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Based on observation, the facility failed to maintain the fire resistance rating of the 2-hour fire rated walls/barriers in accordance with NFPA 101, 2000 Edition, Section 8.2.3.2.4.2¹. This deficiency could affect 3 of 3 smoke compartments.

Findings include:

1. During an observation on 8/10/15 at 1:12 p.m., the 2-hour fire rated wall adjacent to the bathrooms near Shipping/Receiving contained three unsealed penetrations created by open ended conduits.¹

2. During an observation on 8/10/15 at 1:31 p.m., the 2-hour rated south wall of the Lab contained seven unsealed penetrations created by open ended conduits.¹

3. During an observation on 8/10/15 at 2:01 p.m., 2-hour rated north wall of the Central Supply contained an unsealed penetration created by an open ended conduit above the maintenance desk.¹

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

Based on observation and interview, the facility failed to ensure all exit corridor doors closed in accordance with NFPA 101, 2000 Edition, Section 18.3.6.3.2.¹ This deficiency could affect 1 of 3 smoke compartments.

Findings include:

During an observation on 8/10/15 at 2:39 p.m., the corridor door to patient room #7 was exercised. The corridor door failed to latch and could not be closed.¹

During an interview on 8/10/15 at 2:40 p.m., staff member A, facility services supervisor, stated the door was out of alignment.

¹ NFPA 101, 2000 Edition, Section 18.3.6.3.2; Doors shall be provided with positive latching hardware. Roller latches shall be prohibited.
Exception: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.

Based on observation, the facility failed to maintain hazardous one hour fire barriers per NFPA 101, 2000 Edition, Section 8.2.3.2.4.2¹. The deficiency could affect 1 of 3 smoke compartments.

Findings include:

During an observation on 8/10/15 at 12:59 p.m., the 1-hour fire rated wall contained four unsealed penetrations of open ended electrical conduits above the ceiling tiles on the south west wall of Shipping/Receiving.¹

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

Based on record review and interviews, the facility failed to conduct fire drills at a minimum of quarterly on each shift per NFPA 101, 2000 Edition, Section 18.7.1.2. This deficiency could affect all of the occupants in 3 of 3 smoke compartments.

Findings include:

Review of facility fire drill documents reflected fire drills were not conducted since 7/17/14. Fire drills are required to be conducted at least quarterly on all shifts.

During an interview on 8/10/15 at 11:30 a.m., staff member A, facility services supervisor, stated his understanding was to conduct drills on an annual basis.¹

During an interview on 8/10/15 at 3:05 p.m., staff member B, RN, charge nurse, stated she had not been a part of a fire drill for almost two years, since she was hired, but, she only worked the night shifts up until recently.

¹ NFPA 101, 2000 Edition, Section 18.7.1.2; Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Based on record review and interview, the facility failed to conduct load voltage tests on the batteries of the fire alarm control panel (FACP) semiannually as required per NFPA 72, 1999 Edition, Table 7-3.2.¹ The deficiency could affect 3 of 3 smoke compartments.

Findings include:

Review of the FACP test records reflected the annual maintenance of the panel was conducted on 7/17/14 and the load voltage testing had been done on the FACP sealed lead-acid batteries. The load voltage testing was not completed six months after the annual maintenance test by 2/16/15 (6 months plus 30 days).¹

During an interview on 8/10/15 at 11:15 a.m., staff member A, facility services supervisor, stated the load voltage tests were conducted once annually by the service contractor. Staff member A was neither aware of the requirement nor did he provide documentation verifying the load voltage tests were conducted every six months.

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

Based on record review and interview, the facility failed to maintain the fire alarm system maintenance documents in accordance with NFPA 72, 1999 Edition, Section 7-3.2.1¹ and 7-5.2.1². The deficiency could affect 3 of 3 smoke compartments.

Findings include:

Review of the facility's maintenance records reflected lack of annual sensitivity testing records for the smoke detectors after they were installed and first approved on 8/6/12.¹ The smoke detectors and alarm system were last tested on 7/17/14 and sensitivities should have been printed and maintained in the facility files. The next sensitivity test were required to have been conducted and reports printed no later than 8/16/15 (one year plus 30 days). A hard copy or the ability to print an electronic version of the smoke detector sensitivities shall be ready for review when requested.²

During an interview on 8/10/15 at 5:10 p.m., staff member A stated he would contact the service provider and ask for the documentation. On 8/11/15 at 8:52 a.m., staff member A stated in an email that the sensitivity reports were not available.

¹ NFPA 72 National Fire Alarm Code, 1999 Edition, Section 7-3.2.1; Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.

² NFPA 72, 1999 Edition, Section 7-5.2.1; Records shall be retained until the next test and for 1 year thereafter.

Based on record review and interview, the facility failed to ensure the kitchen hood exhaust system was inspected and cleaned on a semiannual basis in accordance with NFPA 96, 1998 Edition, Sections 8-3.1 and 8-3.1.1.¹ ² This deficiency could affect 1 of 3 smoke compartments.

Additionally, the facility failed to ensure the kitchen hood fire extinguishing system was inspected on a semiannual basis and necessary components were replaced annually in accordance with NFPA 96, 1998 Edition, Section 8-2 and 8-2.2.³ 4 This deficiency could affect 1 of 3 smoke compartments.

Findings include:

1. During an interview on 8/10/15 at 1:25 p.m., staff member A, facility services supervisor, stated the kitchen hood exhaust system had not been inspected or cleaned since the hospital was relocated to its new location in September 2012.¹ ²

Review of the facility's maintenance records lacked evidence and documentation that the kitchen hood exhaust system was inspected and cleaned semiannually.

2. Review of the facilities maintenance records reflected lack of evidence that the kitchen hood fire extinguishing system and all of its components were inspected and maintained semiannually. There was no evidence the bulb heads/fusible links were replaced annually.³ 4

During an interview on 8/10/15 at 12:15 p.m., staff member A stated he would contact the service contractor. No additional information was provided as of 8/11/15.

¹ NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 Edition, Section 8-3.1; Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1. Long term care facilities are considered moderate-volume cooking operations and therefore must have cleaning conducted semiannually.

² NFPA 96, 1998 Edition, Section 8-3.1.1; Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction.

³ NFPA 96, 1998 Edition, Sections 8-2; An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons; and Section 8-2.2; Fusible links (including fusible links on fire-actuated damper assemblies) and automatic sprinkler heads shall be replaced at least annually, or more frequently if necessary, to ensure proper operation of the system. Other detection devices shall be serviced or replaced in accordance with the manufacturer's recommendations.
Exception: Where automatic bulb-type sprinklers or spray nozzles are used and annual examination shows no buildup of grease or other material on the sprinkler or spray nozzles.

4 NFPA 96, 1998 Edition, Section 8-2.2; Fusible links (including fusible links on fire-actuated damper assemblies) and automatic sprinkler heads shall be replaced at least annually, or more frequently if necessary, to ensure proper operation of the system. Other detection devices shall be serviced or replaced in accordance with the manufacturer ' s recommendations.
Exception: Where automatic bulb-type sprinklers or spray nozzles are used and annual examination shows no buildup of grease or other material on the sprinkler or spray nozzles.

Based on observation, the facility failed to store oxygen cylinders in accordance with the standards of NFPA 99, 1999 Edition, Section 4-3.5.2.1.¹ This deficiency could affect 1 of 3 smoke compartments.

Findings include:

During an observation on 8/10/15 at 12:33 p.m., the main oxygen storage room contained a free standing E size oxygen cylinder. The cylinder was not secured to prevent it from tipping over.¹

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

Based on observation and interview, the facility failed to identify the branches of the Type I Essential Electrical System (EES) as to emergency system (life safety and critical branches) and the equipment system in accordance with the NFPA 70, 1999 Edition, Section 700-9.¹ The deficiency could affect 3 of 3 smoke compartments.

Findings include:

During on observation on 8/10/15 at 12:41 p.m., the emergency electric room contained three transfer switches for the Type I EES, the emergency generator. None of the automatic transfer switches were marked or labeled with branches of the EES that they served.¹

During an interview on 8/10/15 at 12:44 p.m., staff member A, facility services supervisor, stated he was not aware of the labeling requirement. He stated he would have to check with the contractor who serviced the generator to label EES branches appropriately.

¹ NFPA 70 National Electrical Code, 1999 Edition, 700-9. Wiring, Emergency System
(a) Identification; All boxes and enclosures (including transfer switches, generators, and power panels) for emergency circuits shall be permanently marked so they will be readily identified as a component of an emergency circuit or system.

Based on observation, the facility failed to maintain the electrical system and/or its components in accordance with the Centers for Medicare and Medicaid Services (CMS) Policy S&C-14-46-LSC.¹ This deficiency could affect 1 of 3 smoke compartments.

Findings include:

During an observation on 8/10/15 at 2:35 p.m., a microwave was found plugged into a power strip in the Nurses' lounge on the Acute Hall.¹ The unit was not a United Laboratories (UL) UL1363 listed product.

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

Based on observation, the facility failed to maintain the fire resistance rating of the 2-hour fire rated walls/barriers in accordance with NFPA 101, 2000 Edition, Section 8.2.3.2.4.2¹. This deficiency could affect 3 of 3 smoke compartments.

Findings include:

1. During an observation on 8/10/15 at 1:12 p.m., the 2-hour fire rated wall adjacent to the bathrooms near Shipping/Receiving contained three unsealed penetrations created by open ended conduits.¹

2. During an observation on 8/10/15 at 1:31 p.m., the 2-hour rated south wall of the Lab contained seven unsealed penetrations created by open ended conduits.¹

3. During an observation on 8/10/15 at 2:01 p.m., 2-hour rated north wall of the Central Supply contained an unsealed penetration created by an open ended conduit above the maintenance desk.¹

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

Based on observation and interview, the facility failed to ensure all exit corridor doors closed in accordance with NFPA 101, 2000 Edition, Section 18.3.6.3.2.¹ This deficiency could affect 1 of 3 smoke compartments.

Findings include:

During an observation on 8/10/15 at 2:39 p.m., the corridor door to patient room #7 was exercised. The corridor door failed to latch and could not be closed.¹

During an interview on 8/10/15 at 2:40 p.m., staff member A, facility services supervisor, stated the door was out of alignment.

¹ NFPA 101, 2000 Edition, Section 18.3.6.3.2; Doors shall be provided with positive latching hardware. Roller latches shall be prohibited.
Exception: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.

Based on observation, the facility failed to maintain hazardous one hour fire barriers per NFPA 101, 2000 Edition, Section 8.2.3.2.4.2¹. The deficiency could affect 1 of 3 smoke compartments.

Findings include:

During an observation on 8/10/15 at 12:59 p.m., the 1-hour fire rated wall contained four unsealed penetrations of open ended electrical conduits above the ceiling tiles on the south west wall of Shipping/Receiving.¹

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

Based on record review and interviews, the facility failed to conduct fire drills at a minimum of quarterly on each shift per NFPA 101, 2000 Edition, Section 18.7.1.2. This deficiency could affect all of the occupants in 3 of 3 smoke compartments.

Findings include:

Review of facility fire drill documents reflected fire drills were not conducted since 7/17/14. Fire drills are required to be conducted at least quarterly on all shifts.

During an interview on 8/10/15 at 11:30 a.m., staff member A, facility services supervisor, stated his understanding was to conduct drills on an annual basis.¹

During an interview on 8/10/15 at 3:05 p.m., staff member B, RN, charge nurse, stated she had not been a part of a fire drill for almost two years, since she was hired, but, she only worked the night shifts up until recently.

¹ NFPA 101, 2000 Edition, Section 18.7.1.2; Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Based on record review and interview, the facility failed to conduct load voltage tests on the batteries of the fire alarm control panel (FACP) semiannually as required per NFPA 72, 1999 Edition, Table 7-3.2.¹ The deficiency could affect 3 of 3 smoke compartments.

Findings include:

Review of the FACP test records reflected the annual maintenance of the panel was conducted on 7/17/14 and the load voltage testing had been done on the FACP sealed lead-acid batteries. The load voltage testing was not completed six months after the annual maintenance test by 2/16/15 (6 months plus 30 days).¹

During an interview on 8/10/15 at 11:15 a.m., staff member A, facility services supervisor, stated the load voltage tests were conducted once annually by the service contractor. Staff member A was neither aware of the requirement nor did he provide documentation verifying the load voltage tests were conducted every six months.

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

Based on record review and interview, the facility failed to maintain the fire alarm system maintenance documents in accordance with NFPA 72, 1999 Edition, Section 7-3.2.1¹ and 7-5.2.1². The deficiency could affect 3 of 3 smoke compartments.

Findings include:

Review of the facility's maintenance records reflected lack of annual sensitivity testing records for the smoke detectors after they were installed and first approved on 8/6/12.¹ The smoke detectors and alarm system were last tested on 7/17/14 and sensitivities should have been printed and maintained in the facility files. The next sensitivity test were required to have been conducted and reports printed no later than 8/16/15 (one year plus 30 days). A hard copy or the ability to print an electronic version of the smoke detector sensitivities shall be ready for review when requested.²

During an interview on 8/10/15 at 5:10 p.m., staff member A stated he would contact the service provider and ask for the documentation. On 8/11/15 at 8:52 a.m., staff member A stated in an email that the sensitivity reports were not available.

¹ NFPA 72 National Fire Alarm Code, 1999 Edition, Section 7-3.2.1; Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.

² NFPA 72, 1999 Edition, Section 7-5.2.1; Records shall be retained until the next test and for 1 year thereafter.

Based on record review and interview, the facility failed to ensure the kitchen hood exhaust system was inspected and cleaned on a semiannual basis in accordance with NFPA 96, 1998 Edition, Sections 8-3.1 and 8-3.1.1.¹ ² This deficiency could affect 1 of 3 smoke compartments.

Additionally, the facility failed to ensure the kitchen hood fire extinguishing system was inspected on a semiannual basis and necessary components were replaced annually in accordance with NFPA 96, 1998 Edition, Section 8-2 and 8-2.2.³ 4 This deficiency could affect 1 of 3 smoke compartments.

Findings include:

1. During an interview on 8/10/15 at 1:25 p.m., staff member A, facility services supervisor, stated the kitchen hood exhaust system had not been inspected or cleaned since the hospital was relocated to its new location in September 2012.¹ ²

Review of the facility's maintenance records lacked evidence and documentation that the kitchen hood exhaust system was inspected and cleaned semiannually.

2. Review of the facilities maintenance records reflected lack of evidence that the kitchen hood fire extinguishing system and all of its components were inspected and maintained semiannually. There was no evidence the bulb heads/fusible links were replaced annually.³ 4

During an interview on 8/10/15 at 12:15 p.m., staff member A stated he would contact the service contractor. No additional information was provided as of 8/11/15.

¹ NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 Edition, Section 8-3.1; Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1. Long term care facilities are considered moderate-volume cooking operations and therefore must have cleaning conducted semiannually.

² NFPA 96, 1998 Edition, Section 8-3.1.1; Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction.

³ NFPA 96, 1998 Edition, Sections 8-2; An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons; and Section 8-2.2; Fusible links (including fusible links on fire-actuated damper assemblies) and automatic sprinkler heads shall be replaced at least annually, or more frequently if necessary, to ensure proper operation of the system. Other detection devices shall be serviced or replaced in accordance with the manufacturer's recommendations.
Exception: Where automatic bulb-type sprinklers or spray nozzles are used and annual examination shows no buildup of grease or other material on the sprinkler or spray nozzles.

4 NFPA 96, 1998 Edition, Section 8-2.2; Fusible links (including fusible links on fire-actuated damper assemblies) and automatic sprinkler heads shall be replaced at least annually, or more frequently if necessary, to ensure proper operation of the system. Other detection devices shall be serviced or replaced in accordance with the manufacturer ' s recommendations.
Exception: Where automatic bulb-type sprinklers or spray nozzles are used and annual examination shows no buildup of grease or other material on the sprinkler or spray nozzles.

Based on observation, the facility failed to store oxygen cylinders in accordance with the standards of NFPA 99, 1999 Edition, Section 4-3.5.2.1.¹ This deficiency could affect 1 of 3 smoke compartments.

Findings include:

During an observation on 8/10/15 at 12:33 p.m., the main oxygen storage room contained a free standing E size oxygen cylinder. The cylinder was not secured to prevent it from tipping over.¹

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

Based on observation and interview, the facility failed to identify the branches of the Type I Essential Electrical System (EES) as to emergency system (life safety and critical branches) and the equipment system in accordance with the NFPA 70, 1999 Edition, Section 700-9.¹ The deficiency could affect 3 of 3 smoke compartments.

Findings include:

During on observation on 8/10/15 at 12:41 p.m., the emergency electric room contained three transfer switches for the Type I EES, the emergency generator. None of the automatic transfer switches were marked or labeled with branches of the EES that they served.¹

During an interview on 8/10/15 at 12:44 p.m., staff member A, facility services supervisor, stated he was not aware of the labeling requirement. He stated he would have to check with the contractor who serviced the generator to label EES branches appropriately.

¹ NFPA 70 National Electrical Code, 1999 Edition, 700-9. Wiring, Emergency System
(a) Identification; All boxes and enclosures (including transfer switches, generators, and power panels) for emergency circuits shall be permanently marked so they will be readily identified as a component of an emergency circuit or system.

Based on observation, the facility failed to maintain the electrical system and/or its components in accordance with the Centers for Medicare and Medicaid Services (CMS) Policy S&C-14-46-LSC.¹ This deficiency could affect 1 of 3 smoke compartments.

Findings include:

During an observation on 8/10/15 at 2:35 p.m., a microwave was found plugged into a power strip in the Nurses' lounge on the Acute Hall.¹ The unit was not a United Laboratories (UL) UL1363 listed product.

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