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Based on observations, interviews, and record review during the complaint survey completed on October 3, 2024, it was determined that the facility failed to maintain building construction standards in accordance with 2012 Life Safety Code 101 section 4.6.12 to comply with section 8. Specifically, the facility's hazardous areas, floors, and rated walls were not maintained to provide the intended containment of smoke and fire for passive fire protection.
These failures create the likelihood of serious adverse outcomes for all patients, staff, and visitors if a fire occurs within the facility.

The findings include:
I. Immediate Jeopardy

A. Findings of Immediate Jeopardy

Regulatory Requirement:
2012 Life Safety Code 101 section 19.3.7.3 to comply with section 8.5. Section 8.5.2.2, "Smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces."

2012 Life Safety Code 101 section 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction.

2012 Life Safety Code 101 section 4.6.12.4 Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected, or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.

2012 Life Safety Code 101 section 19.1.6.1 Health care occupancies shall be limited to the building construction types specified in Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7. (See 8.2.1.)

Observations:
Cross-reference to K321 for observations of multiple penetrations in walls and ceilings of hazardous areas that would allow smoke and fire to travel within the facility's maintenance area.

Cross-reference to K371 for observations and interviews related to numerous penetrations that preclude the maintenance of intended fire/smoke barriers.

Cross-reference to K223 for observations of numerous self-closing doors that would allow the travel of smoke and fire and void the fire resistance rating of the area.

Cross-reference to K225 for observations of stairways and smokeproof enclosures that had been modified for storage, which would allow the travel of smoke and fire and void the fire resistance rating of the area.

Cross-reference to K311 Vertical Opening enclosure that had been modified for storage would allow smoke and fire to travel and void the area's fire resistance rating.

Observations of the first floor, including the maintenance shop, boiler room, and maintenance room, revealed missing gypsum board from the ceiling throughout.

Patients, staff, and visitors were observed throughout the facility during the survey.

Interviews:
On 09/25/2024, the facility maintenance director acknowledged that the penetrations in the walls, ceilings, and floors and the floor construction did not conform to the requirements. The maintenance director and the compliance coordinator stated that they were not allowed to spend money on repairs to save money to build a new hospital.

On 09/25/2024, the maintenance director stated that the facility had been cited by its accrediting agency for the damages and modifications to the fire-rated door to the laundry room. However, the chief executive officer would not allow the door replacement because of the budget.

On 09/27/2024, the chief executive officer acknowledged that the facility had some problems with its compliance. He stated that every dollar spent on the current facility pushes them further from their goal of building a new hospital.

B. Notification of Immediate Jeopardy
On September 25, 2024, at 1:36 p.m., the maintenance director and compliance coordinator were informed that the facility's failures to maintain all rated assemblies, as designed, to prevent smoke and fire penetration created the likelihood of serious harm if the failures were not corrected immediately.

C. Facility Plan to Remove Immediate Jeopardy
On September 25, 2024, the facility submitted a plan to remove the immediate jeopardy. The removal plan read:

1) Plan: Patch and repair all penetrations to original fire resistance rating. May consult with design professional.
2) Procedure: Achieve compliance with NFPA 101
3) Monitering [sic]: Facility staff will monitor no less than weekly for ceiling penetrations
4. Person responsible: [staff proper name], Director of Maintenance

5. Completion: Will try to complete all repairs within 60 days bit may seek time-limited waiver if unable to get contractor in time.

D. Removal of Immediate Jeopardy
On September 25, 2024, at 4:30 p.m., the maintenance director and compliance coordinator were notified that the immediate jeopardy had been removed. Deficient practice will remain until all fire barriers and smoke barriers are restored to their rated assemblies per NFPA 101 2012.

Through observation during the survey, it was determined that the facility failed to meet the Egress Doors requirements in accordance with NFPA 101 19.2.2.2.4. This STANDARD is not met, as evidenced by:

Based on observation, the door to the Operating Room has a hasp-style lock on the outside. Through an interview, it was determined that the Operating Room has the Hasp and Lock to maintain its cleanliness after cleaning it.

Based on observation, the Gastroenterology (GI) Lab has a deadbolt-style lock on the door. This deadbolt is 60" above the finished floor. A deadbolt was added due to the field modifications to the door because of the roughness in the door and door frame, where it appears the door was cut in the field. Additionally, since the door was not manufactured for a deadbolt, the deadbolt latch is mounted on the surface of the door edge, creating a sticking point between the door and the door frame.


This did not meet the requirement of LSC Sections

7.2.1.5.1 Door leaves shall be arranged to be opened readily from the egress side whenever the building is occupied.

7.2.1.5.10.1 The releasing mechanism for any latch shall be located as follows: (1) Not less than 34 in. (865 mm) above the finished floor for other than existing installations (2) Not more than 48 in. (1220 mm) above the finished floor

19.2.2.2.4 Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within one smoke compartment. Deficient items were discussed during the survey and at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the Doors with Self-Closing Devices requirements in accordance with NFPA 101, 19.2.2.2.7. This STANDARD is not met, as evidenced by:

Based on observation, doors with self-closing devices were propped open throughout the facility or could not self-close and positively latch shut.

Based on observation, the doors self-closing device between the Hugo Specialty Clinic and the hospital were disabled.

Based on observation, the doors of the self-closing device between the Gordon Clinic and the hospital were disabled.

Based on the door to the stairwell in the main building, there was a door at the bottom with a self-closure device on the door. However, the door handle had been removed. This prevented the door from positively latching shut.

Based on observation, the door to the CT Scan trailer had been disabled by removing the closure arm of the door-closing device.

Based on observation, the door to the laundry room ' s self-closing device had been disabled by removing the closure arm. An interview with the Maintenance Director revealed that the facility's Accreditation Agency had cited them for this door, but the facility had not fixed it due to its price. Additionally, the interview determined that this door had been cut and disabled because of the extreme temperature fluctuations in this area.

This did not meet the requirement of LSC Sections

19.2.2.2.7* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be held open only by an automatic release device that complies with

7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2, shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the Stairways and Smokeproof Enclosures requirements in accordance with NFPA 101, 19.2.2.3. This STANDARD is not met, as evidenced by:

Based on observation, the stairwell next to the second-floor lobby, the stairway, and the smokeproof closure fire resistance rating have been diminished. The stairwell consists of concrete masonry unit (CMU) block wall construction. On level one, on the north side of the stairwell, a portion of the CMU block has been removed from the stairwell. The CMU around the opening is broken and damaged. This area is being used for storage. While standing inside the storage area, looking up at the stairs, the stair's construction is metal, and daylight comes in from the stringer and winders providing evidence that there is no fire-resistance rating between the storage and stairs. There is no sprinkler head in this area.


This did not meet the requirements of LSC Sections.

19.3.1.7 A door in a stair enclosure shall be self-closing and shall normally be kept in the closed position, unless otherwise permitted by 19.3.1.8.

7.2.2.5.3* Usable Space. Enclosed, usable spaces within exit enclosures shall be prohibited, including under stairs, unless otherwise permitted by 7.2.2.5.3.2.

7.2.2.5.3.2 Enclosed, usable space shall be permitted under stairs, provided that both criteria are met: (1) The space shall be separated from the stair enclosure by the same fire resistance as the exit enclosure. (2) Entrance to the enclosed, usable space shall not be from within the stair enclosure. (See also 7.1.3.2.3.)

7.2.2.5.1.2 Inside stairs, other than those serving as an exit or exit component, shall be protected in accordance with Section 8.6.
8.6.5* Required Fire Resistance Rating. The minimum fire-resistance rating for the enclosure of floor openings shall be as follows (see 7.1.3.2.1 for enclosure of exits): (1) Enclosures connecting four or more stories in new construction — 2-hour fire barriers (2) Other enclosures in new construction — 1-hour fire barriers (3) Existing enclosures in existing buildings — 1/2-hour fire barriers (4) Enclosures for lodging and rooming houses — as specified in Chapter 26 (5) Enclosures for new hotels — as specified in Chapter 28 (6) Enclosures for new apartment buildings — as specified in Chapter 30


This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the two smoke compartments. Deficient items were discussed during the survey and at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the Discharge from Exit requirements in accordance with NFPA 101, 19.2.7 . This STANDARD is not met, as evidenced by:

Based on observation, the stairwell door on the southwest side of the building does not terminate at a public way. After exiting the building, there is a concrete landing. At the bottom of the landing, the ground surface is landscaped rock and a decorative paver. Then, around 20 feet of travel through turf grass is made before the public way is reached.

Based on observation, the Exit from the west side does not terminate at a public way. After exiting the building, there is a concrete landing and four steps. At the bottom of the steps, the ground surface is landscaped rock and a decorative paver. Then, around 50 feet of travel through turf grass is made before the public way is reached.

Based on observation, the path to the public way outside the 2nd-floor lobby is of concrete construction. On top of the concrete landings and stairs is a topping of pebbles around one inch thick and permanently held together. On the landing and stairs closest to the building, sections of this topping have come off. This can create potential trip hazards and variations in sizes of adjected tread depths.


This did not meet the requirement of LSC Sections

7.7.1* Exit Termination. Exits shall terminate directly, at a public way, or an exterior exit discharge, unless otherwise provided in 7.7.1.2 through 7.7.1.4.

7.1.6.2 Changes in Elevation. Abrupt changes in elevation of walking surfaces shall not exceed 1/4 in. (6.3 mm). Changes in elevation exceeding 1/4 in. (6.3 mm), but not exceeding 1/2 in. (13 mm), shall be beveled with a slope of 1 in 2. Changes in elevation exceeding 1/2 in. (13 mm) shall be considered a change in level and shall be subject to the requirements of 7.1.7.

7.2.2.3.3.2* Stair treads and landings shall be free of projections or lips that could trip stair users.

7.2.2.3.6.1 Variation in excess of 3/16 in. (4.8 mm) in the sizes of adjacent tread depths or in the height of adjacent risers shall be prohibited unless otherwise permitted in 7.2.2.3.6.3.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at the exit conference.

Through observation, documentation review, and interview, it was determined that the facility failed to meet the Emergency Lighting requirements in accordance with NFPA 101. This STANDARD is not met, as evidenced by:

Through record review, not all of the emergency lights were listed on the emergency light documentation.

Throughout observation, the emergency lighting in the operating room was not connected to the lighting circuit but to a receptacle circuit.

Throughout observation, the emergency lighting in the Gastrointestinal room was not connected to the lighting circuit but to a receptacle circuit.

This did not meet the requirement of LSC Sections

7.9.2.3* The emergency lighting system shall be arranged to provide the required illumination automatically in the event of any interruption of normal lighting due to any of the following: (1) Failure of a public utility or other outside electrical power supply (2) Opening of a circuit breaker or fuse (3) Manual act(s), including accidental opening of a switch controlling normal lighting facilities

7.9.2.4 Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.

7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows: (1)Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2). (2)* The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction. (3) Functional testing shall be conducted annually for a minimum of 11/2 hours if the emergency lighting system is battery powered. (4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3). (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.


This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at the exit conference.

Through documentation, observation review, and interview, it was determined that the facility failed to meet the Exit Signage requirements in accordance with NFPA 101, 19.2.10. This STANDARD is not met, as evidenced by:

1) Based on observation, many exit signs throughout the facility were not illuminated. In an interview, the Maintenance Director acknowledged the low output from the exit lights but stated that if you open the sign, they are illuminated.


This did not meet the requirement of LSC Sections

7.10.9.1 Inspection. Exit signs shall be visually inspected for the operation of the illumination sources at intervals not to exceed 30 days or shall be periodically monitored in accordance with 7.9.3.1.3.

7.9.3.1.3 Testing of required emergency lighting systems shall be permitted to be conducted as follows: (1) Computer-based, self-testing/self-diagnostic battery-operated emergency lighting equipment shall be provided. (2) Not less than once every 30 days, emergency lighting equipment shall automatically perform a test with a duration of a minimum of 30 seconds and a diagnostic routine. (3) The emergency lighting equipment shall automatically perform annually a test for a minimum of 11/2 hours. (4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.3(2) and (3). (5) The computer-based system shall be capable of providing a report of the history of tests and failures at all times.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the Vertical Openings – Enclosure requirements in accordance with NFPA 101, 19.3.1. This STANDARD is not met, as evidenced by:

1) Based on observation, the stairwell next to the second-floor lobby, the stairway, and the smokeproof closure fire resistance rating have been diminished. The stairwell consists of concrete masonry unit (CMU) block wall construction. On level one, on the north side of the stairwell, a portion of the CMU block has been removed from the stairwell. The CMU around the opening is broken and damaged. This area is being used for storage. While standing inside the storage area, looking up at the stairs, the stair's construction is metal, and daylight comes in from the stringer and winders providing evidence that there is no fire-resistance rating between the storage and stairs. There is no sprinkler head in this area.

2) Based on the door to the stairwell in the main building, there was a door at the bottom with a self-closure device on the door. However, the door handle had been removed. This prevented the door from positively latching shut.

This did not meet the requirement of LSC Sections

19.3.1.1 Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.

19.3.1.7 A door in a stair enclosure shall be self-closing and shall normally be kept in the closed position, unless otherwise permitted by 19.3.1.8.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within two smoke compartments. Deficient items were discussed during the survey and at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the Hazardous Areas – Enclosure requirements in accordance with NFPA 101, 19.3.2.1. This STANDARD is not met, as evidenced by:

1) Based on observation, the door to the laundry room ' s self-closing device had been disabled by removing the closure arm. Through an interview with the Maintenance Director, it was learned that the facility's Accreditation Agency had cited them for this door, but the facility had not fixed it due to the price of the door. Additionally, through the interview, it was determined that this door had been cut and disabled because of the extreme temperature fluctuations in this area.

2) Based on observation, the storage room in the Emergency Room is considered hazardous because of its size and contents. The room has a hollow core door and no self-closing device separating it from the emergency room.

3) Based on observation, the maintenance shop had many penetrations on the walls and ceiling of this area. All these penetrations would allow smoke and fire to travel through in the event of a fire.

4) Based on observation, the Materials management door had no self-closing device. Upon further investigation and interview, it was determined that, at some point, this had been an operating room. When accessing this area from the corridor, you pass through a Dutch door, about 6 feet of a hallway, and then there is a door frame. This area must be assessed to ensure the added door will be in the proper door frame.

This did not meet the requirement of LSC Sections

19.3.2.1 Hazardous Areas.Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1.

19.3.2.1.3 The doors shall be self-closing or automatic-closing.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at the exit conference.

Through documentation review, it was determined that the facility failed to meet the Cooking Facilities requirements in accordance with NFPA 101, 19.3.2.5. This STANDARD is not met, as evidenced by:

1) Through document review, it was determined that the kitchen hood fire extinguishing system is past due for a hydrostatic test.

This did not meet the requirement of LSC Sections

19.3.2.5.1 Cooking facilities shall be protected in accordance with 9.2.3, unless otherwise permitted by 19.3.2.5.2, 19.3.2.5.3, or 19.3.2.5.4.

9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 96: 11.1.5 Listed exhaust hoods shall be operated in accordance with the terms of their listings and the manufacturer ' s instructions.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within one smoke compartment. Deficient items were discussed during the survey and at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the Alcohol Based Hand Rub Dispenser (ABHR) requirements in accordance with NFPA 101, 19.3.2.6. This STANDARD is not met, as evidenced by:

1) Based on observation, there is an Alcohol Based Hand Rub dispenser located above a power receptacle in the radiology room.

This did not meet the requirement of LSC Sections

19.3.2.6* Alcohol-Based Hand-Rub Dispensers. Alcohol-based hand-rub dispensers shall be protected in accordance with 8.7.3.1, unless all of the following conditions are met: (8) Dispensers shall not be installed in the following locations: (a) Above an ignition source within a 1 in. (25 mm) horizontal distance from each side of the ignition source (b) To the side of an ignition source within a 1 in. (25 mm) horizontal distance from the ignition source (c) Beneath an ignition source within a 1 in. (25 mm) vertical distance from the ignition source

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within one smoke compartment. Deficient items were discussed during the survey and at the exit conference.

Based on observations, interviews, and record review during the complaint survey completed on September 26, 2024, it was determined that the facility to install and maintain the fire alarm system in accordance with NFPA 101, section 19.1.1.4.4 and 43.5.1.3, including NFPA 72 National Fire Alarm Code. Specifically, the facility utilized a non-permitted fire alarm control panel, had missing smoke detection and had fire alarm devices in imaging trailer corridors, which created the possibility of undetected fire within the facility.

These failures created the likelihood of serious adverse outcomes for all patients, staff, and visitors if a fire occurred within the facility.

The findings include:

I. Immediate Jeopardy

A. Findings of Immediate Jeopardy

Regulatory Requirement:
8 CCR 1507-31 Article 6.5.2 Shop (Installation) drawings for fire protection and life safety systems shall be submitted to the Fire and Life Safety Code Official(s) for review and approval prior to beginning installation of the system. A) Fire sprinkler and fire alarm shop drawings shall be submitted to the Fire and Life Safety Code Officials in accordance with the requirements of the adopted codes in the format as prescribed by the Division and the local fire department.

NFPA 72 Section 10.14.2.1 All systems shall be installed in accordance with the specifications and standards approved by the authority having jurisdiction.

NFPA 72 Section 10.18.1.1 The authority having jurisdiction shall be notified prior to installation or alteration of equipment or wiring.

NFPA 72 Section 10.18.1.2 At the authority having jurisdiction's request, complete information regarding the system or system alterations, including specifications, type of system or service, shop drawings, input/output matrix, battery calculations, and notification appliance circuit voltage drop calculations, shall be submitted for approval.

NFPA 72 Section 10.18.2.1.2.4 A final copy of the record of completion shall be provided after completion of the operational acceptance tests.

NFPA 72 Section 10.18.2.3 Documentation Required. Every system shall include the following documentation, which shall be delivered to the owner or the owner's representative upon final acceptance of the system: (1)* An owner's manual and manufacturer's published instructions covering all system equipment (2) Record drawings (3) For software-based systems, record copy of the site-specific software (4) A written sequence of operation.

NFPA 72 Section 10.18.2.4* Verification of Compliant Installation. Where required, compliance of the completed installation with the requirements of this Code, as implemented via the referring code(s), specifications, and/or other criteria applicable to the specific installation, shall be certified by a qualified and impartial third-party organization acceptable to the authority having jurisdiction.

NFPA 72 Section 10.18.2.4.1 Verification shall ensure that the installed system includes all components and functions, that those components and functions are installed and operate as required, that the system has been 100 percent acceptance tested in accordance with Chapter 14, and that all required documentation has been provided to the system owner.

NFPA 72 Section 10.18.2.4.3 Verification shall include written confirmation that any required corrective actions have been completed.

Observations:
The fire alarm system had the following observed concerns:
-The facility had installed a Potter PFC-5000 Series Fire Alarm Panel with a manufacturer date 2022. This was not the system of record.
-A Public Emergency Alarm Reporting System had been installed. The manufacturer's date was May 2022.
-The corridor to the computerized tomography (CT) scanner had no smoke detection or notification devices.

Patients, staff, and visitors were observed throughout the facility during the survey.

Record Review:
Requests were made for documentation related to the fire alarm control panel and public emergency alarm reporting. Documentation review revealed:
-The new fire alarm control panel (FACP) did not receive initial acceptance testing.
-The facility did not obtain a permit for the new FACP.
-The facility had not obtained a permit for the public emergency alarm reporting.

Interviews:
On 9/26/2024, the facility maintenance director acknowledged that the FACP was changed; however, the change date was unknown. The facility maintenance director stated that the FACP was changed because the fire alarm contractor ruined the existing FACP while inspecting the system. The facility was not charged for the new FACP as the contractor made the mistake. The maintenance director acknowledged that the new FACP was a different make and model than the removed panel.

On 9/26/2024, hospital leadership conducted a video conference meeting with the owner of the fire alarm contractor company. During the meeting/interview, the owner of the fire alarm contractor company acknowledged the following:
-His company had shorted the previous FACP. The owner said the contractor replaced the damaged FACP with a new one. The owner gave a date of September 2022.
-A permit was not pulled with any authorities having jurisdiction.
-Initial acceptance testing was not performed on the replacement FACP.
-His company had added a public emergency alarm reporting system.
-His company did not pull permit with any authorities having jurisdiction for the public emergency alarm reporting system.
-Initial acceptance testing was not performed on the public emergency alarm reporting system.

B. Notification of Immediate Jeopardy
On September 26, 2024, at 9:30 a.m., the maintenance director and compliance coordinator were informed of the facility's failures to install and maintain the fire alarm system in accordance with NFPA 101 and NFPA 72, which created the likelihood of serious harm if the failures were not corrected immediately.

C. Facility Plan to Remove Immediate Jeopardy
On Sep 26, 2024, at 5:23?p.m., the facility submitted a plan to remove the immediate jeopardy. The removal plan read:

"Re: IJ Removal Plan for 8D9821 9-26-2024 @ 0930 Fire Alarms
1. Plan: Facility will go on Fire Watch. Have Nebraska Safety and Fire return to the facility to assess the needs to bring the fire suppression [sic] system up to code.
2. Procedure: Facility began Fire Watch protocols at 1000 on 9/26/24. NE Safety and Fire has been contacted and will be asked to return to facility for assessment and bid of work to be done to get the fire suppression [sic] system up to code.
3. Monitoring: Fire watch protocol has been implemented with completion of log for the entire facility.
4. Person responsible: [staff proper name], Director of Maintenance
5. Completion: Fire watch protocol began at 1000 on 9/26/24. Local fire agency vice chief [proper name] was notified that Lincoln is on Fire Watch at 1057."

D. Removal of Immediate Jeopardy
On September 26, 2024 at 5:30 p.m., the maintenance director and compliance coordinator, were notified the immediate jeopardy was removed. Deficient practice remains the facility installs and maintains a fire alarm system in accordance with NFPA 101, and NFPA 72.

Through documentation review, it was determined that the facility failed to meet the Fire Alarm System – Testing and Maintenance requirements in accordance with NFPA 101 and NFPA 72. This STANDARD is not met, as evidenced by:

1) Document review determined that the fire alarm system had an inspection on 03/14/2024 and 09/18/2024; however, both reports indicate semi-annual inspections. It was not clear which, if either, was an annual inspection.

2) A sensitivity testing report was not provided.


This did not meet the requirement of LSC Sections

19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

NFPA 72: 14.2.2.1* The property or building or system owner or the owner ' s designated representative shall be responsible for inspection, testing, and maintenance of the system and for alterations or additions to this system.

NFPA 72: 14.2.2.3 Inspection, testing, or maintenance shall be permitted to be done by the building or system owner or a person or organization other than the building or system owner if conducted under a written contract.

NFPA 72: 14.4.5 Testing Frequency. Unless otherwise permitted by other sections of this Code, testing shall be performed in accordance with the schedules in Table 14.4.5, or more often if required by the authority having jurisdiction.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at the exit conference.

Through observation, documentation review, and interview, it was determined that the facility failed to meet the Sprinkler System – Installation requirements in accordance with NFPA 101 and NFPA 13. This STANDARD is not met, as evidenced by:

1) Through observation during an above-ceiling inspection near Room 4, a sprinkler head that was not connected to the fire sprinkler system was found. The sprinkler head was in a 4-foot by 6-foot closet, and there was an access hatch through the ceiling in that same location. While looking above the ceiling for the sprinkler head nearest the access hatch, there was no sprinkler piping; some blown-in insulation was moved, and it revealed a 1-inch PVC "T." When the surveyor touched the sprinkler below the ceiling, the PVC "T" moved. The Sprinkler head was unthreaded, and the assembly consisted of a brass-fusible link-style sprinkler head threaded into a PVC fitting(Slip by Female Pipe Thread). The PVC fitting was dry-fitted into a 1-inch PVC T. There was no water to this T. Email correspondence with the Compliance Coordinator determined that in 2015 the maintenance staff made some changes to the walls. The Colorado Division of Fire Prevention and Control has no records of permits being obtained for this work.

2) Through observation, it was determined that a sprinkler head was not in the room 4 closet. This area is related to K-Tag 351 evidence #1. Email correspondence with the Compliance Coordinator determined that in 2015, the maintenance staff made some changes to the walls. The Colorado Division of Fire Prevention and Control has no records of permits being obtained for this work.

3) Through observation and interview, it was determined that room 106 had been converted to a cardiac rehab area. The Compliance Coordinator confirmed that this conversion occurred around 2016-2017. In this area, a room was created within the Cardiac Rehab room; the addition of the walls created sprinkler head obstructions and distances that would not allow the sprinkler to cover all areas of the room in the event of a fire. The Colorado Division of Fire Prevention and Control has no records of permits being obtained for this work.

4) Through observation, it was determined that the Restroon between the GI lab and the Cardiac Rehab rooms had a sprinkler head too close to the wall. The distance between the sprinkler head and the wall was less than 4 inches.

5) Based on observation, the stairwell next to the second-floor lobby, the stairway, and the smokeproof closure fire resistance rating have been diminished. The stairwell consists of concrete masonry unit (CMU) block wall construction. On level one, on the north side of the stairwell, a portion of the CMU block has been removed from the stairwell. The CMU around the opening is broken and damaged. This area is being used for storage. There is no sprinkler head in this area because it was exempt from needing sprinkler protection, but if an area contains storage, it must be protected.

This did not meet the requirement of LSC Sections

19.3.5.4* The sprinkler system required by 19.3.5.1 or 19.3.5.3 shall be installed in accordance with 9.7.1.1(1).

9.7.1.1 * Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following: (1) NFPA 13, Standard for the Installation of Sprinkler Systems (2) NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes (3) NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height

NFPA 13: 8.5.1.2 Sprinklers shall be positioned to provide protection of the area consistent with the overall objectives of this standard by controlling the positioning and allowable area of coverage for each sprinkler.

NFPA 13: 8.6.3.3 Minimum Distances from Walls. Sprinklers shall be located a minimum of 4 in. (102 mm) from a wall.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at the exit conference.

Based on observations, interviews, and record review during the complaint survey completed on October 3, 2024, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, and NFPA 101, 19.3.5, and 4.6.12. Specifically, the facility's failure to maintain its automatic sprinkler system created the potential for a failure to provide the intended sprinkler coverage during a fire.

These failures created the likelihood of serious adverse outcomes for all patients, staff, and visitors if a fire occurs within the facility.

The findings include:

I. Immediate Jeopardy

A. Findings of Immediate Jeopardy

Regulatory Requirement:

NFPA 25 Section 4.1.1.2 Inspection, testing, and maintenance shall be performed by personnel who have developed competence through training and experience.

NFPA 25 Section 4.1.4.1 The property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by this standard.

NFPA 25 Section 4.1.7 Valve Location. The location of shutoff valves shall be identified.

NFPA 25 Section 4.1.8.1 A permanently marked metal or rigid plastic information sign shall be placed at the system control riser supplying an antifreeze loop, dry system, preaction system, or auxiliary system control valve.

NFPA 25 Section 4.3.2 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.

NFPA 25 Section 4.5.1 All components and systems shall be tested to verify that they function as intended.

NFPA 25 Section 5.2.1.1.1 Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).

NFPA 25 Section 5.2.2.1 Pipe and fittings shall be in good condition and free of mechanical damage, leakage, and corrosion.

NFPA 25 Section 5.2.2.2 Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.

NFPA 25 Section 5.3.1.1.1 Where sprinklers have been in service for 50 years, they shall be replaced or representative samples from one or more sample areas shall be tested.

NFPA 25 Section 5.3.1.1.1.6 Dry sprinklers that have been in service for 10 years shall be replaced or representative samples shall be tested and then retested at 10-year intervals.

NFPA 25 Section 5.3.2.1 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge.

NFPA 25 Section 5.3.4 Antifreeze Systems. Annually, before the onset of freezing weather, the antifreeze solution shall be tested using the following procedure:

NFPA 25 Section 5.4.1.5 The stock of spare sprinklers shall include all types and ratings installed and shall be as follows:(1)For protected facilities having under 300 sprinklers - no fewer than 6 sprinklers(2)For protected facilities having 300 to 1000 sprinklers - no fewer than 12 sprinklers(3)For protected facilities having over 1000 sprinklers - no fewer than 24 sprinklers

Observations:
During the course of the survey, the following was observed:
-Sprinkler heads had missing or broken sprinkler escutcheons (flanges) throughout the facility.
-Sprinkler heads throughout the facility were loaded (dusty) or painted.
-Ceilings had missing ceiling tiles or penetrations.
-The IT room had a cardboard partition that obstructed the sprinkler head spray pattern.
-The storage closet near the lobby server room had antifreeze system that was missing information to identify if it was active and evaluated.
-The operating room adjacent storage closet antifreeze system was last inspected 6/15/2015. The pressure gauge for the antifreeze system was dated 2011.

On 9/27/2024 the facility's suppression system contractor conducting the annual inspection. The following concerns were identified:
-The suppression contractor was not aware of where the valves were located.
-An inspector's test valve was opened, water started flowing and suddenly stopped with no human intervention. The valve was manipulated, and the blockage did not clear.
-A main drain valve was connected to the inspector's test valve section. The main drain valve could flow water.

Patients, staff, and visitors were observed throughout the facility during the survey.

Record Review:
The following inspection dates contain zero deficiencies. 09/20/2022, 12/05/2022, 03/08/2023, 06/22/2023, 09/12/2023, 12/13/2023, 03/14/2023, 09/18/2024.

The 6/26/2024 inspection had one deficiency.

On 09/25/2024, the suppression contractor inspected the antifreeze system, which had not been inspected since 06/15/2015. The inspection report revealed three deficiencies.

On 09/27/2024, the suppression contractor completed a full annual wet-based fire suppression system inspection, with a qualified contractor overseeing the inspection. This inspection resulted in 11 deficiencies, seven of which the report listed as "Critical." The deficiencies and notes listed on the Wet Pipe Fire Sprinkler Report include:

1. Main shutoff valve does not shut off completely. No backflow assembly on fire sprinkler system, suggest installing one. No backflow assembly on antifreeze system, suggest installing one. Antifreeze tested at -5°F, suggest considering replacing antifreeze. Inspectors test valve in SW stairwell appears to be clogged with debris.
2. Multiple corroded heads throughout the facility.
3. Most mechanical rooms with obstructed heads
4. Multiple loaded heads throughout the facility
5. Multiple fast response heads throughout the facility due for sample testing/or replacement - will suggest to the customer that it would be most beneficial to replace all sprinkler heads in the facility.
6. Multiple heads throughout the facility over 50 years old or older - suggest replacing all heads in the facility
7. 2 dry pendants and 1 dry sidewall heads due to be replaced
8. The inspectors' test valve was clogged with debris after briefly flowing water. Suggest obstruction investigation.
9. No vertical sidewall heads in the spare cabinet.
10. Signs of corrosion on sprinkler pipe outside maintenance office
11. Wire and tubing zip-tied to sprinkler pipe in maintenance and specialty clinic
12. Could not perform a 5-year inspection because the main shutoff did not shut off completely.

The facility had no evidence that a five-year internal obstruction was completed as required.

Interviews:
On 09/25/2024, a representative from the fire suppression contractor stated that he was in the area of and his boss called and asked him to go to the facility to inspect one of the antifreeze systems. The representative stated that he does not typically do maintenance inspections on this facility. When asked if the antifreeze system had been tested after 06/15/2015, he responded that it did not appear it had been inspected since then.

On 09/26/2024, the facility maintenance director stated that their fire suppression contractor had just been at the facility, and no issues were noted or brought to the facility's attention.

On 09/26/2024, the facility maintenance director acknowledged that at least one antifreeze system was in the facility, which was not listed on the inspection reports.

On 09/27/2024, a representative from the fire suppression contractor could not find the inspector tests throughout the facility. When asked how the tests are performed monthly if the inspectors' tests are not used, they responded that they probably just inspect the main drain test.

On 09/27/2024, a representative from the fire suppression contractor was interviewed about why the dates of the sprinkler head were at or beyond 50 years, and the previous inspection report did not reflect that. The response was that the wording surrounding that section was confusing, and some authorities having jurisdiction did not like it to be checked, and some did. This section reads, "Standard response sprinklers 50 years old or more replaced or successfully sample tested in last 10 years?" The options to choose are Yes, No, or N/A.

B. Notification of Immediate Jeopardy

On September 26, 2024, at 9:30 a.m., the facility maintenance director and compliance coordinator were informed of the facility's failures of the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, and NFPA 101, 4.6.12. created the likelihood of serious harm if the failures were not corrected immediately.

C. Facility Plan to Remove Immediate Jeopardy
On Sep 26, 2024, at 5:23?PM, the facility submitted a plan to remove the immediate jeopardy. The removal plan read:

"IJ Removal Plan for 8D9821 9-26-2024 @ 0930 - Fire Suppression

1. Plan: Facility will go on Fire Watch. Have Nebraska Safety and Fire return to the facility to assess the needs to bring the fire suppression system up to code.

2. Procedure: Facility began Fire Watch protocols at 1000 on 9/26/24. NE Safety and Fire has been contacted and will be asked to return to facility for assessment and bid of work to be done to get the fire suppression system up to code.

3. Monitoring: Fire watch protocol has been implemented with completion of log for the entire facility.

4. Person responsible: [staff member name], Director of Maintenance

5. Completion: Fire watch protocol began at 1000 on 9/26/24. Local fire agency vice chief [proper name] was notified that Lincoln is on Fire Watch at 1057."

D. Removal of Immediate Jeopardy
On September 26, 2024, at 5:30 PM, the maintenance director and compliance coordinator were notified that the immediate jeopardy had been removed. Deficient practice will remain until the automatic sprinkler system is maintained in accordance with National Fire Protection Association (NFPA) 25 and NFPA 101.

Through observation, documentation review, and interview, it was determined that the facility failed to meet the Subdivision of Building Spaces – Smoke Compartments requirements in accordance with NFPA 101, 19.3.7. This STANDARD is not met, as evidenced by:

Through interviews, it was determined that no life safety plans for the building exist; therefore, a thorough and comprehensive survey of the smoke compartments can not be conducted.

Through observation, numerous penetrations above the ceilings do not maintain the suspected fire/smoke barriers.

This did not meet the requirement of LSC Sections

19.1.1.3.2 Because the safety of health care occupants cannot be ensured adequately by dependence on evacuation of the building, their protection from fire shall be provided by appropriate arrangement of facilities; adequate, trained staff; and development of operating and maintenance procedures composed of the following: (1) Design, construction, and compartmentation (2) Provision for detection, alarm, and extinguishment (3) Fire prevention procedures and planning, training, and drilling programs for the isolation of fire, transfer of occupants to areas of refuge, or evacuation of the building

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at the exit conference.

Through observation, interview, and document review during the survey, it was determined that the facility failed to meet the Utilities – Gas and Electric requirements in accordance with NFPA 101, NFPA 99, and NFPA 70. This STANDARD is not met, as evidenced by:

1) On September 25th, 2024, at approximately 10:30 AM, the surveyors started investigating what was believed to be inappropriate wiring in the Operating Room. There were 4 receptacles on the room's west wall and 2 receptacles on the east wall. All the receptacles in the room were in two gang boxes or double receptacles. On the west wall, the receptacles were in surface-mounted duplex boxes, which are common for adding receptacles to a circuit; however, they are uncommon in an operating room setting. One surface-mounted receptacle box was connected to another surface-mounted receptacle box by low profile plastic raceway- or surface-mounted conduit. The maintenance director was asked if the breaker tripped in this area where is the breaker to reset it, and he responded, " I don't know." Through interviews, it was also determined that this operating room provides full sedation to the patients. A receptacle tester was inserted into all the receptacles in the room, and all contained an "open ground," this was verified by a second receptacle tester. The Maintenance Director was asked to remove a receptacle from the raceway cover to check the wiring for compliance with NFPA 99. The wiring inside consisted of 14 gauge- 15 amp ROMEX brand wire, which is prohibited from operating rooms. Within the operating room, two electrical circuits were powering the 6 receptacles. The facility was notified that the operating room could not be used for operations until further assessments and corrective work had occurred. The ROMEX wire has a manufacture date of 11/13/2020.

At 1213, a Colorado Department of Regulatory Agencies(DORA) Electrical Inspector Supervisor was contacted to discuss the site conditions. On 09/26/2024 around 11:30 AM, the Electrical Inspector Supervisor met the Life Safety Surveyors onsite to perform a safety inspection(DORA Permit # 1011354), and the report in part reads

"Corrections:

517.19 Category 1 Spaces, (C)(1) Operating Room Receptacles. Minimum Number and Supply - Operating Room

Comments:
The safety inspection was for the Oprating Room and Maintenace Shop.

Inside the Operating Room, I (Aaron Skubal) observed wiremold with 14-2 NM inside the wiremold. Per DFPC the receptacles had an "open ground" when they checkd it with their receptacle tester, please see the correction below."

2) Through Observation, ROMEX wiring was observed throughout the maintenance shop in the basement. The DORA Electrical Inspector Supervisor confirmed this was not compliant. The DORA Permit #1011354 report in part reads "334.10(3) Uses Permitted, NM in Types III, IV, and V construction. Cables shall be concealed with a 15-minute finish rating - Maintenance area. Inside the Maintenance Shop there were several pieces of 12-2 NM exposed on the surface, please see the correction below.

3)Through observation, ROMEX wiring was observed to supply power to a refrigerator used for medicine storage in the basement near the maintenance shop. Through an interview, it was determined that this was non-compliant by the DORA Electrical Inspector Supervisor.

4) Through observation, wiring above the ceiling near room #4 appears to have a white wire running along sprinkler piping in the corridor.

This did not meet the requirement of LSC Sections

19.5.1.1 Utilities shall comply with the provisions of Section 9.1.

19.5.1.2 Existing installations shall be permitted to be continued in service, provided that the systems do not present a serious hazard to life.

NFPA 99: 6.3.2.2.6.1* Types of Receptacles. (A) Each power receptacle shall provide at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug, despite electrical and mechanical abuse.
NFPA 99: 6.3.2.2.6.2 Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care rooms in accordance with 6.3.2.2.6.2(A) through 6.3.2.2.6.2(E).(C) Receptacles for Operating Rooms (Category 1). Operating rooms shall be provided with a minimum of 36 receptacles.

NFPA 70: 517.61 Wiring and Equipment.
(C) Other-Than-Hazardous (Classified) Anesthetizing Locations.
(1) Wiring Methods. Wiring serving other-than-hazardous (classified) locations, as defined in 517.60, shall be installed in a metal raceway system or cable assembly. The metal raceway system or cable armor or sheath assembly shall qualify as an equipment grounding conductor in accordance with 250.118. Type MC and Type MI cable shall have an outer metal armor, sheath, or sheath assembly that is identified as an acceptable equipment grounding conductor.

NFPA 70: 517.62 Grounding. In any anesthetizing area, all metal raceways and metal-sheathed cables and all normally non–current-carrying conductive portions of fixed electrical equipment shall be connected to an equipment grounding conductor. Grounding and bonding in Class I locations shall comply with 501.30.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at the exit conference.

Through interview and documentation review, it was determined that the facility failed to meet the Fundamentals – Building System Categories requirements in accordance with NFPA 101 and NFPA 99. This STANDARD is not met, as evidenced by:

The surveyor requested a "Risk Assessment assessment with NFPA 99 categories. This shall be determined by following and documenting a defined risk assessment procedure for each room/area. See Chapter 4 of the 2012 NFPA 99." The compliance coordinator responded, "This is something we will need to implement."


This did not meet the requirement of LSC Sections

NFPA 99: 4.1* Building System Categories. Building systems in health care facilities shall be designed to meet system Category 1 through Category 4 requirements as detailed in this code.

NFPA 99: 4.2* Risk Assessment. Categories shall be determined by following and documenting a defined risk assessment procedure.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at the exit conference.

Through interviews and observation during the survey, it was determined that the facility failed to meet the Gas and Vacuum Piped Systems – Other requirements in accordance with NFPA 101 and NFPA 99. This STANDARD is not met, as evidenced by:

1) There was a very old gas valve Across the hall from Human Resources and the Case Management office. When the Facilities Maintenance Director was asked if the gas valve was still in use, the maintenance Director stated, "I don't know."

2) While outside the operating room in the scrub room, the staff was asked if the gas valve was in use. The maintenance director stated he did not know. The facility's Specialty Physician Outreach coordinator noted that it was in use.

This did not meet the requirement of LSC Sections

4.5.5* Situation Awareness. Systems used to achieve the goals of Section 4.1 shall be effective in facilitating and enhancing situation awareness, as appropriate, by building management, other occupants and emergency responders of the functionality or state of critical building systems, the conditions that might warrant emergency response, and the appropriate nature and timing of such responses.


This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the Electrical Systems – Receptacles requirements in accordance with NFPA 101, NFPA 99, and NFPA 70. This STANDARD is not met, as evidenced by:

Electrical receptacles in the Operating room are not grounded.

Entrance to medication room broken outlet cover

The outlet near the ambulance parking area has a cover coming apart. This area is subject to weather.

This did not meet the requirement of LSC Sections

NFPA 70- 314.15 Damp or Wet Locations. In damp or wet locations, boxes, conduit bodies, and fittings shall be placed or equipped so as to prevent moisture from entering or accumulating within the box, conduit body, or fitting. Boxes, conduit bodies, and fittings installed in wet locations shall be listed for use in wet locations.

NFPA 70- 406.6 Receptacle Faceplates (Cover Plates). Receptacle faceplates shall be installed so as to completely cover the opening and seat against the mounting surface. Receptacle faceplates mounted inside a box having a recess-mounted receptacle shall effectively close the opening and seat against the mounting surface.

NFPA 70- 517.13 Grounding of Receptacles and Fixed Electrical Equipment in Patient Care Areas. Wiring in patient care areas shall comply with 517.13(A) and (B). (A) Wiring Methods.All branch circuits serving patient care areas shall be provided with an effective ground-fault current path by installation in a metal raceway system, or a cable having a metallic armor or sheath assembly. The metal raceway system, or metallic cable armor, or sheath assembly shall itself qualify as an equipment grounding conductor in accordance with 250.118.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at the exit conference.

Through documentation review, it was determined that the facility failed to meet the Electrical Systems – Wet Procedure Locations requirements in accordance with NFPA 101 and NFPA 99. This STANDARD is not met, as evidenced by:

1) A written record of the risk assessment is not maintained and available for inspection.

This did not meet the requirement of LSC Sections

NFPA 99- 6.3.2.2.8.4 Operating rooms shall be considered to be a wet procedure location, unless a risk assessment conducted by the health care governing body determines otherwise.

NFPA 99- 6.3.2.2.8.7 Operating rooms defined as wet procedure locations shall be protected by either isolated power or ground-fault circuit interrupters.

NFPA 99- 6.4.4.2 Record Keeping. A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within two smoke compartment. Deficient items were discussed during the survey and at the exit conference.

Through documentation review, it was determined that the facility failed to meet the Electrical Systems – Maintenance and Testing requirements in accordance with NFPA 101 and NFPA 99. This STANDARD is not met, as evidenced by:

1) A written record of the maintenance and testing is not maintained and is not available for inspection.

This did not meet the requirement of LSC Sections

NFPA 99- 6.3.4.1.1 Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device.

NFPA 99- 6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.

NFPA 99- 6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.

NFPA 99- 6.3.4.1.4 The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch (see 6.3.2.6.3.6). For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.

NFPA 99- 6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modification.

NFPA 99- 6.3.4.2.1.2 At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the Electrical Systems – Essential Electric System Receptacles requirements in accordance with NFPA 101, NFPA 99, and NFPA 70. This STANDARD is not met, as evidenced by:

Electrical receptacles or cover plates supplied from the life safety and critical branches do not have a distinctive color or marking

This did not meet the requirement of LSC Sections

NFPA 99- 6.4.2.2.6.2(C)* The electrical receptacles or the cover plates for the electrical receptacles supplied from the life safety and critical branches shall have a distinctive color or marking so as to be readily identifiable.

A.6.4.2.2.6.2(C) If color is used to identify these receptacles, the same color should be used throughout the facility.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at the exit conference.

Through documentation review, it was determined that the facility failed to meet the Electrical Systems – Essential Electric System Maintenance and Testing requirements in accordance with NFPA 101, NFPA 110 and NFPA 99. This STANDARD is not met, as evidenced by:

Generator Batteries are not tested monthly.

Transfer switches are not operated monthly.

This did not meet the requirement of LSC Sections

NFPA 110- 8.3.7* Storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer ' s specifications.

NFPA 110- 8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted.

NFPA 110- 8.4.6 Transfer switches shall be operated monthly.

NFPA 110- 8.4.6.1 The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at the exit conference.

Based on observations, interviews, and record review during the complaint survey completed on October 3, 2024, it was determined that the facility failed to it was determined that the facility failed to maintain electrical power cords in accordance with NFPA 99 and Life Safety Code Section. Specifically, the facility's use of non-permitted, non-listed power cords, particularly in the operating room, created the potential for sparks in the presence of medical gasses, fire, and power failure.

These failures created the likelihood of serious adverse outcomes for all patients undergoing procedures in the operating room and gastrointestinal room due to potential power loss from overloading power equipment.

The findings include:

I. Immediate Jeopardy

A. Findings of Immediate Jeopardy

Regulatory Requirement:
NFPA 99 Section 10.2.3.1.1 The flexible cord, including the grounding conductor, shall be of a type suitable for the particular application; shall be listed for use at a voltage equal to or greater than the rated power line voltage of the appliance; and shall have an ampacity, as given in Table 400.5(A) of NFPA 70, National Electrical Code, equal to or greater than the current rating of the device.

NFPA 99 Section 10.2.3.4.1 Power cords, regardless of whether intended for use on grounded or isolated power systems, shall be connected in accordance with the conventions of a grounded system.

NFPA 99 Section 10.2.4.2.2 Attachment plugs and fittings shall be listed for the purpose.

NFPA 99 Section 10.5.2.3.1 Adapters and extension cords meeting the requirements of 10.2.4 shall be permitted to be used.

NFPA 99 Section 10.5.2.5 System Demonstration. Any system consisting of several electric appliances shall be demonstrated to comply with this code as a complete system.

NFPA 99 Section 10.5.6.1.1 A permanent file of instruction and maintenance manuals shall be maintained and be accessible.

Observations:
Cross-reference to K511 for observations of multiple Utilities-electrical issues that could result in fire.

Cross-reference to K912 for observations of multiple Electrical Systems- Receptacles issues that could result in fire.

Observation of the operating room revealed a non-listed extension-type cord that created another electrical outlet. This outlet was used to plug operating room equipment into the power strip. Medical gas jets and anesthesia equipment were in close proximity to the outlet.

The extension cord in the operating room consisted of a twist-style electrical plug and, from there, a 33' whip or 16/3 cord(maximum current rating of 13 amps). This was run into a junction box intended for use in the wall, but it was surface-mounted onto the gypsum board and connected to a 15A-125V receptacle.

The following equipment was near the non-permissible wiring and is used from this wiring when needed.

Warming Cabinet- 15 amps- Always in use
Stryker Neptune 3 Rover- 12 amps
Electrocurgical Generator- 3 amps
Anesthesia System- 12 amps
Electrocurgical Generator- 3 amps
Endoscopy Machine- 4 amp
Monitor- 4.8 amps.

The gastrointestinal (GI) room had a Non-medical grade extension cord used on patient-use equipment.

The GI room had a daisy chain consisting of a non-medical grade power strip powering a medical grade power strip present.

The facility used extension cords and power strips to power refrigerators and cooking appliances.

The electrical configurations in the Operating Room and the GI Room do not meet the NFPA 99 Building System Category Requirements. These rooms are considered a Category 1 Building System Category: "Facility systems in which failure of such equipment or system is likely to cause major injury or death of patients or caregivers shall be designed to meet system Category 1 requirements as defined in this code."

Patients, staff, and visitors were observed throughout the facility during the survey.

Record Review:
Throughout the document review of Work Order: 901-81634, it was discovered that a "Warming Unit" Model#: T/PUMP Serial#: TP700J317 11 MFG: STRYKER CORPORATION Location: SAL CH 3.1.2024 stated "Note: "I went to unplug this device from the outlet and sparks flew and the device power chord melted." The Lincoln Health Clinical Incident Report Form dated 12/23/2023 states, "Device was received from staff w/ ? (with complaints of) sparks + smoke when being plugged in the device was not being utilized on a pt (patient) @ the time of the incident."

Interviews:
On 09/25/2024, the facility's Specialty Physician Outreach stated that operations had increased from 25 to 40 cases a month in the last three years. These cases include all spectrums of surgeries, with patients undergoing up to full sedation. The Specialty Physician Outreach Coordinator could not estimate when the extension cord was added. The Specialty Physician Outreach Coordinator stated that the extension cord had been there for the duration of their tenure.

On 09/25/2024, the facility maintenance director could not estimate when the extension cord was added. The maintenance director stated that it had been there for the duration of his tenure.

On 09/25/2024, the Facility Compliance Coordinator could not estimate when the extension cord was added, stating it had been there for the duration of their tenure.

On 09/25/2024, the facility director or nursing could not estimate when the extension cord was added, stating it had been there for their whole tenure.

On 09/25/2024, the facility director or nursing could not remember any details about Work Order: 901-81634. In pertinent part the work order read, "Warming Unit" Model#: T/PUMP Serial#: TP700J317 11 MFG: STRYKER CORPORATION Location: SAL CH 3.1.2024 ... Note: I went to unplug this device from the outlet and sparks flew and the device power chord melted." The incident report was requested. The facility provider the incident report, which was reviewed.


B. Notification of Immediate Jeopardy
On September 09/25/2024, 2024, at 11:09 a.m., the Compliance Coordinator, Maintenance Director, and Specialty Physician Outreach were informed that the facility's failures to maintain electrical power cords in accordance with NFPA 99 and Life Safety Code Section 10.2.3.6 created the likelihood of serious harm if the failures were not corrected immediately.

C. Facility Plan to Remove Immediate Jeopardy
On September 25, 2024, the facility submitted a plan to remove the immediate jeopardy. The removal plan read:

1) Plan: The junction box, receptacle, 32 feet of cord, and power strip will be removed from OR. Will have a qualified electrician to inspect and verify integrity, safety and compliance.
2) Procedure: The junction box, receptacle, 32 feet of cord, and powerstrip [sic] was removed from OR on 09/25/2024 at 1145. Will have a qualified electrician to inspect and verify integrity, safety and compliance.
3) Monitering [sic]: Will monitor the OR for noncompliant electrical equipment and will only use equipment permitted by all adopted codes and standards of NFPA 13, 70, 99, and 101. After electrical work is complete, surgery stadd [sic] will complete logs no less an 2x.wk to ensure no noncompliant equipment is used.
4. Person responsible: [proper staff name], Director of Maintenance
5. Completion: 09-25-2024 at 11:45 a.m. Electrician to be here by 9-28-2024.

D. Removal of Immediate Jeopardy
On September 25, 2024, at 4:30 p.m., the Maintenance Director and Compliance Coordinator were notified that the immediate jeopardy had been removed. Deficient practice remains until the facility maintains all electrical power cords per NFPA 101 and NFPA 99.

Through observation during the survey, it was determined that the facility failed to meet the Gas Equipment – Cylinder and Container Storage requirements in accordance with NFPA 101 and NFPA 99. This STANDARD is not met, as evidenced by:

1) On the north side of the building, next to the oxygen farm, there is debris, such as leaves and branches that are too close to the tanks.

2) In the RT area, whether the oxygen tanks are empty or full is undetermined.


This did not meet the requirement of LSC Sections

NFPA 99- 11.3.2.1 Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.

NFPA 99- 11.3.2.3 Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following: (1) Minimum distance of 6.1 m (20 ft) (2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems (3)Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1/2 hour

NFPA 99- 11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders.

NFPA 99- 11.6.5.3 Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at the exit conference.

Through documentation review, it was determined that the facility failed to meet the Gas Equipment – Testing and Maintenance Requirements requirements in accordance with NFPA 101 NFPA 99. This STANDARD is not met, as evidenced by:

The survey team asked for the maintenance documentation for the Anesthesia. The facility's Specialty Physician Outreach stated that maintenance was past due by a few months because the facility was purchasing a new anesthesia unit. The date for the PM Gas Module by Mindray DF USA, Inc. for the maintenance inspection is 04/18/2023. According to the Operating Instructions for the unit, maintenance is due annually. The Anesthesia machine is a Mindtay Model A5.

This did not meet the requirement of LSC Sections

A5/A4 Operating Instructions

Maintenance Schedule The schedules listed in TABLE 7-1 are the minimum frequency based on 2000 hours of usage per year. The equipment should be serviced more frequently if used more than this yearly usage. Maintenance should be performed by a trained technician.

Daily - Clean the external surfaces.
Every 72 hours- Perform 21% O2 calibration (O2 sensor in breathing system). The A5/A4 will prompt the user for 21% O2 calibration (only for units with an galvanic O2 cell).
Monthly– Water trap on AG module.
Annually- Periodic maintenance due, to be performed by a trained technician. Gas Bench calibration. Contact Mindray Technical Support for details.
Every three years- Periodic maintenance due, to be performed by a trained technician. Contact Mindray Technical Support for details.

As necessary · Perform 100% O2 calibration after replacing the O2 sensor. · Replace the O2 sensor if it cannot be calibrated. · Before installing the cylinder, use a new cylinder gasket on the cylinder yoke. · Empty the water trap if there is water buildup. · Replace the soda lime in the canister if soda lime color change is detected. Follow the manufacturer ' s instructions. · Replace the flow sensor if the seal for the flow sensor is damaged, the membrane inside the flow sensor is cracked or distorted, or the flow sensor is cracked or distorted. · Calibrate the flow sensor after re-installing the cleaned or disinfected flow sensor, after replacing with a new flow sensor, or when tidal volume measurement is inaccurate. · Replace the waste gas transfer tube if it is damaged. · Inspect the O2 flush button for normal movement. If not , refer to the service manual for the disassembling and cleaning.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within one smoke compartment. Deficient items were discussed during the survey and at the exit conference.