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Based on observation and staff interview, the facility failed to maintain a two-hour fire barrier that separated two non-conforming construction types (Type V (111) and Type II (111) construction). This condition would allow fire to progress through the fire barriers. Facility census was 21.

Findings are:
Observations during the facility tour on 2/19/14, from 1:08 pm to 2:38 pm revealed:
1. The 90 minute fire doors in the two-hour fire barrier by the Same Day Surgery Room 9 failed to latch when auto-closed.
2. The 90 minute fire doors in the two-hour fire barrier by the 2C Elevator failed to latch when auto-closed.
3. Fire proofing failed to be replaced on a structural member above duct work, above the 90 minute fire doors by the 2C Elevator.
4. Penetrations in the two-hour fire barrier above the 90 minute fire doors by the 2C Elevator failed to be sealed.
In an interview conducted at the time of observations (2/19/14, from 1:08 pm to 2:38 pm), Facilities A confirmed the findings.

Based on observation and staff interview, the facility failed to maintain structural components of Type II (111) construction. This condition would allow fire to weaken structural components. Facility census was 21.

Findings are:
Observations during the facility tour on 2/19/14, at 1:28 pm revealed fire proofing failed to be replaced on a structural I-beam in the Sterilization/Mechanical Room.
In an interview conducted at the time of observations (2/19/14, at 1:28 pm), Facilities A confirmed the findings.

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other compartments. This condition had the potential for fire to spread into the exit corridors and other use areas. Facility census was 21.

Findings are:
Observations during the facility tour on 2/19/14 at 1:12 pm revealed penetrations failed to be sealed in the Recovery Construction Separation. Latching hardware failed to be installed in the door that separated the construction area from the exit corridor.
In an interview conducted at the time of observation, (2/19/14 at 1:12 pm), Facilities A acknowledged the findings.

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other compartments. This condition had the potential for fire to spread into the exit corridors and other use areas. Facility census was 21.

Findings are:
Observations during the facility tour on 2/19/14, from 12:34 pm to 1:04 pm revealed:
1. The Elevator Equipment Room by SRAC failed to latch when self-closed.
2. The Same Day North Storage Room Door failed to latch when self-closed. Painter ' s tape was applied over the strike plate.
In an interview conducted at the time of observation, (2/19/14, from 12:34 pm to 1:04 pm), Facilities A acknowledged the findings.

Based on observation and staff interview, the facility failed to maintain the automatic sprinkler system in accordance with the National Fire Protection Association, 25. This condition would allow heat from a fire to escape above the sprinkler heads. Facility census was 21.

Findings are:
Observation during the facility tour on 2/19/14, at 12:48 pm revealed multiple ceiling tiles failed to be replaced in the PSU Storage Room.
In an interview conducted at the time of observation, (2/19/14, at 12:48 pm), Facilities A confirmed the missing ceiling tiles.

K130A

Based on observation and staff interview, the facility failed to maintain a safe distance from a parked vehicle to the bulk oxygen tank. This condition had the potential of a vehicle fire impinging on the bulk oxygen tank. Facility census was 21.

Findings are:
Observation during the facility tour on 2/19/14, at 1:22 pm revealed a vehicle failed to be parked at least 10 feet from the bulk oxygen tank.
In an interview conducted at the time of observation, (2/19/14, at 1:22 pm) Facilities A confirmed that vehicle was parked within 10 feet of the tank.

Actual NFPA Standard:
NFPA 50, 2001 Edition, 2.2.12
The minimum distance from any bulk oxygen system to any public sidewalk or parked vehicle shall be 10 ft (3 m).

K130B

Based on observation, record review and staff interview, the facility failed to maintain all operating room (OR) line isolation panels. This condition would allow an electrical fault during an operation without notification to staff. Facility census was 21.

Findings are:
Observation during the facility tour on 2/19/14, at 1:51 pm revealed that the line isolation panel in OR 7 failed to produce an audible and visual alarm when tested.
Documentation of monthly testing for the line isolation panel in each OR failed to be provided for review.
In an interview conducted at the time of observation, (2/19/14, at 1:51 pm), OR Staff A confirmed the findings.

Actual NFPA Standard:
NFPA 99, 1999 Edition, 3-3.3.4.2 Line Isolation Monitor Tests.
(a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 X V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.
(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.
(c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months.

Based on observation and staff interview, the facility failed to use electrical wiring in accordance with the National Fire Protection Association, 70. This condition had the potential to cause an electrical fire. Facility census was 21.

Findings are:
Observation during the facility tour on 2/19/14, from 12:41 pm to 2:47 pm revealed:
1. The coffee maker and the mini-fridge failed were plugged into a power strip in the Anesthesia Workroom. The heat producing appliances failed to be plugged directly into a wall outlet, per CMS guidelines.
2. Three-outlet power taps were observed behind the TVs in all patient rooms on the 3rd Floor. The equipment failed to be plugged directly into a wall outlet, or an outlet strip tested in accordance with UL 60601-1.
3. The open junction box above ceiling by the lockers in the PSU Women ' s Locker Room failed to have a blank cover installed over the box.
In an interview conducted at the time of observation (2/19/14, from 12:41 pm to 2:47 pm), Facilities A acknowledged the findings.

Based on observation and staff interview, the facility failed to maintain a two-hour fire barrier that separated two non-conforming construction types (Type V (111) and Type II (111) construction). This condition would allow fire to progress through the fire barriers. Facility census was 21.

Findings are:
Observations during the facility tour on 2/19/14, from 1:08 pm to 2:38 pm revealed:
1. The 90 minute fire doors in the two-hour fire barrier by the Same Day Surgery Room 9 failed to latch when auto-closed.
2. The 90 minute fire doors in the two-hour fire barrier by the 2C Elevator failed to latch when auto-closed.
3. Fire proofing failed to be replaced on a structural member above duct work, above the 90 minute fire doors by the 2C Elevator.
4. Penetrations in the two-hour fire barrier above the 90 minute fire doors by the 2C Elevator failed to be sealed.
In an interview conducted at the time of observations (2/19/14, from 1:08 pm to 2:38 pm), Facilities A confirmed the findings.

Based on observation and staff interview, the facility failed to maintain structural components of Type II (111) construction. This condition would allow fire to weaken structural components. Facility census was 21.

Findings are:
Observations during the facility tour on 2/19/14, at 1:28 pm revealed fire proofing failed to be replaced on a structural I-beam in the Sterilization/Mechanical Room.
In an interview conducted at the time of observations (2/19/14, at 1:28 pm), Facilities A confirmed the findings.

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other compartments. This condition had the potential for fire to spread into the exit corridors and other use areas. Facility census was 21.

Findings are:
Observations during the facility tour on 2/19/14 at 1:12 pm revealed penetrations failed to be sealed in the Recovery Construction Separation. Latching hardware failed to be installed in the door that separated the construction area from the exit corridor.
In an interview conducted at the time of observation, (2/19/14 at 1:12 pm), Facilities A acknowledged the findings.

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other compartments. This condition had the potential for fire to spread into the exit corridors and other use areas. Facility census was 21.

Findings are:
Observations during the facility tour on 2/19/14, from 12:34 pm to 1:04 pm revealed:
1. The Elevator Equipment Room by SRAC failed to latch when self-closed.
2. The Same Day North Storage Room Door failed to latch when self-closed. Painter ' s tape was applied over the strike plate.
In an interview conducted at the time of observation, (2/19/14, from 12:34 pm to 1:04 pm), Facilities A acknowledged the findings.

Based on observation and staff interview, the facility failed to maintain the automatic sprinkler system in accordance with the National Fire Protection Association, 25. This condition would allow heat from a fire to escape above the sprinkler heads. Facility census was 21.

Findings are:
Observation during the facility tour on 2/19/14, at 12:48 pm revealed multiple ceiling tiles failed to be replaced in the PSU Storage Room.
In an interview conducted at the time of observation, (2/19/14, at 12:48 pm), Facilities A confirmed the missing ceiling tiles.

K130A

Based on observation and staff interview, the facility failed to maintain a safe distance from a parked vehicle to the bulk oxygen tank. This condition had the potential of a vehicle fire impinging on the bulk oxygen tank. Facility census was 21.

Findings are:
Observation during the facility tour on 2/19/14, at 1:22 pm revealed a vehicle failed to be parked at least 10 feet from the bulk oxygen tank.
In an interview conducted at the time of observation, (2/19/14, at 1:22 pm) Facilities A confirmed that vehicle was parked within 10 feet of the tank.

Actual NFPA Standard:
NFPA 50, 2001 Edition, 2.2.12
The minimum distance from any bulk oxygen system to any public sidewalk or parked vehicle shall be 10 ft (3 m).

K130B

Based on observation, record review and staff interview, the facility failed to maintain all operating room (OR) line isolation panels. This condition would allow an electrical fault during an operation without notification to staff. Facility census was 21.

Findings are:
Observation during the facility tour on 2/19/14, at 1:51 pm revealed that the line isolation panel in OR 7 failed to produce an audible and visual alarm when tested.
Documentation of monthly testing for the line isolation panel in each OR failed to be provided for review.
In an interview conducted at the time of observation, (2/19/14, at 1:51 pm), OR Staff A confirmed the findings.

Actual NFPA Standard:
NFPA 99, 1999 Edition, 3-3.3.4.2 Line Isolation Monitor Tests.
(a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 X V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.
(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.
(c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months.

Based on observation and staff interview, the facility failed to use electrical wiring in accordance with the National Fire Protection Association, 70. This condition had the potential to cause an electrical fire. Facility census was 21.

Findings are:
Observation during the facility tour on 2/19/14, from 12:41 pm to 2:47 pm revealed:
1. The coffee maker and the mini-fridge failed were plugged into a power strip in the Anesthesia Workroom. The heat producing appliances failed to be plugged directly into a wall outlet, per CMS guidelines.
2. Three-outlet power taps were observed behind the TVs in all patient rooms on the 3rd Floor. The equipment failed to be plugged directly into a wall outlet, or an outlet strip tested in accordance with UL 60601-1.
3. The open junction box above ceiling by the lockers in the PSU Women ' s Locker Room failed to have a blank cover installed over the box.
In an interview conducted at the time of observation (2/19/14, from 12:41 pm to 2:47 pm), Facilities A acknowledged the findings.