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The facility failed to ensure interior wall finishes for rooms and spaces not used for corridors had a Class A or Class B rating.

Observation determined in the Compressor Room in the Southeast Basement there was one inch thick Styrofoam attached to the deck above with wood boards holding the Styrofoam in place. The Styrofoam covered approximately two-thirds of the deck in the room.

The facility failed to ensure corridor doors were equipped with automatic latching hardware suitable for keeping the door closed and resistant to the passage of smoke.

Observation determined the East Nutrition Center on the first floor Medical/Surgical Wing had no door separating the room from the corridor. The area also had no smoke detector.

The facility failed to ensure doors to hazardous areas were equipped with self-closing/automatic latching hardware.

Observation determined the following hazardous areas did not have self-closing devices on the doors:
1) Southeast Basement Print Shop.
2) Soiled Linen Room in the Occupational Health Department.
3) Storage Room west of VP Nursing Office.
4) Room 504 in the G Wing (used for storage).
5) IT Storage Room across from Room 504 in the G Wing.

1) Exits must terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge must be of required width and size to provide all occupants with safe access to a public way. 7.7.1

To ensure adequate exit capability, CMS requires asphalt or concrete surfaces from exterior exits to public ways.

The facility failed to provide hard surfaces from required exits to public ways.

Observation determined that the exterior exit from the corridor between the E and F Wings of the building must transverse over a grass surface to get to a public way.

2) 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. 19.2.2.2.4

The facility failed to ensure all required means of egress are readily accessible at all times.

Observation determined that three (3) of three (3) egress doors from the G Wing corridor were equipped with dead bolt locks that required the use of a key from the egress side.

The facility failed to ensure the illumination of means of egress, including exit discharge, was arranged so that a failure of a single lighting fixture would not leave the area in darkness.

CMS allows a light fixture equipped with a single long life bulb with a quick strike feature to illuminate exit discharge.

Observation determined the exit discharge from the building at Exit Door #5 was not equipped with lighting.

The facility failed to ensure the exits were marked by approved signage that was readily visible from any direction of exit access and that obviously and clearly identifies the exit.

Observation determined the south exit from the hospital into the Craven Hagen Clinic link lacked an exit sign at Door #5.

The facility failed to conduct quarterly drills on each shift.
Review of records did not indicate a fire drill was conducted on the second shift of the second quarter of 2013.

Automatic fire sprinkler systems must be installed in accordance with NFPA 13.

The facility failed to ensure all areas were protected by the automatic fire sprinkler system.

Observation determined that Housekeeping Room 169 did not have any sprinkler coverage.

Automatic fire sprinkler systems must be installed in accordance with NFPA 13.

The facility failed to ensure all areas were protected by the automatic fire sprinkler system.

Observation determined:

1) The Phone Room in the Southeast Basement did not have any sprinkler coverage.
2) The Dialysis Unit in the basement of the Medical /Surgical Wing had inadequate sprinkler coverage. Sprinklers were obstructed by decorations at the Nurses' Station.
3) The Linear Accelerator Room in the basement of the Medical /Surgical Wing did not have automatic sprinkler protection for complete coverage. Sprinklers were not installed following removal of a Fenwall Suppression System from this area.
4) The north stair enclosure in the basement of the Medical /Surgical Wing had three (3) broken ceiling tiles that could delay the activation of the sprinkler system.
5) The OR Locker Room did not have any sprinkler coverage.
6) The closet in the Lab Break Room did not have any sprinkler coverage.
7) Two (2) sprinklers in the X-Ray Room were closer than the minimum of six feet apart.
8) The Elevator Equipment Room and Electrical Room in the Administration Basement had ceiling penetrations that could delay the activation of the sprinkler system.

Testing frequencies for automatic sprinkler systems range from quarterly to annually. Inspection frequencies can be as often as weekly to as long as annually. The frequencies for testing, inspection and maintenance of automatic sprinkler systems are dictated by the requirements as outlined by Table 5-1 of NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems. NFPA 25 requires the facility to complete, maintain and make available to the authority having jurisdiction copies of records which indicate the procedure performed, by whom, the results and the date. These records are to be retained for the life of the system. The automatic sprinkler system is required to have specified maintenance.

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25.

Record review indicated no test was completed in the past twelve (12) months on:

1) The FM 200 Suppression System in the Radiology Equipment Room.
2) The automatic sprinkler system.

1) Emergency lighting in accordance with section 7.9 must be provided for all underground and windowless structures. 39.2.9.2

For the purposes of this requirement, exit access must include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, ramps, and escalators leading to a public way. 7.9.1.1

Emergency illumination must be provided for not less than 1-1/2 hours in the event of failure of normal lighting. Emergency lighting must be arranged to provide initial illumination that is not less than an average of 1 ft-candle measured along the path of egress of floor level. 7.9.2.1

The emergency illumination lighting system must be arranged to provide the required illumination automatically. 7.9.2.2

Observation determined the facility failed to provide emergency illumination throughout the facility. a) The emergency illumination at the south lobby of the MOB portion of the clinic failed to illuminate when tested. b) No emergency illumination was installed at the Main Lobby (door #8) of the Craven Hagen Clinic.

2) Means of egress must have signs in accordance with section 7.10. 39.2.10

Exits and access to exits must be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. 7.10.1.4

Every exit sign must be continuously illuminated during normal and emergency lighting mode. 7.10.5.2

Observation determined the facility failed to provide adequate exit signage that would direct the occupants to the exits. The first floor of the MOB portion of the clinic lacked exit signs at the north and south ends of the corridor.3) Observation determined the MOB Treatment Room across the hall from G-1 had a large amount of combustible storage and contractor's tools and materials. This room was deemed to be a hazardous area. The door to the corridor had no self-closing device.

Maintenance of emergency generator batteries should include checking and recording the value of the specific gravity. NFPA 110, Section A-6-3.6

The facility failed to ensure the emergency generator was in compliance with NFPA 110, Standard for Emergency and Standby Power Systems.

Observation determined the battery in the generator was equipped with non-removable caps so the specific gravity of the battery could not be checked.

Flexible cords and cables must not be used as a substitute for fixed wiring of a structure. NFPA 70, National Electrical Code, 400-8

The facility failed to ensure electrical wiring and electrical equipment met NFPA 70 requirements.
Observation determined:
1) The facility was using a flexible cord as a substitute for fixed wiring. The outside light fixture above the Trash Collection Room was wired with an extension cord to an inside outlet.
2) There was an open electrical junction box and a missing outlet cover in the area behind the sterilizer in the Central Sterile Work Room.
3) There were multiple power strips in use in the Operating Rooms and other areas throughout the facility.

The facility failed to ensure electrical wiring and electrical equipment met NFPA 70 requirements.

Observation determined there were multiple power strips in use in the Operating Rooms.

The facility failed to provide emergency procedures for when the automatic sprinkler system is out of service for more than 4 hours.

Review of records did not indicate the facility had a written Fire Watch and Notification policy.

The facility failed to provide emergency procedures for when the fire alarm system is out of service for more than 4 hours.

Review of records did not indicate the facility had a written Fire Watch and Notification policy.

The facility failed to ensure interior wall finishes for rooms and spaces not used for corridors had a Class A or Class B rating.

Observation determined in the Compressor Room in the Southeast Basement there was one inch thick Styrofoam attached to the deck above with wood boards holding the Styrofoam in place. The Styrofoam covered approximately two-thirds of the deck in the room.

The facility failed to ensure corridor doors were equipped with automatic latching hardware suitable for keeping the door closed and resistant to the passage of smoke.

Observation determined the East Nutrition Center on the first floor Medical/Surgical Wing had no door separating the room from the corridor. The area also had no smoke detector.

The facility failed to ensure doors to hazardous areas were equipped with self-closing/automatic latching hardware.

Observation determined the following hazardous areas did not have self-closing devices on the doors:
1) Southeast Basement Print Shop.
2) Soiled Linen Room in the Occupational Health Department.
3) Storage Room west of VP Nursing Office.
4) Room 504 in the G Wing (used for storage).
5) IT Storage Room across from Room 504 in the G Wing.

1) Exits must terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge must be of required width and size to provide all occupants with safe access to a public way. 7.7.1

To ensure adequate exit capability, CMS requires asphalt or concrete surfaces from exterior exits to public ways.

The facility failed to provide hard surfaces from required exits to public ways.

Observation determined that the exterior exit from the corridor between the E and F Wings of the building must transverse over a grass surface to get to a public way.

2) 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. 19.2.2.2.4

The facility failed to ensure all required means of egress are readily accessible at all times.

Observation determined that three (3) of three (3) egress doors from the G Wing corridor were equipped with dead bolt locks that required the use of a key from the egress side.

The facility failed to ensure the illumination of means of egress, including exit discharge, was arranged so that a failure of a single lighting fixture would not leave the area in darkness.

CMS allows a light fixture equipped with a single long life bulb with a quick strike feature to illuminate exit discharge.

Observation determined the exit discharge from the building at Exit Door #5 was not equipped with lighting.

The facility failed to ensure the exits were marked by approved signage that was readily visible from any direction of exit access and that obviously and clearly identifies the exit.

Observation determined the south exit from the hospital into the Craven Hagen Clinic link lacked an exit sign at Door #5.

The facility failed to conduct quarterly drills on each shift.
Review of records did not indicate a fire drill was conducted on the second shift of the second quarter of 2013.

Automatic fire sprinkler systems must be installed in accordance with NFPA 13.

The facility failed to ensure all areas were protected by the automatic fire sprinkler system.

Observation determined that Housekeeping Room 169 did not have any sprinkler coverage.

Automatic fire sprinkler systems must be installed in accordance with NFPA 13.

The facility failed to ensure all areas were protected by the automatic fire sprinkler system.

Observation determined:

1) The Phone Room in the Southeast Basement did not have any sprinkler coverage.
2) The Dialysis Unit in the basement of the Medical /Surgical Wing had inadequate sprinkler coverage. Sprinklers were obstructed by decorations at the Nurses' Station.
3) The Linear Accelerator Room in the basement of the Medical /Surgical Wing did not have automatic sprinkler protection for complete coverage. Sprinklers were not installed following removal of a Fenwall Suppression System from this area.
4) The north stair enclosure in the basement of the Medical /Surgical Wing had three (3) broken ceiling tiles that could delay the activation of the sprinkler system.
5) The OR Locker Room did not have any sprinkler coverage.
6) The closet in the Lab Break Room did not have any sprinkler coverage.
7) Two (2) sprinklers in the X-Ray Room were closer than the minimum of six feet apart.
8) The Elevator Equipment Room and Electrical Room in the Administration Basement had ceiling penetrations that could delay the activation of the sprinkler system.

Testing frequencies for automatic sprinkler systems range from quarterly to annually. Inspection frequencies can be as often as weekly to as long as annually. The frequencies for testing, inspection and maintenance of automatic sprinkler systems are dictated by the requirements as outlined by Table 5-1 of NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems. NFPA 25 requires the facility to complete, maintain and make available to the authority having jurisdiction copies of records which indicate the procedure performed, by whom, the results and the date. These records are to be retained for the life of the system. The automatic sprinkler system is required to have specified maintenance.

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25.

Record review indicated no test was completed in the past twelve (12) months on:

1) The FM 200 Suppression System in the Radiology Equipment Room.
2) The automatic sprinkler system.

1) Emergency lighting in accordance with section 7.9 must be provided for all underground and windowless structures. 39.2.9.2

For the purposes of this requirement, exit access must include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, ramps, and escalators leading to a public way. 7.9.1.1

Emergency illumination must be provided for not less than 1-1/2 hours in the event of failure of normal lighting. Emergency lighting must be arranged to provide initial illumination that is not less than an average of 1 ft-candle measured along the path of egress of floor level. 7.9.2.1

The emergency illumination lighting system must be arranged to provide the required illumination automatically. 7.9.2.2

Observation determined the facility failed to provide emergency illumination throughout the facility. a) The emergency illumination at the south lobby of the MOB portion of the clinic failed to illuminate when tested. b) No emergency illumination was installed at the Main Lobby (door #8) of the Craven Hagen Clinic.

2) Means of egress must have signs in accordance with section 7.10. 39.2.10

Exits and access to exits must be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. 7.10.1.4

Every exit sign must be continuously illuminated during normal and emergency lighting mode. 7.10.5.2

Observation determined the facility failed to provide adequate exit signage that would direct the occupants to the exits. The first floor of the MOB portion of the clinic lacked exit signs at the north and south ends of the corridor.3) Observation determined the MOB Treatment Room across the hall from G-1 had a large amount of combustible storage and contractor's tools and materials. This room was deemed to be a hazardous area. The door to the corridor had no self-closing device.

Maintenance of emergency generator batteries should include checking and recording the value of the specific gravity. NFPA 110, Section A-6-3.6

The facility failed to ensure the emergency generator was in compliance with NFPA 110, Standard for Emergency and Standby Power Systems.

Observation determined the battery in the generator was equipped with non-removable caps so the specific gravity of the battery could not be checked.

Flexible cords and cables must not be used as a substitute for fixed wiring of a structure. NFPA 70, National Electrical Code, 400-8

The facility failed to ensure electrical wiring and electrical equipment met NFPA 70 requirements.
Observation determined:
1) The facility was using a flexible cord as a substitute for fixed wiring. The outside light fixture above the Trash Collection Room was wired with an extension cord to an inside outlet.
2) There was an open electrical junction box and a missing outlet cover in the area behind the sterilizer in the Central Sterile Work Room.
3) There were multiple power strips in use in the Operating Rooms and other areas throughout the facility.

The facility failed to ensure electrical wiring and electrical equipment met NFPA 70 requirements.

Observation determined there were multiple power strips in use in the Operating Rooms.

The facility failed to provide emergency procedures for when the automatic sprinkler system is out of service for more than 4 hours.

Review of records did not indicate the facility had a written Fire Watch and Notification policy.

The facility failed to provide emergency procedures for when the fire alarm system is out of service for more than 4 hours.

Review of records did not indicate the facility had a written Fire Watch and Notification policy.