 second test, and the 1 1/2 hour annual test of the battery operated emergency lighting. At 11:35 a.m. in an interview with staff member V2, staff member V2 stated they do not conduct a test on the battery operated lighting located in the operating rooms.

Based on record review and staff interview, the facility failed to conduct semi-annual disaster drills. This was evidenced by the failure to conduct disaster drills twice a year at 6 month intervals, that included all staff, providing training to ensure staff have knowledge of what to do if a disaster should occur. This could result in staff not being familiar with emergency procedures in the event of a fire or other emergency, and affected all patients and staff.

NFPA 99, 1999 edition
11-5.3.9 Drills
Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both.

Findings:

During record review with staff on 10/5/10, the disaster drills records were reviewed.

At 2:30 p.m., the facility failed to conduct simulated disaster drills that included all staff members on duty. The facility conducted two disaster drills in a 12 month period, 8 months apart. Disaster drills were conducted on 9/28/09, and on 5/6/10.

During an interview with staff at 2:45 p.m., staff member U3 stated that they were responsible for conducting the facility's disaster drills. They stated that they have been in this current position for approximately 3 weeks.

Based on observation, staff interview and record review, the facility failed to conduct and/or document simulated fire drills, one per shift per quarter, and ensure staff was familiar with the facility's fire and disaster policy and procedures. This was evidenced by incomplete documentation for 12 of 12 fire drills provided, and by 2 of 5 staff that when interviewed were not familiar with the facility's fire/disaster procedures. This could result in staff not being familiar with emergency fire procedures, and affected all patients and staff.

Findings:

During a tour of the facility and record review on 10/04/10 through 10/06/10, the following deficiencies were observed:

a) On 10/05/10 at 2:00 p.m., the documentation provided for fire drills did not include a sign in sheet for all departments/staff members on duty when the fire drill was conducted. The facility documented drills on four different type of forms. Each of the drills was missing a sign in sheet, department list, and shifts on duty during the fire drills conducted. Sign in sheets, fire drill forms, and information requested on the fire drills forms was incomplete and/or missing for the first, second and third quarters of 2010, and the 4th quarter of 2009, for all shifts and departments.

During an interview with staff at 2:45 p.m., staff member U3 stated was aware that the forms were incomplete.

b) On 10/04/10, at 2:32 p.m., dietary staff member V2 was interviewed and was asked to explain the facility's fire and disaster procedures. Staff member V4 did not know the fire procedures. Staff member V4 was asked what they would do if a fire occurred on the dietary stove, and staff member V4 did not know how to activate the ANSEL suppression system, and was not able to locate a manual fire alarm pull station. The ansel supression system is part of the kitchen fire alarm system, and has an activation handle which is pulled to activate the supression system in the event of a fire in the kitchen cooking area.

c) During fire alarm testing on 10/06/10, 4 staff members were being interviewed. At 1:38 p.m., 1 of 4 staff members interviewed did not know the facility's fire and disaster procedures. When staff on the 5th floor of ICU were asked what they would do in the event of a fire, 1 staff was unable to explain the fire procedures.

Based on observation, testing, record review, and staff interview, the facility failed to maintain, inspect and certify all fire alarm system devices. This was evidenced by the failure to ensure certified and qualified personnel inspected, tested and certified all fire alarm devices, by failing to provide complete records of testing and certification of the fire alarm system devices, and by the failure of the fire alarm control panel to re-set after activation of a device. This affected 23 of 23 smoke compartments, and could result in a delay in notification in the event of a fire. A smoke compartment is a space within the building enclosed by smoke barriers on all sides, including the top and the bottom, for the purpose of containing smoke or fire, in the event of a fire.

NFPA 72, 7-1.2.2 Service personnel shall be qualified and experienced in the inspection, testing, and maintenance of fire alarm systems.
Examples of qualified personnel shall be permitted to include, but shall not be limited to, individuals with the following qualifications:
(1) Factory trained and certified
(2) National Institute for Certification in Engineering Technologies fire alarm certified
(3) International Municipal Signal Association fire alarm certified
(4) Certified by a state or local authority
(5) Trained and qualified personnel employed by an organization listed by a national testing laboratory for the servicing of fire alarm systems

NFPA 90A, 1999 edition, 3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.
NFPA 90A, 1999 edition, 3-4.5.1 All fire dampers and ceiling dampers shall close automatically, and they shall remain closed upon the operation of a listed fusible link or other approved heat-actuated device located where readily affected by an abnormal rise of temperature in the air duct.
NFPA 90A, 1999 edition, 5-1 General.
NFPA 90A, 1999 edition, 5-1.1* An acceptance test shall be performed to determine that the protective measures required in this standard function when needed in order to restrict the spread of fire and smoke.
NFPA 90A, 1999 edition, 5-1.2 Records shall be maintained on acceptance test results and shall be available for inspection.

Findings:

During record review, and fire alarm system testing the following deficiencies were observed at the following times and locations:a) On 10/05/10 at 1:15 p.m., the facility failed to provide documentation from a certified fire alarm vendor for the testing and certification of the facility's fire smoke dampers. At 1:18 p.m., an interview was conducted with staff member V2. Staff member V2 stated that the facility does the fire smoke damper inspections in house. Staff member V2 was asked if the designated staff member is a certified fire alarm technician. Staff member V2 stated the staff member responsible for the testing is not certified.
b) On 10/05/10 at 1:59 p.m., the facility failed to provide documentation from a certified fire alarm vendor for the annual testing and certification for the cookson fire fly roll down doors located in the following areas: emergency room, PBX station, in-patient pharmacy, nursing station 3E, mental health cashier window, surgery reception window, 5th floor nursing station B, and the cancer center. An interview was conducted with staff member V2. Staff member V2 stated the facility conducts the testing in-house, and the staff member who is responsible for testing the cookson fire fly doors is not a certified fire alarm technician.
c) On 10/06/10 from 1:17 p.m., through 3:54 p.m., the fire alarm system was tested. 26 devices were activated. Of the 26 devices activated, 24 devices caused the fire alarm system control panel to malfunction. The fire alarm system silenced and/or rest itself after approximately 3 - 4 audible rings for 24 devices activated. At 1:58 p.m., staff member designated to reset the fire alarm control panel stated "I am not re-setting the fire alarm system, it seems to be silencing itself".
The following devices were tested, and after 3 - 4 audile rings, the fire alarm system stopped working:
1)Sprinkler water flow, #38-53, hospital roof.
2)Manual pull station #38-24, hospital roof.
3)Manual pull station #18-60, 5th. floor south exit.
4)Smoke detector, #24-9, 5th. floor by room 566.
5)Sprinkler water flow, #36-30, 5th. floor ancillary building.
6)Manual pull station, #36-29, 5th. floor ICU.
7)Sprinkler system water flow tamper alarm, #36-31, hospital roof.
8)Sprinkler water flow, #37-37, 4th. floor ancillary building.
9)Smoke detector, #37-15, 4th. floor ancillary lobby.
10)Manual pull station, #43-42, 4th. floor south exit.
11)Smoke detector, #31-19, 3rd. floor by laundry room.
12)Manual pull station, #32-1, 3rd. floor east stairwell.
13)Smoke detector, #29-30, 2nd. floor by x-ray room 2.
14)Manual pull station, #6-31, 2nd. floor east hallway.
15)Manual pull station, #1-56, 1st. floor by room 102.
16)Smoke detector, #2-40, 1st floor ancillary building, entrance/lab.
17)Smoke detector, #12-18, B level by room B21.
18)Tamper switch, #12-60, B level.
19)Manual pull station, #13-4, C level by mens bathroom.
20)Sprinkler water flow, #12-59, B level.
21)Manual pull station, #11-52, A level kitchen foyer.
22)Sprinkler system tamper, #1-16, doctors parking lot.
23)Sprinkle water flow, #1-13, 1st floor hospital/doctor parking lot.
24)Sprinkler tamper, #38-54, hospital roof.

Based on document review and interview, the facility failed to ensure all fire alarm devices are tested annually, as evidenced by an incomplete documentation for the annual fire alarm system testing/certification. This affected 23 of 23 smoke compartments, and could result in a malfunction of the fire alarm system. A smoke compartment is a space within the building enclosed by smoke barriers on all sides, including the top and the bottom, for the purpose of containing smoke or fire, in the event of a fire.

NFPA 72, 7-3.2*, Testing. Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual.
Table 7-3.2, #3 shall apply.
3. Engine-Driven Generator - Central Station Facilities and Fire Alarm Systems shall be tested monthly.
Table 7-3.2, Testing Frequencies
1. Control Equipment-Building system connected to supervising station.
(a) functions Annually
(b) Fuses Annually
(c) Interfaced equipment Annually
(d) Lamps and LEDs Annually
(e) Primary (Main)power supply Annually
(f) Transformers Annually

Findings:

During record review on 10/5/10, at 9:43 a.m., the annual fire alarm system report was reviewed. The facility failed to complete 100% of the annual fire alarm system testing. The fire alarm system report showed 90% completed. The facility has 1,248 fire alarm devices (excluding fire smoke dampers). The sprinkler system water flow, in quarter 3, was not tested to complete 100% of the 2009 annual fire alarm certification.

During an interview with staff at 9:45 a.m., staff member U1 stated they were not aware that the water flow was not tested at 100%. Staff explained that they had asked the vendor to come out earlier in the year to test all devices to ensure the facility was 100% completed.

Based on observation and interview, the facility failed to ensure smoke detectors were maintained. This was evidenced by smoke detection devices that were obstructed by storage of items under the device. This affected all patients and staff members in 3 of 23 smoke compartments. A smoke compartment is a space within the building enclosed by smoke barriers on all sides, including the top and the bottom, for the purpose of containing smoke or fire, in the event of a fire.



Findings:During a tour of the facility, the following smoke detectors were observed obstructed at the following times and locations:
a) On 10/04/10 at 11:10 a.m., the smoke detector located in H-516 was observed obstructed. Pillows and blankets were observed obstructing and covering the smoke detector.

b) On 10/04/10 at 1:35 p.m., the smoke detector located in room H-121, was observed obstructed. Items stored in the closet were stored to the ceiling, obstructing the smoke detector.

c) On 10/04/10, at 2:40 p.m., the smoke detector located in the dietary utility closet was observed obstructed. Catering supplies and dishes were observed stacked to the ceiling, touching the base of the smoke detector.

Facility Staff V1 acknowledged the findings at the time of the survey.

Based on observation, record review, interview, and testing of the sprinkler system, the facility failed to maintain the sprinkler system in reliable operating condition. This was evidenced by sprinkler head escutcheon rings that were not maintained flush with the ceiling, by the failure of the Inspector's Test Valve to activate the fire alarm system, and by incomplete records for testing and maintaining the automatic sprinkler system. This affected all patients and staff in 23 of 23 smoke comparments, and could result in a failure of the automatic sprinkler system. A smoke compartment is a space within the building enclosed by smoke barriers on all sides, including the top and the bottom, for the purpose of containing smoke or fire, in the event of a fire.



NFPA 25, table 2-1:
Summary of Sprinkler System Inspection, Testing, and Maintenance. Sprinkler system devices are to be tested quarterly to ensure system remains in a reliable operating condition.
Gauges (dry, preaction deluge systems) Inspection Weekly/monthly 2-2.4.2
Control valves Inspection Weekly/monthly Table 9-1
Alarm devices Inspection Quarterly 2-2.6
Gauges (wet pipe systems) Inspection Monthly 2-2.4.1
Hydraulic nameplate Inspection Quarterly 2-2.7
Buildings Inspection Annually (prior to freezing weather) 2-2.5
Hanger/seismic bracing Inspection Annually 2-2.3
Pipe and fittings Inspection Annually 2-2.2
Sprinklers Inspection Annually 2-2.1.1
Spare sprinklers Inspection Annually 2-2.1.3
Fire department connections Inspection Table 9-1
Valves (all types) Inspection Table 9-1
Alarm devices Test Quarterly 2-3.3
Main drain Test Annually Table 9-1
Antifreeze solution Test Annually 2-3.4
Gauges Test 5 years 2-3.2
Sprinklers - extra-high temp. Test 5 years 2-3.1.1 Exception No. 3
Sprinklers - fast response Test At 20 years and every 10 years thereafter
2-3.1.1 Exception No. 2
Sprinklers Test At 50 years and every 10 years thereafter 2-3.1.1
Valves (all types) Maintenance Annually or as needed Table 9-1
Obstruction investigation Maintenance 5 years or as needed Chapter 10

NFPA 72: 2-6 Sprinkler Waterflow Alarm-Initiating Devices. 2-6.1 The provisions of Section 2-6 shall apply to services that initiate an alarm indicating a flow of water in a sprinkler system. 2-6.2* Initiation of the alarm signal shall occur within 90 seconds of waterflow at the alarm-initiating device when flow occurs that is equal to or greater than that from a single sprinkler of the smallest orifice size installed in the system. Movement of water due to waste, surges, or variable pressure shall not be indicated.


Findings:During a tour of the facility, and testing of the sprinkler system, the following deficiencies were observed at the following times and locations:
a)On 10/04/10, at 10:43 a.m., 18 inches was not maintained between the items stored under the sprinkler header, located in room A-531.
b) On 10/04/10, at 11:46 a.m., 1 of 1 escutcheon rings in the waiting room by A-334, on the 3rd floor of physical therapy, was hanging down from the ceiling. There was an approximately ¼ inch penetration in the ceiling.
c) On 10/04/10, at 11:50 a.m., 1 of 1 escutcheon rings next to treatment room 3, on the 3rd floor of physical therapy, was hanging down from the ceiling. There was an approximately ¼ inch penetration in the ceiling.
d) On 10/04/10, at 11:51 a.m., 2 of 4 escutcheon rings in the speech therapy, on the 3rd floor, was hanging down from the ceiling. There was an approximately 1/4 inch penetration in the ceiling.
e)On 10/04/10, at 11:56 a.m., a 1/2 inch gap was observed around 1 of 2 sprinkler head escutcheon plates located in room A-513.
f)On 10/04/10, at 1:59 p.m., a 1/2 inch gap was observed around 2 of 3 sprinkler head escutcheon plates located in room A-108.
g) During document review with staff, on 10/5/10, at 2:20 p.m., " Fire Alarms & Sprinkler System: Quarterly Test, " records were reviewed. The facility failed to provide documentation for a sprinkler system test conducted for quarter 3. The documentation dated 7/2/10, for the 3rd quarter, was incomplete.
During an interview, at 2:48 p.m., staff member U2 stated the third quarter sprinkler test was not conducted, and the documentation was left blank because the testing was not conducted for that quarter.
h)On 10/06/10, at 1:37 p.m., the sprinkler system inspectors test valve located in the 5th floor stairwell, ICU, failed to activate the fire alarm system within 90 seconds of opening the valve. 200 seconds passed, and the fire alarm system did not activate.
i)On 10/06/10, at 2:00 p.m., the facility failed to provide documentation for the annual sprinkler system testing and certification.

Facility Staff V1 acknowledged the findings at the time of the survey.

Based on observation and interview, the facility failed to maintain the portable fire extinguishers. This was evidenced by portable fire extinguishers that were not mounted at proper heights, identification/location signs that were not provided for the portable fire extinguishers, and by a portable fire extinguisher that was missing the monthly checks of the extinguisher. This could result in a delay in locating and utilizing the portable fire extinguishers in the event of a fire, and affected all patients and staff in 23 of 23 smoke compartments. A smoke compartment is a space within the building enclosed by smoke barriers on all sides, including the top and the bottom, for the purpose of containing smoke or fire, in the event of a fire.



NFPA 10, 1998 Edition.
1-6.6* Fire extinguishers shall not be obstructed or obscured from view.
Exception: In large rooms, and in certain locations where visual obstruction cannot be completely avoided, means all be provided to indicate the location.
1-6.12 Fire extinguishers mounted in cabinets or wall recesses shall be placed so that the fire extinguisher operating instructions face outward. The location of such fire extinguishers shall be marked conspicuously. (See 1-6.6.)
Exception: In large rooms, and in certain locations where visual obstruction cannot be completely avoided, means all be provided to indicate the location.
1-6.7* Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer ' s instructions. Wheeled-type fire extinguishers shall be located in a designated location.
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 3 1/2 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).
1-6.12 Fire extinguishers mounted in cabinets or wall recesses shall be placed so that the fire extinguisher operating instructions face outward. The location of such fire extinguishers shall be marked conspicuously. (See 1-6.6.)


Findings:

During a tour of the facility, on 10/04/10, the following deficiencies were observed at the following times and locations:
a) At 11:06 a.m., the facility failed to provide a fire extinguisher identification sign for the fire extinguisher located by nursing station 5A.
b) At 11:17 a.m., a recessed portable ABC fire extinguisher across from Room A-418, on the 4th floor, was missing an identification sign
c)At11:25 a.m., the facility failed to provide a fire extinguisher identification sign for the fire extinguisher located by nursing station 5D.
d)At 11:30 a.m., the facility failed to provide a fire extinguisher identification sign for the fire extinguisher located by room H-575.
e)At 11:39 a.m., the facility failed to provide a fire extinguisher identification sign for the fire extinguisher located by H-525.
f)At 11:42 a.m., the facility failed to provide a fire extinguisher identification sign for the fire extinguisher located by A-531.
g) At 11:50 a.m., a recessed portable ABC fire extinguisher by Room H-319, on the 3rd floor, was missing an identification sign.
h) At 11:54, a recessed portable ABC fire extinguisher by Room A-332, on the 3rd floor, was missing an identification sign.
I)At 11:57 a.m., the facility failed to provide a fire extinguisher identification sign for the fire extinguisher located by room 8, ICU.
j) At 1:10 p.m., a recessed portable ABC fire extinguisher by Room A-219, on the 2nd floor, was missing an identification sign.
k) At 1:15 p.m., a recessed portable ABC fire extinguisher by Room A-200, on the 2nd floor, was missing an identification sign.
l)At 1:15 p.m., the facility failed to provide a fire extinguisher identification sign for the fire extinguisher located by H-132.
m)At 1:22 p.m., the facility failed to provide a fire extinguisher identification sign for the fire extinguisher located by room H-109.
n)At 1:22 p.m., the fire extinguisher located by room H-109, was observed undercharged, and the fire extinguisher was not signed off for the months of June, July and September 2010. Staff acknowledged that the documentation was missing for the monthly checks for the portable fire extinguishers.
o)At 1:25 p.m., the facility failed to provide a fire extinguisher identification sign for the fire extinguisher located by room H-116.
p)At 1:48 p.m., the facility failed to provide a fire extinguisher identification sign for the fire extinguisher located by room A-105.
q)At 1:54 p.m., the facility failed to provide a fire extinguisher identification sign for the fire extinguisher located by lab room A-109 and A-116.
r)At 2:40 p.m., the #2 "K" class fire extinguisher located in the dietary department was observed mounted higher than 5 feet above the ground.
s)At 2:45 p.m., the facility failed to provide a fire extinguisher identification sign for the fire extinguisher located by room H-123.

Facility Staff V1 acknowledged the failures to maintain the provide fire extinguishers at the time of the survey.

Based on observation and interview, the facility failed to ensure duct work for the heating, ventilation and air conditioning system is maintained in accordance with Section 9.2, NFPA 90A, and the manufacturer's specifications. This was evidenced by a penetration in the duct work. This could result in the spread of smoke or fire in the event of a fire, and affected all patients and staff in 1 of 23 smoke compartments. A smoke compartment is a space within the building enclosed by smoke barriers on all sides, including the top and the bottom, for the purpose of containing smoke or fire, in the event of a fire.

NFPA 90A, 5.4.7
Maintenance
At least every 4 years, the following maintenance shall be performed:
(1) Fusible links (where applicable) shall be removed.
(2) All dampers shall be operated to verify that they close fully.
(3) The latch, if provided, shall be checked.
(4) Moving parts shall be lubricated as necessary.

Findings:During a tour of the facility on 10/04/10, at 10:54 a.m., an approximately 6 inch by 6 inch piece of cardboard was taped to the duct work with duct tape. The cardboard was removed, and there was an approximately 5 inch by 5 inch penetration in the metal duct work.

Facility Staff V1 acknowledged the findings at the time of the survey.

Based on observation and interview, the facility failed to maintain the kitchen hood system and devices, which included the ansel supression system, kitchen hood system, and kitchen hood system automatic sprinkler system devices. This was evidenced by the failure to maintain the kitchen hood system sprinkler caps, and by the failure to provide complete documentation of conducting the semi-annual cleaning of the kitchen hood. This affected one of 23 smoke compartments, and could result in an increased risk of fire. A smoke compartment is a space within the building enclosed by smoke barriers on all sides, including the top and the bottom, for the purpose of containing smoke or fire, in the event of a fire.

NFPA 96, 11.2


Findings:

1. During a tour of the facility, on 10/04/10, at 2:45 p.m., 3 of 8 red blow off caps to the hood system's automatic sprinkler heads were observed detached. The red blow off caps are part of kitchen hood supression system devices.


2. During record review with Staff V2, on 10/5/10, the kitchen records were requested. At 10:45 a.m., the facility failed to provide documentation for two semi-annual cleaning of the kitchen range hood. The range hood was cleaned on 9/15/10. The previous cleaning was done on 10/28/09.

Based on observation and staff interview, the facility failed to enure that portable space heaters used in staff offices do not exceed 212 degrees Farenheit (F). This was evidenced by the use of two electrical space heaters without documentation that they did not exceed 212 degrees F. This could result in an increased risk of fire, and affected all staff and patients in 1 of 23 smoke compartments. A smoke compartment is a space within the building enclosed by smoke barriers on all sides, including the top and the bottom, for the purpose of containing smoke or fire, in the event of a fire.



Findings:During a tour of the facility, on 10/04/10, the following deficiencies were observed:

a) At 1:50 p.m., a portable space heater was observed in Room A-117. Engineering staff was unable to determine if the space heater met the regulatory requirements.
b) At 1:55 p.m., a portable space heater was observed in Room A-120. Engineering staff was unable to determine if the space heater met the regulatory requirements.

Based on observation and staff interview, the facility failed to maintain the corridors to full width. This was evidenced by the storage of items in the exit corridors. This could result in a delay in evacuation, and affected all patients and staff in 2 of 23 smoke compartments. A smoke compartment is a space within the building enclosed by smoke barriers on all sides, including the top and the bottom, for the purpose of containing smoke or fire, in the event of a fire.



Findings:

During a tour of the facility, the following items were observed stored in the corridors at the following times and locations:
a) On 10/04/10 at 11:55 a.m., and on 10/06/10, at 1:20 p.m., two supply carts and a portable x-ray machine were observed stored in the corridor located outside of Room A-513, ICU.
b) On 10/06/10 at 1:50 p.m., and 3:30 p.m., a portable x-ray machine, three x-ray carts, and a book cart were observed stored in the corridor, in the X-ray department by Room A-206.

Facility Staff V1 acknowledged the findings at the time of the survey.

Based on observation and interview, the facility failed to maintain the oxygen storage. This was evidenced by failing to properly store oxygen cylinders in designated room free from combustible materials, failing to secure the cylinders, and failing to ensure electrical light switch plates are not less than five feet above the floor. This affected 3 of 23 smoke compartments, and result in damage to a cylinder. A smoke compartment is a space within the building enclosed by smoke barriers on all sides, including the top and the bottom, for the purpose of containing smoke or fire, in the event of a fire.


NFPA 99, 4-3.1.1.1 Cylinder and Container Management. Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

4-3.5.2.1 (27) freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

4-3.1.1.2 (7) Combustible materials, such as paper, cardboard, plastics, and fabric shall not be stored or kept near supply system cylinders and/or manifolds containing oxygen or nitrous oxide. Racks for cylinder storage shall be permitted to be wooden construction. Wrappers shall be removed prior to storage.

4-3.1.1.2 (4) Electric wall fixtures, switches and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor, as a precaution against their physical damage.

Findings:

During a tour of the facility with staff on 10/4/10, the oxygen rooms were observed.

1. At 11:55 a.m., 12 "E"-type size oxygen tanks were observed stored in the outpatient surgery in Room A-318, on the 3rd floor. The room contained cleaning supplies, and the electrical light switch was mounted at approximately 56 inches from the floor.
2. At 1:14 p.m., one " H " -type size oxygen tank was observed stored next to Room A-202, on the 2nd floor, and the electrical light switch was 56 inches from the floor.
3. At 2:03 p.m., two CO2 tanks were freestanding on the ground in Room C-C12, by the loading dock in C level.
4. At 2:30 p.m., one " D " -type size oxygen tank was observed stored unsecured on the ground, in the exterior medical gas storage area.

Facility Staff V1 acknowledged the findings at the time of the survey.

Based on record review and staff interview, the facility failed to ensure humidity levels for the operating rooms 1, 2 and 3, and the cysto room, were maintained equal or greater than 35%. This was evidenced by humidity levels that were not maintained equal or greater than 35%. This could result in an increased risk of fire, and affected all patients and staff in the operating rooms and the cystology room.

Findings:

During record review, on 10/05/10, at 2:50 p.m., the following operating rooms fell below the required 35% humidity:
1. Operating Room 1 documentation provided showed the humidity fell below 35%, 80 days out of 365 days:
a) The humidity documented for 10/05/09 was 31%.
b) The humidity documented for 10/06/09 was 30%.
c) The humidity documented for 10/07/10 was 31%.
d) The humidity documented for 10/25/09 was 33%.
e) The humidity documented for 10/27/09 was 26%.
f) The humidity documented for 10/28/09 was 19%.
g) The humidity documented for 10/29/09 was 26%.
h) The humidity documented for 11/12/09 was 34%.
i) The humidity documented for 11/13/09 was 33%.
j) The humidity documented for 11/17/09 was 30%.
k) The humidity documented for 11/15/09 was 32%.
l) The humidity documented for 11/16/09 was 34%.
m) The humidity documented for 11/23/09 was 32%.
n) The humidity documented for 11/24/09 was 33%.
o) The humidity documented for 11/27/09 was 31%.
p) The humidity documented for 11/28/09 was 17%.
q) The humidity documented for 11/29/09 was 18%.
r) The humidity documented for 11/30/09 was 27%.
s) The humidity documented for 12/03/09 was 34%.
t) The humidity documented for 12/04/09 was 32%.
u) The humidity documented for 12/05/09 was 18%.
v) The humidity documented for 12/06/09 was 20%.
w) The humidity documented for 12/07/09 was 27%.
x) The humidity documented for 12/08/09 was 25%.
y) The humidity documented for 12/09/09 was 20%.
z) The humidity documented for 12/10/09 was 21%.
aa) The humidity documented for 12/21/09 was 33%.
bb) The humidity documented for 12/22/09 was 27%.
cc) The humidity documented for 12/23/09 was 22%.
dd) The humidity documented for 12/03/09 was 34%.
ee) The humidity documented for 12/04/09 was 32%.
ff) The humidity documented for 12/05/09 was 18%.
gg) The humidity documented for 12/06/09 was 27%.
hh) The humidity documented for 12/08/09 was 25%.
ii) The humidity documented for 12/09/09 was 20%.
jj) The humidity documented for 12/10/09 was 21%.
kk) The humidity documented for 12/21/09 was 33%.
ll) The humidity documented for 12/22/09 was 27%.
mm) The humidity documented for 12/23/09 was 22%.
nn) The humidity documented for 12/24/09 was 33%.
oo) The humidity documented for 12/25/09 was 30%.
pp) The humidity documented for 2/22/10 was 33%.
qq) The humidity documented for 3/05/10 was 33%.
rr) The humidity documented for 3/06/10 was 28%.
ss) The humidity documented for 3/08/10 was 28%.
tt) The humidity documented for 3/09/10 was 26%.
uu) The humidity documented for 3/10/10 was 31%.
vv) The humidity documented for 3/11/10 was 31%.
ww) The humidity documented for 3/13/10 was 20%.
xx) The humidity documented for 3/14/10 was 23%.
yy) The humidity documented for 3/18/10 was 22%.
zz) The humidity documented for 3/19/10 was 21%.
aaa) The humidity documented for 3/20/10 was 30%.
bbb) The humidity documented for 3/23/10 was 25%.
ccc) The humidity documented for 3/27/10 was 28%.
ddd) The humidity documented for 3/28/10 was 27%.
eee) The humidity documented for 3/30/10 was 31%.
fff) The humidity documented for 3/31/10 was 31%.
ggg) The humidity documented for 4/01/10 was 26%.
hhh) The humidity documented for 4/02/10 was 34%.
iii) The humidity documented for 4/03/10 was 32%.
jjj) The humidity documented for 4/05/10 was 32%.
kkk) The humidity documented for 4/06/10 was 30%.
lll) The humidity documented for 4/07/10 was 34%.
mmm) The humidity documented for 4/09/10 was 29%.
nnn) The humidity documented for 4/15/10 was 34%.
ooo) The humidity documented for 4/25/10 was 32%.
ppp) The humidity documented for 4/26/10 was 28%.
qqq) The humidity documented for 4/30/10 was 26%.
rrr) The humidity documented for 5/02/10 was 27%.
sss) The humidity documented for 5/04/10 was 30%.
ttt) The humidity documented for 5/05/10 was 29%.
uuu) The humidity documented for 5/06/10 was 16%.
vvv) The humidity documented for 5/07/10 was 30%.
www) The humidity documented for 5/08/10 was 31%.
xxx) The humidity documented for 5/21/10 was 32%.
yyy) The humidity documented for 5/22/10 was 31%.
zzz) The humidity documented for 5/29/10 was 29%.
aaaa) The humidity documented for 6/11/10 was 34%.
bbbb) The humidity documented for 8/25/10 was 33%.


2. Operating Room 2 documentation provided showed the humidity fell below 35%, 52 days out of 365 days:
a) The humidity documented for 10/05/09 was 31%.
b) The humidity documented for 10/06/09 was 30%.
c) The humidity documented for 10/07/09 was 31%.
d) The humidity documented for 10/27/09 was 25%.
e) The humidity documented for 10/28/09 was 21%.
f) The humidity documented for 10/29/09 was 28%.
g) The humidity documented for 11/12/09 was 33%.
h) The humidity documented for 11/13/09 was 32%.
i) The humidity documented for 11/15/09 was 31%.
j) The humidity documented for 11/16/09 was 33%.
k) The humidity documented for 11/23/09 was 34%.
l) The humidity documented for 11/28/09 was 21%.
m) The humidity documented for 11/29/09 was 23%.
n) The humidity documented for 11/30/09 was 32%.
o) The humidity documented for 12/04/09 was 33%.
p) The humidity documented for 12/05/09 was 19%.
q) The humidity documented for 12/06/09 was 20%.
r) The humidity documented for 12/07/09 was 24%.
s) The humidity documented for 12/08/09 was 24%.
t) The humidity documented for 12/09/09 was 22%.
u) The humidity documented for 12/10/09 was 24%.
v) The humidity documented for 12/22/09 was 27%.
w) The humidity documented for 12/23/09 was 23%.
x) The humidity documented for 12/25/09 was 32%.
y) The humidity documented for 3/08/10 was 33%.
z) The humidity documented for 3/09/10 was 25%.
aa) The humidity documented for 3/10/10 was 29%.
bb) The humidity documented for 3/11/10 was 32%.
cc) The humidity documented for 3/13/10 was 21%.
dd) The humidity documented for 3/14/10 was 25%.
ee) The humidity documented for 3/18/10 was 22%.
ff) The humidity documented for 3/19/10 was 21%.
gg) The humidity documented for 3/20/10 was 31%.
hh) The humidity documented for 3/23/10 was 32%.
ii) The humidity documented for 3/27/10 was 31%.
jj) The humidity documented for 3/28/10 was 30%.
kk) The humidity documented for 3/30/10 was 34%.
ll) The humidity documented for 3/31/10 was 34%.
mm) The humidity documented for 4/01/10 was 29%.
nn) The humidity documented for 4/06/10 was 34%.
oo) The humidity documented for 4/09/10 was 26%.
pp) The humidity documented for 4/25/10 was 32%.
qq) The humidity documented for 4/26/10 was 29%.
rr) The humidity documented for 4/30/10 was 27%.
ss) The humidity documented for 5/02/10 was 28%.
tt) The humidity documented for 5/04/10 was 31%.
uu) The humidity documented for 5/05/10 was 30%.
vv) The humidity documented for 5/06/10 was 19%.
ww) The humidity documented for 5/07/10 was 30%.
xx) The humidity documented for 5/08/10 was 31%.
yy) The humidity documented for 5/22/10 was 32%.
zz) The humidity documented for 5/29/10 was 33%.


3. Operating Room 3 documentation provided showed the humidity fell below 35% 47 days out of 365 days:
a) The humidity documented for 10/06/09 was 33%.
b) The humidity documented for 10/07/09 was 33%.
c) The humidity documented for 10/27/09 was 23%.
d) The humidity documented for 10/28/09 was 19%.
e) The humidity documented for 10/29/09 was 24%.
f) The humidity documented for 11/13/09 was 33%.
g) The humidity documented for 11/15/09 was 31%.
h) The humidity documented for 11/16/09 was 34%.
i) The humidity documented for 11/23/09 was 31%.
j) The humidity documented for 11/24/09 was 31%.
k) The humidity documented for 11/28/09 was 20%.
l) The humidity documented for 11/29/09 was 22%.
m) The humidity documented for 11/30/09 was 32%.
n) The humidity documented for 12/05/09 was 18%.
o) The humidity documented for 12/06/09 was 20%.
p) The humidity documented for 12/07/09 was 25%.
q) The humidity documented for 12/08/09 was 23%.
r) The humidity documented for 12/09/09 was 21%.
s) The humidity documented for 12/10/09 was 21%.
t) The humidity documented for 12/22/09 was 26%.
u) The humidity documented for 12/23/09 was 22%.
v) The humidity documented for 12/24/09 was 34%.
w) The humidity documented for 12/25/09 was 30%.
x) The humidity documented for 12/26/09 was 33%.
y) The humidity documented for 3/08/10 was 34%.
z) The humidity documented for 3/09/10 was 26%.
aa) The humidity documented for 3/10/10 was 32%.
bb) The humidity documented for 3/13/10 was 24%.
cc) The humidity documented for 3/14/10 was 27%.
dd) The humidity documented for 3/18/10 was 23%.
ee) The humidity documented for 3/19/10 was 23%.
ff) The humidity documented for 3/20/10 was 34%.
gg) The humidity documented for 3/23/10 was 28%.
hh) The humidity documented for 3/27/10 was 32%.
ii) The humidity documented for 3/28/10 was 32%.
jj) The humidity documented for 4/01/10 was 31%.
kk) The humidity documented for 4/03/10 was 34%.
ll) The humidity documented for 4/09/10 was 30%.
mm) The humidity documented for 4/25/10 was 34%.
nn) The humidity documented for 4/26/10 was 29%.
oo) The humidity documented for 4/30/10 was 29%.
pp) The humidity documented for 5/02/10 was 30%.
qq) The humidity documented for 5/05/10 was 32%.
rr) The humidity documented for 5/06/10 was 18%.
ss) The humidity documented for 5/07/10 was 30%.
tt) The humidity documented for 5/08/10 was 31%.
uu) The humidity documented for 5/29/10 was 30%.


4. Cystology Room documentation provided showed the humidity fell below 35%, 38 days out of 365 days:
a) The humidity documented for 10/06/09 was 32%.
b) The humidity documented for 10/07/09 was 34%
c) The humidity documented for 10/27/09 was 27%.
d) The humidity documented for 10/28/09 was 22%.
e) The humidity documented for 10/29/09 was 28%.
f) The humidity documented for 11/28/09 was 21%.
g) The humidity documented for 11/29/09 was 22%.
h) The humidity documented for 11/30/09 was 30%.
i) The humidity documented for 12/05/09 was 23%.
j) The humidity documented for 12/06/09 was 24%.
k) The humidity documented for 12/07/09 was 28%.
l) The humidity documented for 12/08/09 was 27%.
m) The humidity documented for 12/09/09 was 23%.
n) The humidity documented for 12/10/09 was 24%.
o) The humidity documented for 12/22/09 was 30%.
p) The humidity documented for 12/23/09 was 26%.
q) The humidity documented for 12/25/09 was 34%.
r) The humidity documented for 3/09/10 was 31%.
s) The humidity documented for 3/10/10 was 34%.
t) The humidity documented for 3/13/10 was 26%.
u) The humidity documented for 3/14/10 was 29%.
v) The humidity documented for 3/18/10 was 25%.
w) The humidity documented for 3/19/10 was 24%.
x) The humidity documented for 3/20/10 was 33%.
y) The humidity documented for 3/23/10 was 29%.
z) The humidity documented for 3/27/10 was 34%.
aa) The humidity documented for 3/28/10 was 34%.
bb) The humidity documented for 4/01/10 was 34%.
cc) The humidity documented for 4/08/10 was 31%.
dd) The humidity documented for 4/25/10 was 33%.
ee) The humidity documented for 4/26/10 was 29%.
ff) The humidity documented for 4/30/10 was 30%.
gg) The humidity documented for 5/02/10 was 31%.
hh) The humidity documented for 5/05/10 was 33%.
ii) The humidity documented for 5/06/10 was 21%.
jj) The humidity documented for 5/07/10 was 30%.
kk) The humidity documented for 5/08/10 was 31%.
ll) The humidity documented for 9/06/10 was 33%.

0n 10/05/10 at 4:00 p.m., an interview was conducted with staff members V2 and V3. Both staff members stated that the facility does not have a way to control the humidity levels in the Operating rooms and cystology room. Staff stated that several years ago the facility disconnected the system that was originally installed to control the humidity levels in the operating rooms.

Based on document review and interview, the facility failed to provide complete records for weekly inspections of the emergency generator. This was evidenced by incomplete records for 13 of 40 weekly generator inspections. This could result in a failure of the emergency generator in the event of a loss of power, and affected all patients and staff in the facility.


Findings:

During record review, on 10/05/10, at 3:00 p.m., the following records for the weekly inspections for the emergency generator were incomplete:
a) f) The facility failed to provide documentation for the week of 10/18/09 - 10/24/09.
b) The facility failed to provide documentation for the week of 10/11/09 - 10/17/09.
c) The facility failed to provide documentation for the week of 10/04/09 - 10/17/09.
d) The facility failed to provide documentation for the week of 11/22/09 - 11/28/09.
e) The facility failed to provide documentation for the week of 11/15/09 - 11/21/09.
f) The facility failed to provide documentation for the week of 11/08/09 - 11/14/09.
g) The facility failed to provide documentation for the week of 11/01/09 - 11/07/09.
h) The facility failed to provide documentation for the week of 10/25/09 - 10/31/09.
i) The facility failed to provide documentation for the week of 12/20/09 - 12/26/09.
j) The facility failed to provide documentation for the week of 4/25/10 - 5/01/10.
k) The facility failed to provide documentation for the week of 9/19/10 - 9/25/10.
l) The facility failed to provide documentation for the week of 9/12/10 - 9/18/10.
m) The facility failed to provide documentation for the week of 9/05/10 - 9/11/10.

Staff acknowledged that the documentation was missing for the weekly inspections of the emergency generator.




.

Based on observation, interview and record review, the facility failed to maintain the electrical utilities and connections in accordance with NFPA 70, NFPA 99, and the National Electrical Code (NEC). This was evidenced by the use of extension cords, by failing to maintain the electrical panels, and by failing to provide complete records of testing and maintaining the electrical outlets. This could result in an increased risk of an electrical fire, and affected all patients and staff in 23 of 23 smoke compartments. A smoke compartment is a space within the building enclosed by smoke barriers on all sides, including the top and the bottom, for the purpose of containing smoke or fire, in the event of a fire.

NFPA 70, 400-8 1999 edition, Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceiling, or floors.
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces

NFPA 70, article 240-4 1999 edition, Protection of Flexible Cords and Fixture Wires.
Flexible cord, including tinsel cord and extension cords, and fixtures wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixtures wire shall be protected against overcurrent in accordance with its ampacity as specified in table 402-5. Supplementary overcurrent protection, as in section 240-10, shall be permitted to be an acceptable mean cor providing this protection.
(b) Supply cord of listed appliance or portable lamps. Where flexible cord or tinsel cord is approved for and used with specific listed appliance or portable lamp, it shall be permitted to be supplied by a branch circuit of Article 210.
Also, HCFA transmittal notice 22-99, prohibits the use of extension cords without overcurrent protection (surge protectors).

NEC 70: 110-22: Connecting means required by this code for motors and or appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is clearly evident. The marking shall be of sufficient durability to withstand the environment involved.

NEC 70: 400-8 1999 edition, Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceiling, or floors.
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces

NFPA 99, 3-3.3.3 Receptacle Testing in Patient Care Areas.
(a) The physical integrity of each receptacle shall be confirmed by visual
inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be
verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle
shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle
(except locking-type receptacles) shall be not less than 115 grams (4 ounces).

7-6.2.1.2 Testing Intervals.
(a) The facility shall establish policies and protocols for the type of test and intervals of testing for each appliance. (b) All appliances used in patient care areas shall be tested in accordance with 7-5.1.3 or 7-5.2.2.1 before being put into

NFPA 99, 3-3.4.3.1 General - A record shall be maintained of the tests required by this chapter and associated repairs or modifications. At a minimum, this record shall contain the dates, the rooms or areas tested, and an indication of which items have met or have failed to meet the performance requirements of this chapter.

Findings:

During a tour of the facility, on 10/04/10 through 10/07/10, the following deficiencies were observed at the following times and locations:
a) On 10/04/10, at 10:55 a.m., an extension cord was observed plugged into a telephone/server "glenqyre" machine, located in the fan room, on the roof.
b) On 10/04/10, at 11:28 a.m., electrical panel #0218, located by Room 544, had electrical breakers 4, 16, and 22 listed as spare breakers. The breakers were not capped off or turned to the off position.
c) On 10/04/10, at 1:16 p.m., there was a surge protector was plugged into a surge protector, in Room H-138.
d) On 10/04/10, at 1:20 p.m., electrical panel #PNL3041, located in Room H-112, had electrical breakers 35. 37, 39, 41, and 42 listed as spare breakers. The breakers were not capped off or turned to the off position.
e) On 10/04/10, at 1:22 p.m., electrical panel #PNL3042, located in Room H-112, had electrical breakers 17, 19, 21, 25, 27, 33, and 35 listed as spare breakers. The breakers were not capped off or turned to the off position.
f) On 10/04/10, at 1:25 p.m., there was a surge protector plugged into a surge protector, in Room H-116A.
g) On 10/04/10, at 1:32 p.m., a 6 plug outlet adaptor was observed in the activities storage room, located next to Room H-116A.
h) On 10/04/10, at 1:35 p.m., a surge protector was plugged into a surge protector, in Room A-121.
i) On 10/06/10, at 10:26 a.m., the facility failed to provide semi-annual receptacle testing for wet location outlets located in the morgue, kitchen and cystology room.

Facility Staff V1 acknowledged the findings at the time of the survey.