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Based on observation, the facility failed to maintain the fire resistance rating of 2-hour fire rated walls/barriers in accordance with NFPA 101 2000, Section 8.2.3.2.4.2. This deficiency affects 1 of 3 main floor smoke compartments.

Findings include:

During an observation on 2/9/16 at 8:40 a.m., the 2-hour barrier between the CAH and clinic way was inspected. There were Information Technology wires penetrating the barrier that were not sealed properly around the wires.¹

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

Based on observation, the facility failed to ensure that all corridor walls in the sprinkled building could resist the passage of smoke in accordance with NFPA 101, 2000 Edition, Section 39.3.2.1. The deficiency affects 1 of 3 smoke compartments.

Findings include:

During an observation on 2/9/16 at 8:12 a.m., the soiled laundry room in the laundry was inspected. There was a penetration out of the room through the corridor wall.¹

¹ NFPA 101, 2000 Edition, Section 39.3.2.1; Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4.

Based on observation, the facility failed to safeguard the corridor by using non-fire-rated building material in a temporary enclosure of a hallway under construction in accordance with NFPA 241 Standard for Safeguarding Construction, Alteration, and Demolition, 1996 Edition, Section 2-2.1. This deficiency affects 1 of 3 smoke compartments on the main floor of the CAH.

Findings include:

During an observation on 2/9/16 at 7:15 a.m., the east hall was inspected. The end of the hall, near the exit was partitioned off by a temporary enclosure. The enclosure was made of standard two by six inch construction framework and sheeted on one side by plywood. There was no fire-rated material covering the temporary construction.¹

¹ NFPA 241 Standard for Safeguarding Construction, Alteration, and Demolition, 1996 Edition, Section 2-2.1; Only noncombustible panels or flame-resistant tarpaulins or approved materials of equivalent fire-retardant characteristics shall be used. Any other fabrics or plastic films used shall be certified as conforming to the requirements of the Large-Scale Test contained in NFPA 701, Standard Methods of Fire Tests for Flame-Resistant Textiles and Films.

Based on observations, the facility failed to maintain vertical penetrations as needed to keep the two hour rating between floors in accordance with NFPA 101, 2000 Edition, Section 39.3.1.1. This deficiency affects 3 of 3 smoke compartments.

Findings include:

1. During an observation on 2/9/16 at 8:07 a.m., the soiled laundry room was inspected. The laundry chute empties into the room. The door of the chute was blocked open by a screw, and it would not close all the way when the screw was removed.¹

2. During an observation on 2/9/16 at 8:10 a.m., the service elevator was inspected. The corridor door to the elevator shaft was of a swinging hinge type. It had a regular door knob, but was lacking the latch. The door would only latch when the elevator lifted off the basement area. It had a separate special latching mechanism. When the elevator came down to the basement, the special latch unlocked, and left the corridor door to the shaft unable to latch.¹

3. During an observation on 2/9/16 at 8:34 a.m., the top of the laundry chute on the main floor was inspected. The one and a half hour door would not latch.¹

¹ NFPA 101, 2000 Edition, Section 39.3.1.1; Any vertical opening shall be enclosed or protected in accordance with 8.2.5.
Exception No. 1: Unenclosed vertical openings in accordance with 8.2.5.8 shall be permitted.
Exception No. 2: Exit access stairs shall be permitted to be unenclosed in two-story single-tenant spaces that are provided with a single exit in accordance with Exception No. 4 to 39.2.4.2.
Exception No. 3: In buildings protected throughout by an approved automatic sprinkler system in accordance with Section 9.7, unprotected vertical openings shall be permitted. This exception shall be permitted only where no unprotected vertical opening serves as any part of any required means of egress and all required exits consist of outside stairs in accordance with 7.2.2, smokeproof enclosures in accordance with 7.2.3, or horizontal exits in accordance with 7.2.4.

Based on observation, the facility failed to maintain the self-closing door at the bottom of a protected stairwell in accordance with NFPA 101, 2000 Edition, Section 39.3.1.1. This deficiency affects 1 of 3 smoke compartments.

Findings include:

During an observation on 2/8/16 at 4:30 p.m., the south stairwell to PT was inspected. The 1.5 hour-rated door at the bottom the stairwell would not close and latch under the power of the self-closer. ¹ ²

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 39.3.1.1; Any vertical opening shall be enclosed or protected in accordance with 8.2.5.
Exception No. 1: Unenclosed vertical openings in accordance with 8.2.5.8 shall be permitted.
Exception No. 2: Exit access stairs shall be permitted to be unenclosed in two-story single-tenant spaces that are provided with a single exit in accordance with Exception No. 4 to 39.2.4.2.
Exception No. 3: In buildings protected throughout by an approved automatic sprinkler system in accordance with Section 9.7, unprotected vertical openings shall be permitted. This exception shall be permitted only where no unprotected vertical opening serves as any part of any required means of egress and all required exits consist of outside stairs in accordance with 7.2.2, smokeproof enclosures in accordance with 7.2.3, or horizontal exits in accordance with 7.2.4.

Based on observation, the facility failed to maintain the two-hour fire protection of the self-closing doors used as a horizontal exit in accordance with NFPA 101, 2000 Edition, Section 8.2.3.2.1 and NFPA 80, 1999 Edition, Section 2-4.1.4. This deficiency affects 1 of 3 main floor smoke compartments.

Findings include:

During an observation on 2/9/16 at 8:58 a.m., the two-hour door separating the CAH from the administration offices, housed in the old nursing home, was exercised. The door would not latch upon closing.¹

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 8.2.3.2.1; Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire doors and Fire Windows.

² NFPA 80 Standard for Fire Doors and Fire Windows, 1999 Edition, Section 2-4.1.4; All closing mechanisms shall be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.

Based on observations, the facility failed to ensure that access to exits was marked by approved, readily visible signs properly denoting the way to the means of egress in accordance with NFPA 101, 2000 Edition, Section 7.10.1.4. These deficiencies affect 2 of 3 main floor smoke compartments.

Findings include:

1. During an observation 2/8/16 at 2:52 p.m., the exit sign near the employee break room was identified as being misleading. It was mounted next to the door to the employee break room with the chevron pointing to the door of the break room. The exit out of the break room was marked as "no exit."

The corridor going down by the old kitchen was the exit corridor. There was no sign in the hall outside the door to the old kitchen corridor guiding someone to the corridor. You would walk by the corridor to the employee break room because the sign above the break room door seemed to direct one into the break room.¹

2. During an observation on 2/9/16 at 7:15 a.m., the exit egress leading down the east corridor was inspected. There was an exit sign at the end of the corridor directing people toward the temporary wall and door blocking the construction zone, the exit door of the east hall is in the construction zone. The sign on the temporary door stated, "Construction site, do not enter."¹ It was not readily apparent where the exit was in the east corridor.¹

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 7.10.1.4; Access to exits shall 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. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
Exception: Signs in exit access corridors in existing buildings shall not be required to meet the placement distance requirements.

Based on observations, the facility failed to maintain smoke barriers per NFPA 101, 2000 Edition, Section 8.3.6.1. These deficiencies affect 3 of 3 main floor smoke compartments.

Findings include:

1. During an observation on 2/9/16 at 8:45 a.m., the smoke barrier wall of the north wing was inspected. There were IT wires penetrating the smoke wall above the doors that were not sealed properly around the wires.¹

2. During an observation on 2/9/16 at 8:50 a.m., the smoke barrier wall of the east wing was inspected. There were IT wires penetrating this wall. The penetration was not sealed properly around the wires.¹

¹ NFPA 101, 2000 Edition, Section 8.3.6.1; Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on observations, the facility failed to protect hazardous areas with a self closing door per NFPA 101, 2000 Edition, Section 19.3.2.1. These deficiencies affect 3 of 3 main floor smoke compartments.

Findings include:

1. During an observation on 2/8/16 at 2:51 p.m., the storage room next to the employee break room was inspected. The room is over 50 square feet and opens to the corridor. The door lacked a self-closer.¹

2. During an observation on 2/8/16 at 3:41 p.m., the clean linen storage room on east hall was inspected. The room is over 50 square feet, the door would not latch with the self-closer.¹

3. During an observation 2/8/16 at 3:49 p.m., the storage room on north hall was inspected. The room is over 50 square feet and the door was lacking a self-closer.¹


¹ NFPA 101, 2000 Edition, Section 19.3.2.1; 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 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 square feet (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 square feet (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have non-rated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Based on observations, the facility failed to protect hazardous areas with a self closing door per NFPA 101, 2000 Edition, Section 39.3.2.1. These deficiencies affect 1 of 3 smoke compartments.

Findings include:

During an observation on 2/9/16 at 8:03 a.m., the laundry was inspected. Both doors to the laundry, clean side and dirty side, would not self-close and latch. The dirty side did not have a self-closer.¹

¹ NFPA 101, 2000 Edition, Section 39.3.2.1*; Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4.

Based on observation, the facility failed to maintain egress thresholds at less than 1/2 inch high, in accordance with NFPA 101, 2000 Edition, Section 7.2.1.3. This deficiency affects 1 of 3 smoke compartments.

Findings include:

During and observation on 2/9/16 at 7:15 a.m., the temporary wall and door at the end of east hall was inspected. The threshold of the door was set on a 1 1/2" high board.¹ One would need to negotiate the high threshold to get to the exit door on the east hall.

¹ NFPA 101, 2000 Edition, Section 7.2.1.3 Floor Level; The elevation of the floor surfaces on both sides of a door shall not vary by more than 1/2 in. (1.3 cm). The elevation shall be maintained on both sides of the doorway for a distance not less than the width of the widest leaf. Thresholds at doorways shall not exceed 1/2 in. (1.3 cm) in height. Raised thresholds and floor level changes in excess of 1/4 in. (0.64 cm) at doorways shall be beveled with a slope not steeper than 1 in 2.
Exception No. 1: In one- and two-family dwellings and in existing buildings where the door discharges to the outside or to an exterior balcony or exterior exit access, the floor level outside the door shall be permitted to be one step lower than the inside, but shall not be in excess of 8 in. (20.3 cm) lower.
Exception No. 2: In one- and two-family dwellings and existing buildings, a door at the top of a stair shall be permitted to open directly at a stair, provided that the door does not swing over the stair and the door serves an area with an occupant load of fewer than 50 persons.

Based on observations, the facility failed to maintain continuous illumination for all exit signs in accordance with NFPA 101, 2000 Edition, Section 7.10.5.2. These deficiencies affect 1 of 3 smoke compartments.

Findings include:

1. During an observation on 2/8/16 at 2:52 p.m., one of the exit signs down the old kitchen hall was found to have both bulbs burned out.¹

2. During an observation on 2/9/16 at 9:10 a.m., the exit sign above the nurses' station was inspected. It was found to have only one functioning bulb.¹

¹ NFPA 101, 2000 Edition, Section 7.10.5.2; Exit signs shall be continuously illuminated. Exit signs that are internally illuminated must meet UL (Underwriters Laboratories) 924 standards and are listed for use only with all bulbs evenly and uniformly illuminating the letters.

Based on record review, the facility failed to perform fire drills every shift for every quarter in accordance with NFPA 101, 2000 Edition, Section 19.7.1.2. This deficiency affects all three smoke compartments.

Findings include:

During a record review on 2/8/16 at 10:30 a.m., the facility's fire drill reports were examined. There were missing drills for the night shift in the first quarter of 2015 and both day and night shifts for second quarter of 2015.¹

¹ NFPA 101, 2000 Edition, Section 19.7.1.2; Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Based on record review and interview, the facility failed to conduct load voltage tests on the batteries of the fire alarm control panel (FACP) semi-annually, as required per NFPA 72, 1999 Edition, Table 7-3.2. This deficiency affects 3 of 3 smoke compartments.

Finding include:

During a record review on 2/8/16 at 10:30 a.m., facility fire alarm reports were examined. There was no documentation the FACP backup batteries had been voltage tested semi-annually. The batteries were new on 7/24/15, but they had not been voltage tested since.¹

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

Based on observations, the facility failed to maintain the automatic sprinkler system per NFPA 13, 1999 Edition, Section 5.1.1. These deficiencies affect 1 of 3 smoke compartments.

Findings include:

1. During an observation on 2/8/16 at 4:20 p.m., the "staff only" storage room next to the PTA office was inspected. The sprinkler head escutcheon ring and ceiling tiles around the sprinkler were ajar and lifted, creating a large gap around the sprinkler head.¹

2. During an observation on 2/8/16 at 4:22 p.m., the north stairwell was inspected. There was a water damaged ceiling tile which had fallen out, creating a large hole in the ceiling.¹

3. During an observation on 2/9/16 at 7:45 a.m., the west stairwell was inspected. There was a water damaged roof tile which had fallen out, leaving a large hole in the drop-down ceiling.¹

¹ NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-1.1*;
The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution
Exception No. 1: For locations permitting omission of sprinklers, see 5-13.1, 5-13.2, and 5-13.9.
Exception No. 2: When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.
Exception No. 3: Clearance between sprinklers and ceilings exceeding the maximum specified in 5-6.4.1, 5-7.4.1, 5-8.4.1, 5-9.4.1, 5-10.4.1, and 5-11.4.1 shall be permitted provided that tests or calculations demonstrate comparable sensitivity and performance of the sprinklers to those installed in conformance with these sections.

Based on observations, the facility failed to maintain the automatic sprinkler system per NFPA 13, 1999 Edition, Section 5.1.1. These deficiencies affect 2 of 3 smoke compartments.

Findings include:

1. During an observation on 2/8/16 at 2:40 p.m., the air handling penthouse was inspected. There was a large duct in the room creating a five feet by five feet area under the ductwork which did not have sprinkler coverage.¹

2. During an observation on 2/8/16 at 3:49 p.m., the store room on north hall was inspected. There was a ceiling tile in the room which was held ajar by an IT wire which was not properly run in a track.²

3. During an observation on 2/8/16 at 4:12 p.m., the IT room with the video camera equipment was inspected. The room was missing a ceiling tile and the sprinkler head was missing the escutcheon ring.²

¹ NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, 5-5.5.3.1; Sprinklers shall be installed under fixed obstructions over 4 ft (1.2 m) wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors.
Exception: Obstructions that are not fixed in place such as conference tables.

² NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-1.1*
The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution
Exception No. 1: For locations permitting omission of sprinklers, see 5-13.1, 5-13.2, and 5-13.9.
Exception No. 2: When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.
Exception No. 3: Clearance between sprinklers and ceilings exceeding the maximum specified in 5-6.4.1, 5-7.4.1, 5-8.4.1, 5-9.4.1, 5-10.4.1, and 5-11.4.1 shall be permitted provided that tests or calculations demonstrate comparable sensitivity and performance of the sprinklers to those installed in conformance with these sections.

Based on observation, the facility failed to ensure the means of egress were continuously maintained free of all obstructions to full instant use in the case of fire or other emergency in accordance with NFPA 101, 2000 Edition, Section 7.1.10.1. This deficiency affects 1 of 3 smoke compartments.

Findings include:

During an observation on 2/9/16 at 7:15 a.m., the emergency exit corridor in front of the temporary enclosure had a large PT stair step and a rolling bedside table left in the corridor.¹

¹ NFPA 101, 2000 Edition, Section 7.1.10.1; Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on observations, the facility failed to meet the medical gas bulk storage requirements in accordance with NFPA 50, 1996 Edition, Sections 1-3 and 4-2.1 and gas storage requirements per NFPA 99, 1999 Edition, Section 4-3.5.2.1. These deficiencies could affect 1 of 3 smoke compartments.

Findings include:

1. During an observation on 2/8/16 at 1:58 p.m., the oxygen storage area was inspected. There was liquid oxygen and compressed gas tanks stored in the room. Four containers of liquid oxygen amounting to 19,372 cu. ft. of oxygen, as well as 11 "K" tanks, amounting to a total 22,672 cu. ft. of oxygen. This amount of stored oxygen requires an annual inspection of "bulk" storage.¹

In an interview on 2/8/16 at 1:58 p.m., staff member A stated there is no annual med gas report.²

2. During an observation on 2/8/16 at 1:58 p.m., there were seven "E" sized cylinders sitting on the floor of oxygen storage room. They were not in a rack, and the chain around the "K" sized tanks was higher then the tops of the "E" sized tanks on the floor, rendering them unrestrained.³

3. During an observation on 2/8/16 at 3:18 p.m., there was an unsecured "E" tank sitting on the floor in respiratory therapy.³

¹ NFPA 50 Standard for Bulk Oxygen Systems at Consumer Sites, 1996 Edition, Section 1-3 Definitions; For the purpose of the standard, the following terms are defined as follows:Bulk Oxygen System. A bulk oxygen system is an assembly of equipment, such as oxygen storage containers, pressure regulators, safety devices, vaporizers, manifolds, and interconnecting piping, that has a storage capacity of more than 20,000 ft3 (566 m3) of oxygen (NTP) including unconnected reserves on hand at the site. The bulk oxygen system terminates at the point where oxygen at service pressure first enters the supply line. The oxygen containers may be stationary or movable, and the oxygen may be stored as gas or liquid.

² NFPA 50, 1996 Edition, Section 4-2.1; Each bulk oxygen system installed on consumer premises shall be inspected annually and maintained by a qualified representative of the equipment owner.

³ NFPA 99, 1999 Edition, Section 4-3.5.2.1; Gases in Cylinders and Liquefied Gases in Containers - Level 1.
(a) * Handling of Gases. Administrative authorities shall provide regulations to ensure that standards for safe practice in the specifications for cylinders; marking of cylinders, regulators, and valves; and cylinder connections have been met by vendors of cylinders containing compressed gases supplied to the facility.
(b) Special Precautions - Oxygen Cylinders and Manifolds. Great care shall be exercised in handling oxygen to prevent contact of oxygen under pressure with oils, greases, organic lubricants, rubber, or other materials of an organic nature. The following regulations, based on those of the CGA Pamphlet G-4, Oxygen, shall be observed:
27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Based on observation, interview and record review, the facility failed to ensure that the piped medical gas system met the standards of NFPA 99, 1999 Edition, Section 4-3.5.4.2. This deficiency affects 1 of 3 smoke compartments.

Findings include:

During an observation on 2/8/16 at 3:00 p.m., the labor and delivery room and operating room were inspected. The oxygen and vacuum shutoff valves outside each room were not labeled as to which room or rooms they shut off.¹

¹ NFPA 99 Standard for Health Care Facilities, 1999 Edition, Section 4-3.5.4.2; The shutoff valves described in 4-3.1.2.3, 4-3.1.2.3(m), and 4-3.1.2.3(n) shall be labeled to reflect the rooms that are controlled by such valves. Labeling shall be kept current from initial construction through acceptance. Valves shall be labeled in substance as follows:
CAUTION:
(NAME OF MEDICAL GAS) VALVE DO NOT CLOSE EXCEPT IN EMERGENCY THIS VALVE CONTROLS SUPPLY TO . . . .

Based on observation, the facility failed to maintain the electrical system and/or its components in accordance with NFPA 101, 2000 Edition, Section 39.5.1. This deficiency affects 1 of 3 smoke compartments.

Findings include:

During an observation on 2/8/16 at 4:18 p.m., the PTA office was inspected. There was a microwave plugged into a power strip.¹

¹ NFPA 101, 2000 Edition, Section 39.5.1; Utilities shall comply with the provisions of Section 9.1.

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

Findings include:

1. During an observation on 2/8/16 at 2:38 p.m., the employee break room was inspected. There was a multi plug adapter in the wall between two recliners. It was not circuit protected.¹

2. During an observation on 2/8/16 at 2:38 p.m., the microwave in the employee break room was plugged into a power strip, the power strip was dangling, unsupported.¹

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

Based on observation, the facility failed to fully sprinkler protect the elevator hoistway in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-13.6.1*. This deficiency affects 1 of 3 smoke compartments.

Findings include:

During an observation on 2/9/16 at 8:10 a.m., the elevator hoistway was inspected. There was no sprinkler coverage at the top or the bottom of the hoistway. The elevator uses hydraulic fluid in the machine room.¹ ²

¹ NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-13.6.1*; Sidewall spray sprinklers shall be installed at the bottom of each elevator hoistway not more than 2 ft (0.61 m) above the floor of the pit.
Exception: For enclosed, noncombustible elevator shafts that do not contain combustible hydraulic fluids, the sprinklers at the bottom of the shaft are not required.

² NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-13.6.3*; Upright or pendent spray sprinklers shall be installed at the top of elevator hoistways.
Exception: Sprinklers are not required at the tops of noncombustible hoistways of passenger elevators with car enclosure materials that meet the requirements of ASME A17.1, Safety Code for Elevators and Escalators.

Based on observation, the facility failed to ensure that alcohol-based hand rub (ABHR) dispensers were not installed directly over an ignition source per CMS Survey & Certification Policy S&C-05-33. This deficiency affects 1 of 3 smoke compartments.

Findings include:

During an observation on 2/8/16 at 3:08 p.m., the lab was inspected. There was an ABHR dispenser mounted over the light switch in the lab.¹

¹ CMS interpretations under Survey & Certification (S&C)-05-33 policy issued on June 9, 2005, states ABHR dispensers shall meet the NFPA amendment to the 2000 Life Safety Code regarding the installation of ABHR dispensers in exit corridors and on interior walls. The Certification Bureau enforces that ABHR dispensers be offset by at least one inch and not mounted directly above any electrical source.

Based on observation, the facility failed to maintain the fire resistance rating of 2-hour fire rated walls/barriers in accordance with NFPA 101 2000, Section 8.2.3.2.4.2. This deficiency affects 1 of 3 main floor smoke compartments.

Findings include:

During an observation on 2/9/16 at 8:40 a.m., the 2-hour barrier between the CAH and clinic way was inspected. There were Information Technology wires penetrating the barrier that were not sealed properly around the wires.¹

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

Based on observation, the facility failed to ensure that all corridor walls in the sprinkled building could resist the passage of smoke in accordance with NFPA 101, 2000 Edition, Section 39.3.2.1. The deficiency affects 1 of 3 smoke compartments.

Findings include:

During an observation on 2/9/16 at 8:12 a.m., the soiled laundry room in the laundry was inspected. There was a penetration out of the room through the corridor wall.¹

¹ NFPA 101, 2000 Edition, Section 39.3.2.1; Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4.

Based on observation, the facility failed to safeguard the corridor by using non-fire-rated building material in a temporary enclosure of a hallway under construction in accordance with NFPA 241 Standard for Safeguarding Construction, Alteration, and Demolition, 1996 Edition, Section 2-2.1. This deficiency affects 1 of 3 smoke compartments on the main floor of the CAH.

Findings include:

During an observation on 2/9/16 at 7:15 a.m., the east hall was inspected. The end of the hall, near the exit was partitioned off by a temporary enclosure. The enclosure was made of standard two by six inch construction framework and sheeted on one side by plywood. There was no fire-rated material covering the temporary construction.¹

¹ NFPA 241 Standard for Safeguarding Construction, Alteration, and Demolition, 1996 Edition, Section 2-2.1; Only noncombustible panels or flame-resistant tarpaulins or approved materials of equivalent fire-retardant characteristics shall be used. Any other fabrics or plastic films used shall be certified as conforming to the requirements of the Large-Scale Test contained in NFPA 701, Standard Methods of Fire Tests for Flame-Resistant Textiles and Films.

Based on observations, the facility failed to maintain vertical penetrations as needed to keep the two hour rating between floors in accordance with NFPA 101, 2000 Edition, Section 39.3.1.1. This deficiency affects 3 of 3 smoke compartments.

Findings include:

1. During an observation on 2/9/16 at 8:07 a.m., the soiled laundry room was inspected. The laundry chute empties into the room. The door of the chute was blocked open by a screw, and it would not close all the way when the screw was removed.¹

2. During an observation on 2/9/16 at 8:10 a.m., the service elevator was inspected. The corridor door to the elevator shaft was of a swinging hinge type. It had a regular door knob, but was lacking the latch. The door would only latch when the elevator lifted off the basement area. It had a separate special latching mechanism. When the elevator came down to the basement, the special latch unlocked, and left the corridor door to the shaft unable to latch.¹

3. During an observation on 2/9/16 at 8:34 a.m., the top of the laundry chute on the main floor was inspected. The one and a half hour door would not latch.¹

¹ NFPA 101, 2000 Edition, Section 39.3.1.1; Any vertical opening shall be enclosed or protected in accordance with 8.2.5.
Exception No. 1: Unenclosed vertical openings in accordance with 8.2.5.8 shall be permitted.
Exception No. 2: Exit access stairs shall be permitted to be unenclosed in two-story single-tenant spaces that are provided with a single exit in accordance with Exception No. 4 to 39.2.4.2.
Exception No. 3: In buildings protected throughout by an approved automatic sprinkler system in accordance with Section 9.7, unprotected vertical openings shall be permitted. This exception shall be permitted only where no unprotected vertical opening serves as any part of any required means of egress and all required exits consist of outside stairs in accordance with 7.2.2, smokeproof enclosures in accordance with 7.2.3, or horizontal exits in accordance with 7.2.4.

Based on observation, the facility failed to maintain the self-closing door at the bottom of a protected stairwell in accordance with NFPA 101, 2000 Edition, Section 39.3.1.1. This deficiency affects 1 of 3 smoke compartments.

Findings include:

During an observation on 2/8/16 at 4:30 p.m., the south stairwell to PT was inspected. The 1.5 hour-rated door at the bottom the stairwell would not close and latch under the power of the self-closer. ¹ ²

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 39.3.1.1; Any vertical opening shall be enclosed or protected in accordance with 8.2.5.
Exception No. 1: Unenclosed vertical openings in accordance with 8.2.5.8 shall be permitted.
Exception No. 2: Exit access stairs shall be permitted to be unenclosed in two-story single-tenant spaces that are provided with a single exit in accordance with Exception No. 4 to 39.2.4.2.
Exception No. 3: In buildings protected throughout by an approved automatic sprinkler system in accordance with Section 9.7, unprotected vertical openings shall be permitted. This exception shall be permitted only where no unprotected vertical opening serves as any part of any required means of egress and all required exits consist of outside stairs in accordance with 7.2.2, smokeproof enclosures in accordance with 7.2.3, or horizontal exits in accordance with 7.2.4.

Based on observation, the facility failed to maintain the two-hour fire protection of the self-closing doors used as a horizontal exit in accordance with NFPA 101, 2000 Edition, Section 8.2.3.2.1 and NFPA 80, 1999 Edition, Section 2-4.1.4. This deficiency affects 1 of 3 main floor smoke compartments.

Findings include:

During an observation on 2/9/16 at 8:58 a.m., the two-hour door separating the CAH from the administration offices, housed in the old nursing home, was exercised. The door would not latch upon closing.¹

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 8.2.3.2.1; Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire doors and Fire Windows.

² NFPA 80 Standard for Fire Doors and Fire Windows, 1999 Edition, Section 2-4.1.4; All closing mechanisms shall be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.

Based on observations, the facility failed to ensure that access to exits was marked by approved, readily visible signs properly denoting the way to the means of egress in accordance with NFPA 101, 2000 Edition, Section 7.10.1.4. These deficiencies affect 2 of 3 main floor smoke compartments.

Findings include:

1. During an observation 2/8/16 at 2:52 p.m., the exit sign near the employee break room was identified as being misleading. It was mounted next to the door to the employee break room with the chevron pointing to the door of the break room. The exit out of the break room was marked as "no exit."

The corridor going down by the old kitchen was the exit corridor. There was no sign in the hall outside the door to the old kitchen corridor guiding someone to the corridor. You would walk by the corridor to the employee break room because the sign above the break room door seemed to direct one into the break room.¹

2. During an observation on 2/9/16 at 7:15 a.m., the exit egress leading down the east corridor was inspected. There was an exit sign at the end of the corridor directing people toward the temporary wall and door blocking the construction zone, the exit door of the east hall is in the construction zone. The sign on the temporary door stated, "Construction site, do not enter."¹ It was not readily apparent where the exit was in the east corridor.¹

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 7.10.1.4; Access to exits shall 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. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
Exception: Signs in exit access corridors in existing buildings shall not be required to meet the placement distance requirements.

Based on observations, the facility failed to maintain smoke barriers per NFPA 101, 2000 Edition, Section 8.3.6.1. These deficiencies affect 3 of 3 main floor smoke compartments.

Findings include:

1. During an observation on 2/9/16 at 8:45 a.m., the smoke barrier wall of the north wing was inspected. There were IT wires penetrating the smoke wall above the doors that were not sealed properly around the wires.¹

2. During an observation on 2/9/16 at 8:50 a.m., the smoke barrier wall of the east wing was inspected. There were IT wires penetrating this wall. The penetration was not sealed properly around the wires.¹

¹ NFPA 101, 2000 Edition, Section 8.3.6.1; Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on observations, the facility failed to protect hazardous areas with a self closing door per NFPA 101, 2000 Edition, Section 19.3.2.1. These deficiencies affect 3 of 3 main floor smoke compartments.

Findings include:

1. During an observation on 2/8/16 at 2:51 p.m., the storage room next to the employee break room was inspected. The room is over 50 square feet and opens to the corridor. The door lacked a self-closer.¹

2. During an observation on 2/8/16 at 3:41 p.m., the clean linen storage room on east hall was inspected. The room is over 50 square feet, the door would not latch with the self-closer.¹

3. During an observation 2/8/16 at 3:49 p.m., the storage room on north hall was inspected. The room is over 50 square feet and the door was lacking a self-closer.¹


¹ NFPA 101, 2000 Edition, Section 19.3.2.1; 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 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 square feet (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 square feet (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have non-rated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Based on observations, the facility failed to protect hazardous areas with a self closing door per NFPA 101, 2000 Edition, Section 39.3.2.1. These deficiencies affect 1 of 3 smoke compartments.

Findings include:

During an observation on 2/9/16 at 8:03 a.m., the laundry was inspected. Both doors to the laundry, clean side and dirty side, would not self-close and latch. The dirty side did not have a self-closer.¹

¹ NFPA 101, 2000 Edition, Section 39.3.2.1*; Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4.

Based on observation, the facility failed to maintain egress thresholds at less than 1/2 inch high, in accordance with NFPA 101, 2000 Edition, Section 7.2.1.3. This deficiency affects 1 of 3 smoke compartments.

Findings include:

During and observation on 2/9/16 at 7:15 a.m., the temporary wall and door at the end of east hall was inspected. The threshold of the door was set on a 1 1/2" high board.¹ One would need to negotiate the high threshold to get to the exit door on the east hall.

¹ NFPA 101, 2000 Edition, Section 7.2.1.3 Floor Level; The elevation of the floor surfaces on both sides of a door shall not vary by more than 1/2 in. (1.3 cm). The elevation shall be maintained on both sides of the doorway for a distance not less than the width of the widest leaf. Thresholds at doorways shall not exceed 1/2 in. (1.3 cm) in height. Raised thresholds and floor level changes in excess of 1/4 in. (0.64 cm) at doorways shall be beveled with a slope not steeper than 1 in 2.
Exception No. 1: In one- and two-family dwellings and in existing buildings where the door discharges to the outside or to an exterior balcony or exterior exit access, the floor level outside the door shall be permitted to be one step lower than the inside, but shall not be in excess of 8 in. (20.3 cm) lower.
Exception No. 2: In one- and two-family dwellings and existing buildings, a door at the top of a stair shall be permitted to open directly at a stair, provided that the door does not swing over the stair and the door serves an area with an occupant load of fewer than 50 persons.

Based on observations, the facility failed to maintain continuous illumination for all exit signs in accordance with NFPA 101, 2000 Edition, Section 7.10.5.2. These deficiencies affect 1 of 3 smoke compartments.

Findings include:

1. During an observation on 2/8/16 at 2:52 p.m., one of the exit signs down the old kitchen hall was found to have both bulbs burned out.¹

2. During an observation on 2/9/16 at 9:10 a.m., the exit sign above the nurses' station was inspected. It was found to have only one functioning bulb.¹

¹ NFPA 101, 2000 Edition, Section 7.10.5.2; Exit signs shall be continuously illuminated. Exit signs that are internally illuminated must meet UL (Underwriters Laboratories) 924 standards and are listed for use only with all bulbs evenly and uniformly illuminating the letters.

Based on record review, the facility failed to perform fire drills every shift for every quarter in accordance with NFPA 101, 2000 Edition, Section 19.7.1.2. This deficiency affects all three smoke compartments.

Findings include:

During a record review on 2/8/16 at 10:30 a.m., the facility's fire drill reports were examined. There were missing drills for the night shift in the first quarter of 2015 and both day and night shifts for second quarter of 2015.¹

¹ NFPA 101, 2000 Edition, Section 19.7.1.2; Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Based on record review and interview, the facility failed to conduct load voltage tests on the batteries of the fire alarm control panel (FACP) semi-annually, as required per NFPA 72, 1999 Edition, Table 7-3.2. This deficiency affects 3 of 3 smoke compartments.

Finding include:

During a record review on 2/8/16 at 10:30 a.m., facility fire alarm reports were examined. There was no documentation the FACP backup batteries had been voltage tested semi-annually. The batteries were new on 7/24/15, but they had not been voltage tested since.¹

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

Based on observations, the facility failed to maintain the automatic sprinkler system per NFPA 13, 1999 Edition, Section 5.1.1. These deficiencies affect 1 of 3 smoke compartments.

Findings include:

1. During an observation on 2/8/16 at 4:20 p.m., the "staff only" storage room next to the PTA office was inspected. The sprinkler head escutcheon ring and ceiling tiles around the sprinkler were ajar and lifted, creating a large gap around the sprinkler head.¹

2. During an observation on 2/8/16 at 4:22 p.m., the north stairwell was inspected. There was a water damaged ceiling tile which had fallen out, creating a large hole in the ceiling.¹

3. During an observation on 2/9/16 at 7:45 a.m., the west stairwell was inspected. There was a water damaged roof tile which had fallen out, leaving a large hole in the drop-down ceiling.¹

¹ NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-1.1*;
The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution
Exception No. 1: For locations permitting omission of sprinklers, see 5-13.1, 5-13.2, and 5-13.9.
Exception No. 2: When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.
Exception No. 3: Clearance between sprinklers and ceilings exceeding the maximum specified in 5-6.4.1, 5-7.4.1, 5-8.4.1, 5-9.4.1, 5-10.4.1, and 5-11.4.1 shall be permitted provided that tests or calculations demonstrate comparable sensitivity and performance of the sprinklers to those installed in conformance with these sections.

Based on observations, the facility failed to maintain the automatic sprinkler system per NFPA 13, 1999 Edition, Section 5.1.1. These deficiencies affect 2 of 3 smoke compartments.

Findings include:

1. During an observation on 2/8/16 at 2:40 p.m., the air handling penthouse was inspected. There was a large duct in the room creating a five feet by five feet area under the ductwork which did not have sprinkler coverage.¹

2. During an observation on 2/8/16 at 3:49 p.m., the store room on north hall was inspected. There was a ceiling tile in the room which was held ajar by an IT wire which was not properly run in a track.²

3. During an observation on 2/8/16 at 4:12 p.m., the IT room with the video camera equipment was inspected. The room was missing a ceiling tile and the sprinkler head was missing the escutcheon ring.²

¹ NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, 5-5.5.3.1; Sprinklers shall be installed under fixed obstructions over 4 ft (1.2 m) wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors.
Exception: Obstructions that are not fixed in place such as conference tables.

² NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-1.1*
The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution
Exception No. 1: For locations permitting omission of sprinklers, see 5-13.1, 5-13.2, and 5-13.9.
Exception No. 2: When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.
Exception No. 3: Clearance between sprinklers and ceilings exceeding the maximum specified in 5-6.4.1, 5-7.4.1, 5-8.4.1, 5-9.4.1, 5-10.4.1, and 5-11.4.1 shall be permitted provided that tests or calculations demonstrate comparable sensitivity and performance of the sprinklers to those installed in conformance with these sections.

Based on observation, the facility failed to ensure the means of egress were continuously maintained free of all obstructions to full instant use in the case of fire or other emergency in accordance with NFPA 101, 2000 Edition, Section 7.1.10.1. This deficiency affects 1 of 3 smoke compartments.

Findings include:

During an observation on 2/9/16 at 7:15 a.m., the emergency exit corridor in front of the temporary enclosure had a large PT stair step and a rolling bedside table left in the corridor.¹

¹ NFPA 101, 2000 Edition, Section 7.1.10.1; Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on observations, the facility failed to meet the medical gas bulk storage requirements in accordance with NFPA 50, 1996 Edition, Sections 1-3 and 4-2.1 and gas storage requirements per NFPA 99, 1999 Edition, Section 4-3.5.2.1. These deficiencies could affect 1 of 3 smoke compartments.

Findings include:

1. During an observation on 2/8/16 at 1:58 p.m., the oxygen storage area was inspected. There was liquid oxygen and compressed gas tanks stored in the room. Four containers of liquid oxygen amounting to 19,372 cu. ft. of oxygen, as well as 11 "K" tanks, amounting to a total 22,672 cu. ft. of oxygen. This amount of stored oxygen requires an annual inspection of "bulk" storage.¹

In an interview on 2/8/16 at 1:58 p.m., staff member A stated there is no annual med gas report.²

2. During an observation on 2/8/16 at 1:58 p.m., there were seven "E" sized cylinders sitting on the floor of oxygen storage room. They were not in a rack, and the chain around the "K" sized tanks was higher then the tops of the "E" sized tanks on the floor, rendering them unrestrained.³

3. During an observation on 2/8/16 at 3:18 p.m., there was an unsecured "E" tank sitting on the floor in respiratory therapy.³

¹ NFPA 50 Standard for Bulk Oxygen Systems at Consumer Sites, 1996 Edition, Section 1-3 Definitions; For the purpose of the standard, the following terms are defined as follows:Bulk Oxygen System. A bulk oxygen system is an assembly of equipment, such as oxygen storage containers, pressure regulators, safety devices, vaporizers, manifolds, and interconnecting piping, that has a storage capacity of more than 20,000 ft3 (566 m3) of oxygen (NTP) including unconnected reserves on hand at the site. The bulk oxygen system terminates at the point where oxygen at service pressure first enters the supply line. The oxygen containers may be stationary or movable, and the oxygen may be stored as gas or liquid.

² NFPA 50, 1996 Edition, Section 4-2.1; Each bulk oxygen system installed on consumer premises shall be inspected annually and maintained by a qualified representative of the equipment owner.

³ NFPA 99, 1999 Edition, Section 4-3.5.2.1; Gases in Cylinders and Liquefied Gases in Containers - Level 1.
(a) * Handling of Gases. Administrative authorities shall provide regulations to ensure that standards for safe practice in the specifications for cylinders; marking of cylinders, regulators, and valves; and cylinder connections have been met by vendors of cylinders containing compressed gases supplied to the facility.
(b) Special Precautions - Oxygen Cylinders and Manifolds. Great care shall be exercised in handling oxygen to prevent contact of oxygen under pressure with oils, greases, organic lubricants, rubber, or other materials of an organic nature. The following regulations, based on those of the CGA Pamphlet G-4, Oxygen, shall be observed:
27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Based on observation, interview and record review, the facility failed to ensure that the piped medical gas system met the standards of NFPA 99, 1999 Edition, Section 4-3.5.4.2. This deficiency affects 1 of 3 smoke compartments.

Findings include:

During an observation on 2/8/16 at 3:00 p.m., the labor and delivery room and operating room were inspected. The oxygen and vacuum shutoff valves outside each room were not labeled as to which room or rooms they shut off.¹

¹ NFPA 99 Standard for Health Care Facilities, 1999 Edition, Section 4-3.5.4.2; The shutoff valves described in 4-3.1.2.3, 4-3.1.2.3(m), and 4-3.1.2.3(n) shall be labeled to reflect the rooms that are controlled by such valves. Labeling shall be kept current from initial construction through acceptance. Valves shall be labeled in substance as follows:
CAUTION:
(NAME OF MEDICAL GAS) VALVE DO NOT CLOSE EXCEPT IN EMERGENCY THIS VALVE CONTROLS SUPPLY TO . . . .

Based on observation, the facility failed to maintain the electrical system and/or its components in accordance with NFPA 101, 2000 Edition, Section 39.5.1. This deficiency affects 1 of 3 smoke compartments.

Findings include:

During an observation on 2/8/16 at 4:18 p.m., the PTA office was inspected. There was a microwave plugged into a power strip.¹

¹ NFPA 101, 2000 Edition, Section 39.5.1; Utilities shall comply with the provisions of Section 9.1.

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

Findings include:

1. During an observation on 2/8/16 at 2:38 p.m., the employee break room was inspected. There was a multi plug adapter in the wall between two recliners. It was not circuit protected.¹

2. During an observation on 2/8/16 at 2:38 p.m., the microwave in the employee break room was plugged into a power strip, the power strip was dangling, unsupported.¹

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

Based on observation, the facility failed to fully sprinkler protect the elevator hoistway in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-13.6.1*. This deficiency affects 1 of 3 smoke compartments.

Findings include:

During an observation on 2/9/16 at 8:10 a.m., the elevator hoistway was inspected. There was no sprinkler coverage at the top or the bottom of the hoistway. The elevator uses hydraulic fluid in the machine room.¹ ²

¹ NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-13.6.1*; Sidewall spray sprinklers shall be installed at the bottom of each elevator hoistway not more than 2 ft (0.61 m) above the floor of the pit.
Exception: For enclosed, noncombustible elevator shafts that do not contain combustible hydraulic fluids, the sprinklers at the bottom of the shaft are not required.

² NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-13.6.3*; Upright or pendent spray sprinklers shall be installed at the top of elevator hoistways.
Exception: Sprinklers are not required at the tops of noncombustible hoistways of passenger elevators with car enclosure materials that meet the requirements of ASME A17.1, Safety Code for Elevators and Escalators.