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Based on Life Safety Code (LSC) survey, Woodlawn Hospital was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 42 CFR 485.623(d)(1), Life Safety from Fire and the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies for the original building (Bldg 01) and the Rochester Medical Center (Bldg. 02) and NFPA 101, LSC Chapter 18, New Health Care Occupancies for an addition (Bldg 04) built in 2010 and the Shafer Medical Center (Bldg 03) that was renovated and occupied in 2012.

The original facility (Building 01) was a two story building and was determined to be of Type II (222) construction and was fully sprinklered except for the bathroom in resident room 240. Building 04, an addition attached to Building 01 was a fully sprinklered two story building of Type II (111) construction with the exception of the elevator machine room and Building 03 was a fully sprinklered one story building of Type II (000) construction. Building 02 was a nonsprinklered, one story building of Type II (000) construction. Building 01 has a fire alarm system with smoke detectors in the corridors and common areas.

Based on LSC survey and deficiencies found (see CMS 2567L), it was determined that the facility failed to ensure in Building 04, a complete automatic sprinkler system was installed to provide complete coverage for all portions of the building (radiology department and elevator equipment room), failed to ensure 1 of 12 resident room bathroom was provided with an automatic sprinkler head, failed to ensure 2 of 9 steel armover sprinkler pipes were installed in accordance with the requirements of NFPA 13 (see K 056), failed to ensure 2 of 2 exit stairs were provided with handrails on both sides (see K 130) and failed to ensure 1 of 1 emergency generators was equipped with a working remote manual stop (see K 144).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that all locations from which it provides services are constructed, arranged, and maintained to ensure the provision of quality health care in a safe environment.

Based on observation and interview, the facility failed to ensure in Building 04, a complete automatic sprinkler system was installed to provide complete coverage for all portions of the building (radiology department and elevator equipment room), failed to ensure 1 of 12 resident room bathroom was provided with an automatic sprinkler head, failed to ensure 2 of 9 steel armover sprinkler pipes were installed in accordance with the requirements of NFPA 13, failed to ensure 2 of 2 exit stairs were provided with handrails on both sides and failed to ensure 1 of 1 emergency generators was equipped with a working remote manual stop.

Findings:

1. Observation on 12/02/14 at 1:00 p.m. with DQ#1, Director of Quality and MS#1, Maintenance Supervisor noted the nine foot by nine foot storage alcove in Radiology had two sprinklers with a distance of two feet between the sprinklers.

2. In interview on 12/02/14 at 1:00 p.m., DQ#1 and MS#1 confirmed the nine foot by nine foot storage alcove in Radiology had a wall removed several years ago leaving two sprinklers with a distance of two feet between the sprinklers.

3. Observation on 12/02/14 at 10:50 a.m. with MS#1 noted the bathroom in resident room 240 was not provided with sprinkler head protection.

4. In interview, concurrent with the observation, MS#1 acknowledged the aforementioned room was not equipped with sprinkler head protection.

5. On 12/02/14 during the tour between 12:15 p.m. to 12:49 p.m. with MS#1, the steel sprinkler pipe armovers observed in the Mechanical Penthouse next to air handler number one was measured to be 48 inches long. Furthermore, the entrance into the Mechanical Penthouse at the top of the stairs had an armover which measured thirty six inches long and both were unsupported.

6. In interview, concurrent with the observations, MS#1 acknowledged the aforementioned steel sprinkler pipe armovers exceeded twenty four inches in length and were unsupported.

7. Observation on 12/02/14 at 1:30 p.m. with DQ#1 and MS#1 noted the elevator
equipment room in the new hospital addition lacked sprinkler coverage or alternative protection from an automatic extinguishing system.

8. In interview on 12/02/14 at 1:30 p.m., DQ#1 and MS#1 acknowledged the elevator equipment room in the new hospital addition lacked sprinkler coverage or alternative protection from an automatic extinguishing system.

9. Observation on 01/09/15 at 10:15 a.m. with MD#1, the Maintenance Director, indicated the west and and south exits had two or more steps and were not provided with handrails on both sides of the steps.

10. In interview at the time of observation, MD#1 acknowledged the lack of handrails on the west and south exit steps.

11. During observation of generator equipment on 12/02/14 at 2:45 p.m. with MS#1, a remote shut off device was found inside the Boiler Power house, but, when tested during a generator exercise, would not shut the generator down. The generator was installed after 2003 and over 100 horsepower and was required to have a working means to shut the generator off.

12. In interview on 12/02/14 at 2:48 p.m., MS#1 acknowledged the facility was unaware the remote shut off for the generator was not working.