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Based on observation with the Director of Plant Operations, it was determined the facility failed to provide a safe means of egress from the exit corridor located by Materials Management on the second floor of the Curahealth Hospital Phoenix.

NFPA 101, Life Safety Code, 2012, Chapter 19, Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. 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." Section 7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits or their access thereto egress therefrom, or visibility thereof."

Findings include:

On July 5, 2017, the surveyors, accompanied by the Director of Plant Operations observed the exit corridor located by Materials Management was being reduced from eight feet to approximate four feet and blocking the exit access with the following items being stored in the exit corridor:

1. Wooden pallets of hand sanitizers and dispensers in boxes.
2. A flat cart for recycling.
3. A wooden pallet with sharps containers.
4. PPE containers in shelving and a flat cart.

During the exit conference on July 5, 2017, the above findings were again acknowledged by the Director of Plant Operations the Chief Executive Officer and Chief Quality Officer.

Failure to provide a clear and unimpeded means of egress could cause harm to the patients and staff in a fire emergency.

Based on record review with the Director of Plant Operations, it was determined the facility had no documentation of testing of the multiple battery backup emergency lights located throughout the Curahealth Hospital Phoenix..

NFPA 101, Life Safety Code, 2012, Chapter 19, Section 19.2.9.1 "Emergency lighting shall be provided in accordance with Section 7.9". Section 7.9.3 " Periodic Testing of Emergency Lighting Equipment" " Section 7.9.3.1 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) The Test interval shall be permitted to be extended beyond 30 days with the approval of authority having jurisdiction.(3) Functional testing shall be conducted annually for a minimum of 1/1/2 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."

Findings include:

On June 26, 2017, the surveyor accompanied by the Director of Plant Operations determined the facility had no documentation of testing of the multiple battery backup emergency lights throughout the Curahealth Hospital Phoenix. There was no documentation for the entire year of 2016 to include January, February and March of 2017. No documentation was available to review for the Monthly 30 second tests.

During the exit conference on July 5, 2017, the above findings were again acknowledged by the Director of Plant Operations the Chief Executive Officer and Chief Quality Officer.

Failing to test and document the battery backup emergency lighting units in time of an emergency could cause harm to the patients in an emergency power outage.

Based on observation with the Director of Plant Operations, it was determined the facility failed to provide automatic sprinkler protection for the canopies or provide documentation that the canopies were flame retardant. The blue canopies were attached to the roof overhangs on the North and South side of CuraHealth Hospital Northwest. The blue canopies were measured to be six and a half feet in width.

NFPA 101 Life Safety Code 2012, Chapter 19, Section 19.3.5.1 "Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with section 9.7, unless otherwise permitted by 19.3.5.5. Section 19.3.5.5 In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where the authority having jurisdiction has prohibited sprinklers, without causing the building to be classified as non-sprinklered."
Section 9.7." Chapter 9, Section 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" NFPA 13, Section 8.15.7

Exterior roofs, Canopies, Porte-Cochers, Balconies, Decks or Similar Projections.
Section 8.15.7.1 Unless the requirements of 8.15.7.2,8.15.7.3 , or 8.15.7.4 are met sprinklers shall be installed under exterior roofs, canopies,Porte-cocheres, balconies decks, or similar projections exceeding 4 ft in width."

Section 8.15.7.2 "Sprinklers shall be permitted to be omitted where the canopies, roofs, Porte-cocheres balconies, decks, or similar projections are constructed with materials that are noncombustible, limited combustible, or fire retardant-treated wood as defined in NFPA 703, Standard for Fire Retardant-Treated Wood and Fire Retardant Coatings for Building Materials."

Findings include:

On July 05, 2017, the surveyors accompanied by the Director of Plant Operations observed the exterior blue canopies were attached to the roof overhangs on the North and South side of CuraHealth Hospital Northwest. There was no documentation provided to the surveyors while on site that the canopies were flame retardant.
The blue canopies appeared to be made of combustible material and are greater than 4 feet in depth, and were not sprinklered.

During the exit conference on July 5, 2017, the above findings were again acknowledged by the Director of Plant Operations the Chief Executive Officer and Chief Quality Officer.

Failing to provide automatic sprinklers to all areas of the facility could cause harm to the patients in time of a fire.

Based on observation with the Director of Plant Operations, it was determined that the facility failed to maintain the sprinkler heads in the 300 and 400 areas of the patient rooms in the Curahealth Hospital Phoenix.

NFPA 101 Life Safety Code, 2012 edition, Chapter 19, Section 19.3.5.1 "Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Chapter 9, Section 9.7.1 "Each automatic sprinkler system required by another section of this Code shall be in accordance with on of the following." " NFPA 13, Standard for the Installation of Sprinkler Systems." Chapter 26, Section 26.1 "General." "A sprinkler system installed in accordance with standard shall be properly inspected, tested, and maintained by the property owner or their authorized representative in accordance with NFPA 25. NFPA 25, Section 5.2.1 "Sprinklers, Section 5.2.1.1.1 "Sprinklers shall not show signs of leakage, shall be free of corrosion, foreign materials, paint and physical damage...."

Findings Include:

On July 05, 2017, the surveyors accompanied by the Director of Plant Operations observed sprinkler heads in the the following locations had either paint or sheetrock overspray on the sprinklers. This was observed either in the patient rooms or the patient bathrooms.

1. Rooms 304, 306 308 , 310, 416, 419, 420, 423, 425. In addition: one sprinkler was missing in one closet of the CuraHealth Hospital Admissions area offices.

During the exit conference on July 5, 2017, the above findings were again acknowledged by the Director of Plant Operations the Chief Executive Officer and Chief Quality Officer.

Failing to maintain sprinkler heads free from paint or sheetrock overspray could cause harm to residents and staff by allowing a fire to spread before the temperature is reached to set of the sprinkler head.

Based on observation, it was determined the facility failed to provide a protective guard on light bulbs located in the telephone closet at the Curahealth Hospital Phoenix Northwest.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1. Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70, 2011 Edition, "National Electrical Code." NEC, 2011, Article 110, Section 110-27 (b) Prevent Physical Damage."In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage...."

Findings include:

On July 5, 2017, the surveyors, accompanied by the Director of Plant Operations observed the light bulbs in the telephone closet at the Curahealth Hospital Phoenix Northwest were exposed with no protective guards on the light bulbs.

During the exit conference on July 5, 2017, the above findings were again acknowledged by the Director of Plant Operations the Chief Executive Officer and Chief Quality Officer.

Failure to keep light guards on the light bulbs could cause accidental damage or possibly a fire, which could cause harm to the patients.

Based on record review, it was determined the facility failed to provide documentation of the Monthly elevator recall testing from January 2016 to March of 2017.

NFPA 101 Life Safety Code, Chapter 19, Section 19.5.3. "Elevators, Escalators, and Conveyors. Elevators, escalators and conveyors shall comply with the provisions of Section 9.4 Section 9.4.6 Elevator testing Elevators shall be subject to routine and periodic inspections and tests as specified in ASME/ANSI A17.1, Safety Code for Elevators and Escalators. All elevators equipped with firefighter service in accordance with 9.4.3 and 9.4.5 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASME/ANSI A17.1 Safety Code for Elevators and Escalators...."

Findings include:

On June 26, 2017, the surveyor, accompanied by the Director of Plant Operations reviewed the Monthly elevator fire service testing log sheets for the Curahealth Hospital Phoenix. The elevator recall was not tested Monthly according to the documentation shown to the surveyor from January 2016 to March of 2017.

During the exit conference on July 5, 2017, the above findings were again acknowledged by the Director of Plant Operations the Chief Executive Officer and Chief Quality Officer.

Failure to test and document the Monthly elevator recall testing could result in harm to the patients if the elevator is not working in an emergency.

Based on observation and interview with staff at the Curahealth Hospital Phoenix and Curahealth Hospital Phoenix Northwest, it was determined the facility failed to provide a written plan for the protection of all patients in time of a fire or emergency at the nurses stations.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.7.1.1 "The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of a fire, for their evacuation to areas of refuge, and from the evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator's position or at the security center."

Findings include:

On July 5, 2017, the surveyors, accompanied by the Director of Plant Operations, asked the nursing staff for the written emergency policy manual at the nurse's stations. The written fire and emergency policy was not found or seen during the survey at the nursing stations for the following locations:

1. Curahealth Hospital Phoenix, third floor ICU nurses station.

2. Curahealth Hospital Phoenix Northwest, North nurses station.

During the exit conference on July 5, 2017, the above findings were again acknowledged by the Director of Plant Operations the Chief Executive Officer and Chief Quality Officer.

In time of an emergency, an emergency policy manual must be readily available for the staff. Patients will be harmed if the Staff is not trained or is unable to locate the emergency evacuation policy manual.

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Based on record review and interview with the Director of Plant Operations, it was determined that there was no fire drill documentation for four quarters of fire drills from Year 2016 to the second quarter of 2017. No documentation of the fire drills was provided to the surveyor to review while on site during the survey.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.7.1.6 "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 PM and 6:00 am a coded announcement shall be permitted to be used instead of audible alarms."

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.7.2.2 "written health care occupancy fire safety plan shall provide for the following:

1. Use of alarms
2. Transmission to the fire department
3. Emergency phone call to the fire department
4. Response to alarms
5. Isolation of fire
6. Evacuation of immediate area
7. Evacuation of smoke compartment
8. Preparation of floors and building for evacuation
9. Extinguishment of fire."

Findings include:

On June 26, 2017, the surveyor accompanied by the Director of Plant Operations reviewed the fire drills. The Director of Plant Operations could not provide documentation that the following fire drills were conducted for the following quarters.

The Curahealth Hospital Phoenix and Northwest both facilities have two 12 hour shifts for the fire drill.

Curahealth Hospital Phoenix and Curahealth Hospital Phoenix - Northwest
Year 2016:

Missing or not found on site. All four quarters January to December for both shifts.

Curahealth Hospital Phoenix and Curahealth Hospital Phoenix - Northwest
Year 2017:

Missing or not found on site. First quarter both shifts.

During the exit conference on July 5, 2017, the above findings were again acknowledged by the Director of Plant Operations the Chief Executive Officer and Chief Quality Officer.

Failing to conducted the fire drills in accordance with the life safety code to familiarize staff with conditions under an actual fire can result in harm to patients and staff during a an actual fire or emergency situation.

Based on interview with the Director of Plant Operations, it was determined that the facility failed to conduct, maintain, and document electrical receptacle testing in all patient care areas for 2016 for the Curahealth Hospital Phoenix Northwest.

NFPA 101, Life Safety Code, 2012 Edition, Chapter 19, Section 19.7.6 " Maintenance, Inspection and Testing (See 4.6.12)" Section 4.6.12.1, "Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained. Maintenance shall be in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction." Section 4.6.12.3 "Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed."

NFPA 99, Health Care Facilities Code, 2012, Chapter 6, Section 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."

Findings include:

On June 26, 2017, the surveyor, accompanied by the Director of Plant Operations when asked for the annual receptacle testing and documentation, the surveyor was advised there was no documentation of the annual testing completed for all of the patient care areas tested in 2016 for the Curahealth Hospital Phoenix Northwest.

The hospital has half hospital grade receptacle outlets and half normal receptacle grade outlets in patient care areas of the hospital. No documentation was found or shown to the surveyor while on site to review of the normal hospital grade receptacle outlets to indicate it was completed in 2016.

During the exit conference on July 5, 2017, the above findings were again acknowledged by the Director of Plant Operations the Chief Executive Officer and Chief Quality Officer.

Failing to test the receptacles annually could lead to an ignition hazard in a patient care area resulting in fire and/or injury to the patients.

Based on record review and interview with the Director of Plant Operations, it was determined the Curahealth Hospital Phoenix and Curahealth Hospital Phoenix Northwest failed to document the required testing of the emergency generator for the weekly visual checks and monthly under load tests for the emergency generator.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.7.6 "Maintenance and Testing (See 4.6.12) Section 4.6.12.2 " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 99 "HEALTH CARE FACILITIES" 2012, Chapter 6, Section 6.4.4.1.1.4 (A) Test Criteria. Generator sets shall be tested 12 times a year with testing intervals of not less than 20 days nor more than 40 days. Generator sets serving essential electrical systems shall be tested in accordance with NFPA 110, Standards for Emergency and Standby Power Systems, Chapter 8. Operational Inspection and Testing. Section 8.4.1 EPPS , including all appurtenant components, shall be inspected weekly and exercised under load at least monthly."

Findings Include:

1. Curahealth Hospital Phoenix and Curahealth Hospital Phoenix Northwest

On June 26, 2017, the surveyor, accompanied by the Director of Plant Operations reviewed the generator test records. No documentation of weekly visual checks and monthly under load testing was available to review from January of 2016 to March of 2017.

During the exit conference on July 5, 2017, the above findings were again acknowledged by the Director of Plant Operations the Chief Executive Officer and Chief Quality Officer.

Failure to visually inspect and document the emergency generator could result in harm to patients during emergency system failures.

Based on observation with the Director of Plant Operations, it was determined the facility allowed the use of a six way multiple outlet adapters, extension cords, and daisy chained power strips together for appliances that were not plugged directly into the wall receptacle outlets for all the appliances observed during the survey.

NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 "The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , "All Patient Care Areas," Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters."

Findings include:

On July 05, 2017, the surveyors, accompanied by the Director of Plant Operations observed the following:

Curahealth Hospital Phoenix

1. Nursing Supervisor Office, power strips daisy chained connected together for two printers.
2. Fourth Floor Case Manager Office, extension cord into the printer, connected to a power strip.
3. Pharmacy, power strips daisy chained connected together for computers.
4. Admissions Office, daisy chained connected together for appliances.

Curahealth Hospital Phoenix Northwest

1. Therapy Rehabilitation Care, extension cord into a printer/copier.
During the exit conference on July 5, 2017, the above findings were again acknowledged by the Director of Plant Operations the Chief Executive Officer and Chief Quality Officer.

The use of multiple outlet adapters and extension cords could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.