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Based on observation and record review, the facility failed to ensure that all doors protecting corridor openings, close and latch. This was evidenced by 1 door that did not latch after self closure. This affected 1 of 2 smoke compartments and could result in the passage of smoke and flames in the event of a fire.

Findings:

On 12/18/12, during a tour of the facility with the facilities director, the doors were observed.

At 9:44 a.m., the dialysis room door failed to latch after closing. A piece of paper was placed in the latching plate and obstructed the latching action.

During record review, the Life Safety Code validation survey, dated 3/30/12 was reviewed. The survey indicated the same door was obstructed from latching, on 3/28/12.

Based on observation, the facility failed to maintain the smoke barrier walls. This was evidenced by a penetration in one smoke barrier wall. This affected 1 of 2 smoke compartments, and could result in the passage of smoke and flames in the event of a fire.

Findings:

On 12/18/12, during a tour of the facility with the facilities director, the smoke barrier walls were observed.

At 10:34 a.m., there was an approximately three foot piece of gypsum board missing, in the corridor wall above the suspended ceiling, above Room 121 on the first floor.

Based on observation, the facility failed to maintain the smoke barrier doors. This was evidenced by doors that failed to close, and by doors that were obstructed. This affected 2 of 2 smoke compartments, and had the potential to allow the passage of smoke and flames in the event of a fire.

Findings:

On 12/18/12, during a tour of the facility with the facilities director, the smoke barrier doors were observed.

1. At 1:33 p.m., the left leaf of the smoke barrier doors, near Room 203, failed to close, when released from the magnetic door hold open device, after activation of the fire alarm system. The door failed to close and latch during 2 of 3 attempts.

2. At 1:33 p.m., the right door leaf was obstructed by a food cart placed in front of it. Staff failed to move the cart upon activation of the fire alarm system.

Based on document review, and interview, the facility failed to ensure that fire drills were conducted a least annually in The Center. This was evidenced by no documentation for a current fire drill during the past twelve months. This had the potential to cause a delay in evacuation in the event of a fire. This affected the entire suite.

NFPA 101, Life Safety Code, 2000 Edition
4.7* Fire Drills
4-7.2* Drill Frequency. Emergency egress and relocation drills, where required by Chapters 11 through 42 or the authority having jurisdiction, shall be held with sufficient frequency to familiarize occupants with the drill procedure and to establish conduct of the drill as a matter of routine. Drills shall include suitable procedures to ensure that all persons subject to the drill participate.
4.7.5* Simulated Conditions. Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.
4.7.6 Relocation Area. Drill participants shall relocate to a predetermined location and remain at such location until a recall or dismissal signal is given.

Findings:

On 12/19/12, at 10 a.m., during a tour of the facility with the facilities director, staff at The Center were interviewed. Center Staff 1 was asked if she had participated in a fire drill. She stated that she had, but could not remember the date of the last drill.

At 10:15 a.m., the fire drills were reviewed with the facilities director. The last documented fire drill for The Center was on 8/4/11.

Based on document review, the facility failed to ensure that all smoke detectors are tested as required. This was evidenced by no documentation of annual testing and smoke detector sensitivity testing, for three of three smoke detectors in the MRI trailer. This affected the entire Magnetic Resonance Imaging (MRI) trailer, and could result in the failure of the smoke detectors in the event of fire.

Findings:

On 12/19/12, during a tour of the MRI trailer, with the facilities director, the smoke detectors were observed.

At 9:23 a.m., there were three smoke detectors. One was located above the imaging machine, one in the lobby/office area, and one in the equipment room. Records were requested for testing the three smoke detectors.

At 9:45 a.m., annual fire alarm system testing records, dated 6/2012, did not include the smoke detectors in the MRI trailer. During an interview, the facilities director reported there was no documentation for testing the MRI smoke detectors.

Based on document review and interview, the facility failed to maintain the emergency generator, as evidenced by no remote annunciator alarm. This could delay staff response if the emergency generator failed, in the event of a power outage. This affected the entire facility. The facility had previously requested a time limited waiver for K144. The waiver will expire on 12/31/12.

NFPA 110 Standard for Emergency and Standby Power Systems, 1999 Edition
3-5.6.1 A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2 (d). This remote alarm shall be located outside of the EPS (Emergency Power Supply) service room at a work site readily observable by personnel.

Findings:

During record review, on 12/19/12, the survey record for the 3/30/12 LSC survey was reviewed. The survey indicated that there was not remote annunciator for the emergency generator.

During an interview with the facilities director, on 12/19/12, at 9:05 a.m., he reported the project is still in progress. The plans are currently held up at OSHPD, awaiting approval. The facility has requested a six month extension for their waiver.

Based on observation and interview, the facility failed to maintain the building electrical wiring and equipment. This was evidenced by no emergency power in the the GI Lab, by the use of extension cords, and by appliances plugged into surge protectors. This had the potential to increase the risk of an electrical fire and to delay staff response in the event of a power outage. This affected 1 of 9 smoke compartments. The facility had previously requested a time limited waiver for repair and installation of electrical receptacles backed up by the generator. The waiver will expire on 12/31/12.

NFPA 99, Health Care Facilities, 1999 Edition
3-2.4.2 Need to Maintain Power. Interruption of the supply of electric power in a facility can be a hazard. Implementation of the requirements of this chapter serves to maintain the required level of continuity and quality of electrical power for patient care electrical appliances.

3-4.2.2.4 Wiring Requirements.
(a) * Separation from other circuits. The life Safety branch and critical branch of the emergency system shall be kept entirely independent of all other wiring and equipment.
(b) Receptacles.
1. The number of receptacles on a single branch circuit for areas described in 3-4.2.2.2 (c) (8) shall be minimized to limit the effects of a branch circuit outage. Branch circuit overcurrent devices shall be readily accessible to nursing and other authorized personnel.
2. * The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable.
(c) Switches. Switches installed in the lighting circuits connected to the essential electrical system shall comply with Article 700, Section E.

NFPA 101, Life Safety Code
NEC 70, National Electrical Code, 1999 Edition
400-8. Uses Not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the
provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

During record review, the survey dated 3/27/2012, indicated that there was no emergency power or lighting in the GI Lab area.

On 12/19/2012, at 9 a.m., during an interview with the facilities director, he reported that the project for emergency power in the GI Lab is still on going. The GI lab is not used and is locked with the only key in the facilities department. The project plan approval is held up in OSHPD at this time. The facility has requested a six month extension for their waiver for K147.

On 12/19/2012, at 10:23 a.m., there was a surge protector plugged into a surge protector, in the first cubicle area, in the Birth Certificate room. A refrigerator was plugged into the surge protector.

At 10:39 a.m., in the first room on the left there was an extension cord in use.


On March 28, 2012, during a tour of the facility the emergency lights were observed.

Based on observation, the facility failed to ensure that Alcohol Based Hand Rub Dispensers (ABHRs), were installed away from any ignition source. This affects one of two smoke compartments on the second floor and one of nine smoke compartments on the first floor.

Findings:

On 12/18/12, during a tour of the facility with the facilities director, the ABHRs were observed.

1. At 9:52 a.m., the ABHR was installed above a night light in Room 212.
2. At 11:08 a.m., the ABHR was installed adjacent to a light switch in the EMS Oasis room.

Based on observation and record review, the facility failed to ensure that all doors protecting corridor openings, close and latch. This was evidenced by 1 door that did not latch after self closure. This affected 1 of 2 smoke compartments and could result in the passage of smoke and flames in the event of a fire.

Findings:

On 12/18/12, during a tour of the facility with the facilities director, the doors were observed.

At 9:44 a.m., the dialysis room door failed to latch after closing. A piece of paper was placed in the latching plate and obstructed the latching action.

During record review, the Life Safety Code validation survey, dated 3/30/12 was reviewed. The survey indicated the same door was obstructed from latching, on 3/28/12.

Based on observation, the facility failed to maintain the smoke barrier walls. This was evidenced by a penetration in one smoke barrier wall. This affected 1 of 2 smoke compartments, and could result in the passage of smoke and flames in the event of a fire.

Findings:

On 12/18/12, during a tour of the facility with the facilities director, the smoke barrier walls were observed.

At 10:34 a.m., there was an approximately three foot piece of gypsum board missing, in the corridor wall above the suspended ceiling, above Room 121 on the first floor.

Based on observation, the facility failed to maintain the smoke barrier doors. This was evidenced by doors that failed to close, and by doors that were obstructed. This affected 2 of 2 smoke compartments, and had the potential to allow the passage of smoke and flames in the event of a fire.

Findings:

On 12/18/12, during a tour of the facility with the facilities director, the smoke barrier doors were observed.

1. At 1:33 p.m., the left leaf of the smoke barrier doors, near Room 203, failed to close, when released from the magnetic door hold open device, after activation of the fire alarm system. The door failed to close and latch during 2 of 3 attempts.

2. At 1:33 p.m., the right door leaf was obstructed by a food cart placed in front of it. Staff failed to move the cart upon activation of the fire alarm system.

Based on document review, and interview, the facility failed to ensure that fire drills were conducted a least annually in The Center. This was evidenced by no documentation for a current fire drill during the past twelve months. This had the potential to cause a delay in evacuation in the event of a fire. This affected the entire suite.

NFPA 101, Life Safety Code, 2000 Edition
4.7* Fire Drills
4-7.2* Drill Frequency. Emergency egress and relocation drills, where required by Chapters 11 through 42 or the authority having jurisdiction, shall be held with sufficient frequency to familiarize occupants with the drill procedure and to establish conduct of the drill as a matter of routine. Drills shall include suitable procedures to ensure that all persons subject to the drill participate.
4.7.5* Simulated Conditions. Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.
4.7.6 Relocation Area. Drill participants shall relocate to a predetermined location and remain at such location until a recall or dismissal signal is given.

Findings:

On 12/19/12, at 10 a.m., during a tour of the facility with the facilities director, staff at The Center were interviewed. Center Staff 1 was asked if she had participated in a fire drill. She stated that she had, but could not remember the date of the last drill.

At 10:15 a.m., the fire drills were reviewed with the facilities director. The last documented fire drill for The Center was on 8/4/11.

Based on document review, the facility failed to ensure that all smoke detectors are tested as required. This was evidenced by no documentation of annual testing and smoke detector sensitivity testing, for three of three smoke detectors in the MRI trailer. This affected the entire Magnetic Resonance Imaging (MRI) trailer, and could result in the failure of the smoke detectors in the event of fire.

Findings:

On 12/19/12, during a tour of the MRI trailer, with the facilities director, the smoke detectors were observed.

At 9:23 a.m., there were three smoke detectors. One was located above the imaging machine, one in the lobby/office area, and one in the equipment room. Records were requested for testing the three smoke detectors.

At 9:45 a.m., annual fire alarm system testing records, dated 6/2012, did not include the smoke detectors in the MRI trailer. During an interview, the facilities director reported there was no documentation for testing the MRI smoke detectors.

Based on document review and interview, the facility failed to maintain the emergency generator, as evidenced by no remote annunciator alarm. This could delay staff response if the emergency generator failed, in the event of a power outage. This affected the entire facility. The facility had previously requested a time limited waiver for K144. The waiver will expire on 12/31/12.

NFPA 110 Standard for Emergency and Standby Power Systems, 1999 Edition
3-5.6.1 A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2 (d). This remote alarm shall be located outside of the EPS (Emergency Power Supply) service room at a work site readily observable by personnel.

Findings:

During record review, on 12/19/12, the survey record for the 3/30/12 LSC survey was reviewed. The survey indicated that there was not remote annunciator for the emergency generator.

During an interview with the facilities director, on 12/19/12, at 9:05 a.m., he reported the project is still in progress. The plans are currently held up at OSHPD, awaiting approval. The facility has requested a six month extension for their waiver.

Based on observation and interview, the facility failed to maintain the building electrical wiring and equipment. This was evidenced by no emergency power in the the GI Lab, by the use of extension cords, and by appliances plugged into surge protectors. This had the potential to increase the risk of an electrical fire and to delay staff response in the event of a power outage. This affected 1 of 9 smoke compartments. The facility had previously requested a time limited waiver for repair and installation of electrical receptacles backed up by the generator. The waiver will expire on 12/31/12.

NFPA 99, Health Care Facilities, 1999 Edition
3-2.4.2 Need to Maintain Power. Interruption of the supply of electric power in a facility can be a hazard. Implementation of the requirements of this chapter serves to maintain the required level of continuity and quality of electrical power for patient care electrical appliances.

3-4.2.2.4 Wiring Requirements.
(a) * Separation from other circuits. The life Safety branch and critical branch of the emergency system shall be kept entirely independent of all other wiring and equipment.
(b) Receptacles.
1. The number of receptacles on a single branch circuit for areas described in 3-4.2.2.2 (c) (8) shall be minimized to limit the effects of a branch circuit outage. Branch circuit overcurrent devices shall be readily accessible to nursing and other authorized personnel.
2. * The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable.
(c) Switches. Switches installed in the lighting circuits connected to the essential electrical system shall comply with Article 700, Section E.

NFPA 101, Life Safety Code
NEC 70, National Electrical Code, 1999 Edition
400-8. Uses Not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the
provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

During record review, the survey dated 3/27/2012, indicated that there was no emergency power or lighting in the GI Lab area.

On 12/19/2012, at 9 a.m., during an interview with the facilities director, he reported that the project for emergency power in the GI Lab is still on going. The GI lab is not used and is locked with the only key in the facilities department. The project plan approval is held up in OSHPD at this time. The facility has requested a six month extension for their waiver for K147.

On 12/19/2012, at 10:23 a.m., there was a surge protector plugged into a surge protector, in the first cubicle area, in the Birth Certificate room. A refrigerator was plugged into the surge protector.

At 10:39 a.m., in the first room on the left there was an extension cord in use.


On March 28, 2012, during a tour of the facility the emergency lights were observed.