HospitalInspections.org

1. Based on observation and interview, the facility failed to maintain a minimum two-hour rated construction for 1 of 1 separation walls between business occupancy and health care occupancy. This deficient practice could affect all patients, staff, and visitors on the third and fourth floor.

Findings include:

Based on observations with the SJRMC Manager of Emergency Preparedness and the Property Management Technician for Cressy & Everett during a tour of the facility from 10:40 a.m. to 10:55 a.m. on 08/30/17, the following was noted:
a. a six inch by four inch rectangular shaped hole for the passage of data cables was noted in the two hour rated fire wall separating the Medical Office Building from the hospital on the third floor above the suspended ceiling above the rolling fire door. In addition, the six inch annular space surrounding a two inch in diameter copper colored pipe which penetrated the aforementioned fire wall was filled with clear plastic.
b. a one inch in diameter hole was noted in the two hour rated fire wall separating the Medical Office Building from the hospital on the fourth floor above the suspended ceiling above the rolling fire door.
The clear plastic and the holes failed to maintain the minimum two-hour rated construction for the separation wall between the Medical Office Building and the health care occupancy. Based on interview at the time of the observations, Property Management Technician agreed the aforementioned clear plastic and the holes in the tenant separation wall failed to maintain the minimum two-hour rated construction for the tenant separation wall.

2. Based on observation and interview, the facility failed to ensure 1 of 1 2nd floor Health Care/ MOB occupancy separation fire barrier walls was maintained to ensure the fire resistance of the barrier. Centers for Medicare & Medicaid Services (CMS) requires sets of fire barrier doors which swing in the same direction and equipped with an astragal to have a coordinator to ensure the door which must close first always closes first. This deficient practice could affect staff and at least 25 residents.

Findings include:

Based on an observation with the Director of Facility Resources on 08/30/17 at 11:43 a.m., the 2nd floor Health Care/ MOB occupancy separation fire barrier had set of cross corridor doors that swung in the same direction. When the doors were closed they left a three quarter inch gap between the doors. The cross corridor doors lacked an astragal and coordinating device. Based on interview at the time of each observation, the Director of Facility Resources acknowledged the gap between the doors was not covered by an astragal and lacked a coordinating device.

Based on observation and interview, the facility failed to maintain corridors on 3 of 7 floors from obstructions per 19.2.3.5. LSC 19.2.3.4.5 requires aisles, corridors, and ramps to be arranged to avoid any obstructions to the convenient removal of nonambulatory persons carried on stretchers or on mattresses serving as stretchers. This deficient practice could affect staff and at least 80 residents.

Findings include:

Based on observation with the Director of Facility Resources on 08/29/17 between 11:39 a.m. and 3:06 p.m.,
a) a soiled linen container was in the aisle next to the 6th floor Dialysis Nurse's station
b) a table was in the corridor near 6th floor Stair E
c) a printer and a shred container was in the aisle on the 5th floor outside room A5424
d) a forty four gallon trash container was in the 4th floor Nursery corridor
e) a floor sign was in the corridor near the 4th floor IMU and Mother/Baby separation
Based on interview at the time of each observation, the Director of Facility Resources acknowledged each aforementioned condition were potential obstructions to the convenient removal of nonambulatory persons carried on stretchers or on mattresses serving as stretchers.

1. Based on observation and interview, the facility failed to ensure 1 of 2 battery powered emergency lights was maintained in accordance with LSC 7.9. LSC 39.2.9 states emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exists:
(1) The building is three or more stories in height.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.
LSC 7.9.2.6 states battery operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition. Batteries used in such lights or units shall be approved for their intended use and shall comply with NFPA 70 National Electric Code. This deficient practice could affect all patients, staff and visitors in the facility.

Findings include:

Based on observations with the SJRMC Manager of Emergency Preparedness and the Property Management Technician for Cressy & Everett during a tour of the facility from 9:30 a.m. to 10:15 a.m. on 08/30/17, a total of two battery operated emergency lighting systems were located in the path of egress for the facility. The battery operated light by the second floor stairwell by the Communications Room failed to illuminate when its respective test button was pushed five separate times. Based on interview at the time of the observations, the Property Management Technician agreed the aforementioned battery lighting systems failed to illuminate when its respective test button was pushed.

2. Based on observation and interview, the facility failed to document monthly and annual testing for 2 of 2 battery backup lights in accordance with LSC 7.9. LSC 39.2.9 states emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exists:
(1) The building is three or more stories in height.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.
Section 7.9.3.1.1 states testing of 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).
(2) The test interval shall be permitted to be extended beyond 30 days with the approval of the 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 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.
This deficient practice could affect all patients, staff and visitors in the facility.

Findings include:

Based on observations with the SJRMC Manager of Emergency Preparedness and the Property Management Technician for Cressy & Everett during a tour of the facility from 9:30 a.m. to 10:15 a.m. on 08/30/17, a total of two battery operated emergency lighting systems were located in the path of egress for the facility and each light illuminated when its respective test button was pushed except for the light located by the second floor stairwell by the Communications Room. Based on interview at the time of the observations, the Property Management Technician stated life safety documentation is maintained at the corporate office for Cressy & Everett but monthly and annual functional testing documentation for the most recent twelve month period for each of the two battery operated emergency lighting systems was not available for review at the time of the survey.

1. Based on observation and interview, the facility failed to ensure 2 of 6 battery powered emergency lights was maintained in accordance with LSC 7.9. LSC 39.2.9 states emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exists:
(1) The building is three or more stories in height.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.
LSC 7.9.2.6 states battery operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition. Batteries used in such lights or units shall be approved for their intended use and shall comply with NFPA 70 National Electric Code. This deficient practice could affect all patients, staff and visitors in the facility.

Findings include:

Based on observations with the SJRMC Manager of Emergency Preparedness and the Property Management Technician for Cressy & Everett during a tour of the facility from 1:40 p.m. to 2:25 p.m. on 08/29/17, a total of six battery operated emergency lighting systems were located in the facility. The battery operated light by Treatment Room 7 failed to illuminate when its respective test button was pushed five separate times. The test button for the battery light located in the adjoining Sports Medicine waiting area was inaccessible as the bottom of the lighting system with the test button was installed on top of the exit door frame and could not be pushed. The battery light failed to illuminate when electrical wiring for the lighting system was disconnected. Based on interview at the time of the observations, the Property Management Technician acknowledged the aforementioned battery lighting systems failed to illuminate using battery power.

2. Based on observation and interview, the facility failed to document monthly and annual testing for 6 of 6 battery backup lights in accordance with LSC 7.9. LSC 39.2.9 states emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exists:
(1) The building is three or more stories in height.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.
Section 7.9.3.1.1 states testing of 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).
(2) The test interval shall be permitted to be extended beyond 30 days with the approval of the 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 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.
This deficient practice could affect all patients, staff and visitors in the facility.

Findings include:

Based on observations with the SJRMC Manager of Emergency Preparedness and the Property Management Technician for Cressy & Everett during a tour of the facility from 1:40 p.m. to 2:25 p.m. on 08/29/17, a total of six battery operated emergency lighting systems were located in the facility and each light illuminated when its respective test button was pushed except for the light located by Treatment Room 7 and the light in the adjoining Sports Medicine waiting area. Based on interview at the time of the observations, the Property Management Technician stated life safety documentation is maintained at the corporate office for Cressy & Everett but monthly and annual functional testing documentation for the most recent twelve month period for each of the six battery operated emergency lighting systems was not available for review at the time of the survey.

Based on observation and interview, the facility failed to document monthly and annual testing for 1 of 1 battery backup lights in accordance with LSC 7.9. LSC 39.2.9 states emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exists:
(1) The building is three or more stories in height.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.
Section 7.9.3.1.1 states testing of 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).
(2) The test interval shall be permitted to be extended beyond 30 days with the approval of the 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 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.
This deficient practice could affect all patients, staff and visitors in the facility.

Findings include:

Based on observations with the SJRMC Manager of Emergency Preparedness and the Property Management Technician for Cressy & Everett during a tour of the facility from 10:40 a.m. to 10:55 a.m. on 08/30/17, a total of one battery operated emergency lighting systems were located in the facility and the light illuminated when its test button was pushed. Based on interview at the time of the observations, the Property Management Technician stated life safety documentation is maintained at the corporate office for Cressy & Everett but monthly and annual functional testing documentation for the most recent twelve month period for the battery operated emergency lighting system was not available for review at the time of the survey.

Based on observation and interview, the facility failed to document monthly and annual testing for 2 of 2 battery backup lights in accordance with LSC 7.9. LSC 39.2.9 states emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exists:
(1) The building is three or more stories in height.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.
Section 7.9.3.1.1 states testing of 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).
(2) The test interval shall be permitted to be extended beyond 30 days with the approval of the 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 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.
This deficient practice could affect all patients, staff and visitors in the facility.

Findings include:

Based on observations with the SJRMC Manager of Emergency Preparedness and the Property Management Technician for Cressy & Everett during a tour of the facility from 10:30 a.m. to 10:40 a.m. on 08/30/17, a total of two battery operated emergency lights were located in the facility. Each light illuminated when its respective test button was pushed. Based on interview at the time of the observations, the Property Management Technician stated life safety documentation is maintained at the corporate office for Cressy & Everett but monthly and annual functional testing documentation for the most recent twelve month period for the two battery operated emergency lighting systems was not available for review at the time of the survey.

Based on observation and interview, the facility failed to document monthly and annual testing for 2 of 2 battery backup lights in accordance with LSC 7.9. LSC 39.2.9 states emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exists:
(1) The building is three or more stories in height.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.
Section 7.9.3.1.1 states testing of 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).
(2) The test interval shall be permitted to be extended beyond 30 days with the approval of the 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 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.
This deficient practice could affect all patients, staff and visitors in the facility.

Findings include:

Based on observations with the SJRMC Manager of Emergency Preparedness and the Property Management Technician for Cressy & Everett during a tour of the facility from 11:25 a.m. to 12:50 p.m. on 08/29/17, a total of two battery operated emergency lights were located in the path of egress for the facility. Each light illuminated when its respective test button was pushed. Based on interview at the time of the observations, the Property Management Technician stated life safety documentation is maintained at the corporate office for Cressy & Everett but monthly and annual functional testing documentation for the most recent twelve month period for the two battery operated emergency lighting systems was not available for review at the time of the survey.

Based on observation and interview, the facility failed to document monthly and annual testing for 2 of 2 battery backup lights in accordance with LSC 7.9. LSC 39.2.9 states emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exists:
(1) The building is three or more stories in height.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.
Section 7.9.3.1.1 states testing of 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).
(2) The test interval shall be permitted to be extended beyond 30 days with the approval of the 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 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.
This deficient practice could affect all patients, staff and visitors in the facility.

Findings include:

Based on observations with the SJRMC Manager of Emergency Preparedness and the Property Management Technician for Cressy & Everett during a tour of the facility from 2:25 p.m. to 3:10 p.m. on 08/29/17, a total of two battery operated emergency lights were located in the facility. Each light illuminated when its respective test button was pushed. Based on interview at the time of the observations, the Property Management Technician stated life safety documentation is maintained at the corporate office for Cressy & Everett but monthly and annual functional testing documentation for the most recent twelve month period for the two battery operated emergency lighting systems was not available for review at the time of the survey.

Based on observation and interview, the facility failed to document monthly and annual testing for 8 of 8 battery backup lights in accordance with LSC 7.9. LSC 39.2.9 states emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exists:
(1) The building is three or more stories in height.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.
Section 7.9.3.1.1 states testing of 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).
(2) The test interval shall be permitted to be extended beyond 30 days with the approval of the 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 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.
This deficient practice could affect all patients, staff and visitors in the facility.

Findings include:

Based on observations with the SJRMC Manager of Emergency Preparedness and the Property Management Technician for Cressy & Everett during a tour of the facility from 10:55 a.m. to 11:15 a.m. on 08/30/17, a total of eight battery operated emergency lights were located in the facility. Each light illuminated when its respective test button was pushed. Based on interview at the time of the observations, the Property Management Technician stated life safety documentation is maintained at the corporate office for Cressy & Everett but monthly and annual functional testing documentation for the most recent twelve month period for the eight battery operated emergency lighting systems was not available for review at the time of the survey.

Based on observation and interview, the facility failed to ensure the protection of 1 of 2 stairway in accordance of 8.6. LSC 39.3.1.1 states vertical openings shall be enclosed or protected in accordance with Section 8.6, unless otherwise permitted. LSC 8.6.1 requires every floor that separates stories in a building shall be constructed as a smoke barrier. LSC 8.7.1.3 requires doors in barriers required to have a fire resistive rating shall have a minimum ¾ hour fire protection rating and be self-closing or automatic closing. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observations with the SJRMC Manager of Emergency Preparedness and the Property Management Technician for Cressy & Everett during a tour of the facility from 11:25 a.m. to 12:50 p.m. on 08/29/17, the 90 minute fire rated door to the Stair 1 stairwell on the first floor by the service hall failed to self close and latch into the door frame as the door hit the frame on the handle side when tested to self close five separate times. This was verified by Manager of Emergency Preparedness at the time of observations.

Based on observation and interview, the facility failed to ensure the protection of 1 of 6 stairways in accordance of 8.6. LSC 39.3.1.1 states vertical openings shall be enclosed or protected in accordance with Section 8.6, unless otherwise permitted. LSC 8.6.1 requires every floor that separates stories in a building shall be constructed as a smoke barrier. LSC 8.7.1.3 requires doors in barriers required to have a fire resistive rating shall have a minimum ¾ hour fire protection rating and be self-closing or automatic closing. This deficient practice could affect 12 patients, staff and visitors on the third floor Progressive Care Unit.

Findings include:

Based on observations with the SJRMC Construction Manager and the Maintenance Technician during a tour of the facility from 3:20 p.m. to 4:00 p.m. on 08/30/17, the 90 minute fire rated door to the Stair E stairwell on the third floor Progressive Care Unit failed to self-close and latch into the door frame as air movement in the stairwell kept the door from fully closing and latching when tested to self-close five separate times. This was verified by Maintenance Technician at the time of observations.

1. Based on observation and interview, the facility failed to ensure 2 of over 34 alcohol based hand sanitizer dispensers were installed with a minimum of 4-foot horizontal spacing in the emergency room. NFPA 101, in 19.1.1.3 requires all health facilities to be designed, constructed, maintained and operated to minimize the possibility of a fire emergency requiring the evacuation of occupants. This deficient practice could affect over 20 patients, staff and visitors in the emergency room.

Findings include:

Based on observations with the SJRMC Construction Manager during a tour of the facility from 3:20 p.m. to 4:00 p.m. on 08/30/17, an alcohol based hand sanitizer was installed on the wall in the corridor outside patient room A1418 in the emergency room three feet from a second alcohol based hand sanitizer installed on the wall in the corridor outside patient room A1420. Manufacturer's documentation affixed to each dispenser's hand sanitizer solution stated it contained 62% ethyl alcohol by weight. Based on interview at the time of the observations, the SJRMC Construction Manager verified the two alcohol based hand sanitizers were installed less than four feet apart.

2. Based on observation and interview, the facility failed to install 1 of 1 Soiled Utility room A4414 and 1 of 1 Cath IR #3 room alcohol based hand rub dispensers were at least 1 inch away from an ignition source. This deficient practice could affect staff and at least 7 patients.

Findings include:

Based on observation with the Director of Facility Resources on 08/29/17 at 3:17 p.m., an alcohol based hand rub dispenser was directly over an outlet in the Soiled Utility room A4414.
Based on observation with the Director of Facility Resources on 08/30/17 at 10:11 a.m., an alcohol based hand rub dispenser was directly over an outlet in the Cath IR #3 room.
Based on interview at the time of each observation, the Director of Facility Resources confirmed the dispensers contained alcohol and were directly over an outlet.

Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm systems was installed in accordance with 19.3.4.1. NFPA 72, 17.7.4.1 requires in spaces served by air handling systems, detectors shall not be located where air flow prevents operation of the detectors. A.17.7.4.1 states detectors should not be located in a direct airflow or closer than 36 inches. This deficient practice could affect up to 4 staff in the Pastoral Care office.

Findings include:

Based on observation with the Maintenance Technician #1 on 08/30/17 at 11:08 a.m., the Pastoral Care office on the third floor, or room A 3027, had a smoke detector approximately 10 inches from an air outlet. Based on interview at the time of the observation, the Maintenance Technician #1 acknowledged the aforementioned condition.

1. Based on record review and interview, the facility failed to ensure 1 of 1 fire alarm systems was maintained in accordance with NFPA 72, National Fire Alarm and Signaling Code. LSC 39.3.4.1 states a fire alarm system in accordance with 9.6 shall be provided in all business occupancies where any one of the following conditions exist:
(1) The building is three or more stories in height.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.
LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained in accordance with NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm Code. NFPA 72, 2010 Edition, 14.2.1.2.1 states the requirements of Section 10.19 shall be applicable when a system is impaired. Section 14.2.1.2.2 states system defects and malfunctions shall be corrected. This deficient practice could affect all patients, staff, and visitors.

Findings include:

Based on review of Communication Company of South Bend's "Fire Alarm and Life Safety Inspection Certificate" documentation dated 08/18/17 with the SJRMC Manager of Emergency Preparedness during record review at 4:00 p.m. on 08/30/17, 2 of 134 facility fire alarm initiating devices were listed as "Failed Test" on the "Discrepancy Report" section of the 08/18/17 testing documentation. In addition, seven fire alarm control system batteries were also listed as "Failed Test" or "Date Expired" on the 08/18/17 report. Based on interview at the time of the observations, the SJRMC Manager of Emergency Preparedness stated life safety documentation is maintained at the corporate office for Cressy & Everett but fire alarm system repair documentation on or after 08/18/17 was not available for review at the time of the survey.

2. Based on record review and interview, the facility failed to ensure 1 of 1 fire alarm systems was maintained in accordance with 9.6.1.3. LSC 39.3.4.1 states a fire alarm system in accordance with 9.6 shall be provided in all business occupancies where any one of the following conditions exist:
(1) The building is three or more stories in height.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.
LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained in accordance with NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm Code. NFPA 72, 2010 Edition, Section 14.4.5 requires testing shall be performed in accordance with Table 14.4.5 Testing Frequencies. Section 14.4.5.3.1 states sensitivity shall be checked within 1 year after installation. Section 14.4.5.3.2 states sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3. 14.4.5.3.5 states smoke detectors or smoke alarms found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced. Section 14.6.2.4 states a record of all inspections, testing and maintenance shall be provided that includes all applicable information requested in Figure 14.6.2.4. This deficient practice could affect all patients, staff, and visitors.

Findings include:

Based on record review with the SJRMC Manager of Emergency Preparedness during record review at 4:00 p.m. on 08/30/17, documentation of smoke detector sensitivity testing within the most recent two year period was not available for review. Based on interview at the time of the observations, the SJRMC Manager of Emergency Preparedness stated life safety documentation is maintained at the corporate office for Cressy & Everett and smoke detector sensitivity documentation within the most recent two year period was not available for review at the time of the survey.

Based on record review and interview, the facility failed to provide a complete 1 of 1 written policy for the protection of residents indicating procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a twenty four hour period in accordance with LSC, Section 9.6.1.6. This deficient practice affects all occupants.

Findings include:

Based on record review with the Team Leader of Facility Resources on 08/29/2017 at 2:19 p.m., the facility provided fire watch documentation but it was incomplete. The plan failed to include:
a) contacting the insurance company and the appropriate phone number for said insurance company.
b) contacting the building owner and the appropriate phone number for said building owner.
c) that the person conducting the fire watch shall be a trained person with no other duties.
d) contacting the Indiana State Department of Health via the ISDH Gateway link at https://gateway.isdh.in.gov as the primary method or by the secondary method when the ISDH Gateway is nonoperational by completing the Incident Reporting form and e-mailing it to incidents@isdh.in.gov
Based on interview during the record review at 2:21 p.m., the Team Leader of Facility Resources acknowledged all the above mentioned missing items in the document provided that was titled 'Fire Watch Policy".

1. Based on observation and interview, the facility failed to ensure 2 of 2 exterior fabric canopies were provided with sprinklers in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, 2010 edition, Section 8.15.7.1 states 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 canopies or similar projections exceeding four feet in width. Sprinklers shall be permitted to be omitted where canopies 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. This deficient practice could affect over 20 residents, staff and visitors if needing to exit the facility at the Emergency Room exit.

Findings include:

Based on observations with the SJRMC Construction Manager and the Maintenance Technician during a tour of the facility from 3:20 p.m. to 4:00 p.m. on 08/30/17, the red fabric canopy attached to the building at the Emergency Room exit extended more than four feet from the building and was not provided with sprinkler coverage. In addition, the silver fabric canopy attached to the building at the Associate Entrance also extended more than four feet from the building and was also not provided with sprinkler coverage. Flame spread rating documentation was not affixed to either fabric canopy. Based on interview at the time of the observations, the SJRMC Construction Manager stated no other fabric canopy flame spread rating documentation was available for review and verified the aforementioned two fabric canopies which extended more than four feet from the building were not provided with sprinkler coverage.

2. Based on observation and interview, the facility failed to maintain the ceiling construction in 2 of over 1000 rooms. NFPA 13, 2010 edition, Section 6.2.7 states plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic, or shall be listed for use around a sprinkler. This deficient practice could affect staff and up to 12 staff in the facility.

Findings include:

Based on observation with the Maintenance Technician #1 on 08/30/17 between 11:00 a.m. and 4:07 p.m. the following was noted:
a) Room A 1114 was missing an escutcheon
b) The Medical Air room outside Ultrasound near room A 1229 had a missing escutcheon
Based on interview at the time of each observation, the Maintenance Technician #1 acknowledged each of the above mentioned areas as having missing escutcheons.

3. Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was installed in 1 of 1 Penthouse in accordance with 19.3.5.1. NFPA 13, 2010 Edition, Standard for the Installation of Sprinkler Systems, Section 9.1.1.7, Support of Non-System Components, requires sprinkler piping or hangers shall not be used to support non-system components. This deficient practice could affect staff only.

Findings include:

Based on observations with the Director of Facility Resources on 08/29/17 at 10:48 a.m., eight CAT5 cables were zip tied around the sprinkler pipe in the Penthouse Additionally, three drip pans were attached on separate sprinkler pipes. Based on interview at the time of each observation, the Director of Facility Resources agreed the cables and drip pans were being supported by the sprinkler pipe.

4. Based on observation and interview, the facility failed to install 1 of 1 Electrical room A3250 sprinkler head deflectors within 12 inches of the ceiling. NFPA 13, 2010 Edition, Section 8.6.4.1.1.1 under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 inch and a maximum of 12 inches throughout the area of coverage of the sprinkler. This deficient practice could affect staff only.

Findings include:

Based on observation with the Director of Facility Resources on 08/30/17 at 10:19 a.m., the 2nd floor Electrical room A2050 contained one sprinkler head. The upright sprinkler head deflector was about thirty six inches from the ceiling. Based on interview at the time of observation, the Director of Facility Resources provided the measurement and confirmed the sprinkler head should have been mounted higher.

1. Based on observation and interview, the facility failed to provide written documentation or other evidence the sprinkler system components had been inspected and tested for 2 of 4 quarters. LSC 4.6.12.1 requires any device, equipment or system required for compliance with this Code be maintained in accordance with applicable NFPA requirements. Sprinkler systems shall be properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 2011 Edition, Section 4.3.1 requires records shall be made for all inspections, tests, and maintenance of the system components and shall be made available to the authority having jurisdiction upon request. Section 4.3.2 requires that records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date. Section 5.2.5 requires that waterflow alarm devices shall be inspected quarterly to verify they are free of physical damage. Section 5.3.3.1 requires the mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly. Section 5.3.3.2 requires vane-type and pressure switch-type waterflow alarm devices shall be tested semiannually. This deficient practice could affect all patients, staff, and visitors.

Findings include:

Based on observations with the SJRMC Manager of Emergency Preparedness and the Property Management Technician for Cressy & Everett during a tour of the facility from 11:25 a.m. to 12:50 p.m. on 08/29/17, Shambaugh & Son had affixed hanging tags to the facility's wet sprinkler system riser documenting sprinkler system inspection and testing on 01/30/17, 05/22/17 and 08/22/17. Documentation of sprinkler system inspection and testing documentation for the fourth quarter of 2016 was not available for review. In addition, it had been greater than 90 days in between documented quarterly sprinkler system inspection and testing on 01/30/17 to 05/22/17. Based on interview at the time of the observations, the Property Management Technician stated life safety documentation is maintained at the corporate office for Cressy & Everett but additional quarterly sprinkler system inspection and testing documentation for the most recent twelve month period was not available for review at the time of the survey.

2. Based on observation and interview, the facility failed to document sprinkler system inspections in accordance with NFPA 25. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.4.1 states gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained. Section 5.1.2 states valves and fire department connections shall be inspected, tested, and maintained in accordance with Chapter 13. Section 13.1.1.2 states Table 13.1.1.2 shall be utilized for inspection, testing and maintenance of valves, valve components and trim. Section 4.3.1 states records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request. This deficient practice could affect all patients, staff, and visitors.

Findings include:

Based on observations with the SJRMC Manager of Emergency Preparedness and the Property Management Technician for Cressy & Everett during a tour of the facility from 11:25 a.m. to 12:50 p.m. on 08/29/17, Shambaugh & Son had affixed hanging tags to the facility's wet sprinkler system riser documenting sprinkler system gauge and valve inspections on 01/30/17, 05/22/17 and 08/22/17. Monthly wet sprinkler system gauge inspection documentation for 9 months of the most recent 12 month period was not available for review. In addition, monthly inspection documentation for all sprinkler system control valves for 9 months of the most recent 12 month period was also not available for review. Based on interview at the time of the observations, the Property Management Technician stated life safety documentation is maintained at the corporate office for Cressy & Everett but additional quarterly sprinkler system inspection documentation for the most recent twelve month period was not available for review at the time of the survey.

3. Based on observation and interview, the facility failed to ensure automatic sprinkler system components had been inspected and tested annually. LSC 4.6.12.1 requires any device, equipment or system required for compliance with this Code be maintained in accordance with applicable NFPA requirements. Sprinkler systems shall be properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 2011 Edition, Section 4.3.1 requires records shall be made for all inspections, tests, and maintenance of the system components and shall be made available to the authority having jurisdiction upon request. 4.3.2 requires that records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date. Section 13.6.2 states all backflow preventers installed in fire protection system piping shall be tested annually. This deficient practice could affect all patients, staff, and visitors in the facility.

Findings include:

Based on observations with the SJRMC Manager of Emergency Preparedness and the Property Management Technician for Cressy & Everett during a tour of the facility from 11:25 a.m. to 12:50 p.m. on 08/29/17, Mishawaka Utilities had affixed a hanging tag to the facility's wet sprinkler system riser documenting sprinkler system backflow preventer testing on 05/04/16. Based on interview at the time of the observations, the Property Management Technician stated life safety documentation is maintained at the corporate office for Cressy & Everett but additional sprinkler system backflow testing documentation for the most recent twelve month period was not available for review at the time of the survey.

1. Based on record review and interview, the facility failed to document sprinkler system inspections in accordance with NFPA 25. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.4.1 states gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained. Section 5.2.4.2 states gauges on dry pipe sprinkler systems shall be inspected weekly to ensure that normal air and water pressures are being maintained. Section 5.1.2 states valves and fire department connections shall be inspected, tested, and maintained in accordance with Chapter 13. Section 13.1.1.2 states Table 13.1.1.2 shall be utilized for inspection, testing and maintenance of valves, valve components and trim. Section 4.3.1 states records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request. This deficient practice could affect all residents, staff, and visitors within the facility.

Findings include:

Based on review of Shambaugh and Sons L.P.'s "Sprinkler Inspection Certificate" documentation for the most recent twelve month period with the Team Leader of Facility Resources during record review at 1:45 p.m. on 08/29/17, weekly dry sprinkler system gauge inspection documentation for 52 weeks of the most recent 52 week period was not available for review. Monthly wet sprinkler system gauge inspection documentation for 12 months of the most recent 12 month period was available for review. In addition, monthly inspection documentation for all sprinkler system control valves for 12 months of the most recent 12 month period was also available for review. Based on interview at the time of record review, the Team Leader of Facility Resources acknowledged sprinkler system gauge and control valve inspection documentation for the aforementioned monthly periods was being completed, but that the weekly inspections of the gauges on the dry sprinkler system was not being conducted and therefore documentation was not available for review.

2. Based on observation and interview, the facility failed to replace 1 of 1 loaded sprinkler heads in 4th floor Suite 4 Triage room A4114 in accordance with LSC 9.7.5. NFPA 25, 2011 edition, at 5.2.1.1.1 sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., up-right, pendent, or sidewall). Furthermore, at 5.2.1.1.2 any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage (2) Corrosion (3) Physical Damage (4) Loss of fluid in the glass bulb heat responsive element (5) Loading (6) Painting unless painted by the sprinkler manufacturer. This deficient practice could affect staff and up to 18 patients.

Findings include:

Based on observation with the Director of Facility Resources on 08/29/17 at 2:50 p.m., one sprinkler head was covered in drywall in 4th floor Suite 4 Triage room A4114 bathroom. Based on interview at the time of observation, the Director of Facility Resources acknowledged the sprinkler deflector was covered in a white substance and claimed the substance was drywall material.

Based on record review and interview, the facility failed to provide a written policy containing procedures to be followed for the protection of 212 of 212 residents in the event the automatic sprinkler system has to be placed out-of-service for 10 hours or more in a 24-hour period in accordance with LSC, Section 9.7.5. LSC 9.7.5 requires sprinkler impairment procedures comply with NFPA 25, 2011 Edition, the Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 15.5.2 requires nine procedures that the impairment coordinator shall follow. This deficient practice could affect all occupants in the facility.

Findings include:

Based on record review with the Team Leader of Facility Resources on 08/29/17 at 2:19 p.m., the facility provided fire watch plan documentation but it was incomplete. The plan failed to include contacting the Indiana State Department of Health via the ISDH Gateway link at https://gateway.isdh.in.gov as the primary method or by the secondary method when the ISDH Gateway is nonoperational by completing the Incident Reporting form and e-mailing it to incidents@isdh.in.gov Based on interview during the record review, the Team Leader of Facility Resources acknowledged the fire watch documentation provided named "Fire Watch Policy" did not state to contact the Indiana State Department of Health via the ISDH Gateway link or at the e-mail address listed above.

1. Based on observation and interview, the facility failed to ensure 1 of 4 portable fire extinguishers were installed in accordance with NFPA 10. LSC 39.3.5 states portable fire extinguishers shall be provided in every business occupancy in accordance with 9.7.4.1. LSC 9.7.4.1 states portable fire extinguishers shall be selected, installed, inspected and maintained in accordance with NFPA 10. NFPA 10, Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.4 states portable fire extinguishers other than wheeled extinguishers shall be installed using any of the following means:
(1) Securely on a hanger intended for the extinguisher
(2) In the bracket supplied by the extinguisher manufacturer
(3) In a listed bracket approved for such purpose
(4) In cabinets or wall recesses
Section 6.1.3.8.1 states fire extinguishers having a gross weight not exceeding 40 lb shall be installed so that the top of the fire extinguisher is not more than five feet above the floor. Section 6.1.3.8.3 states in no case shall the clearance between the bottom of the hand portable fire extinguisher and the floor be less than four inches. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observations with the SJRMC Manager of Emergency Preparedness and the Property Management Technician for Cressy & Everett during a tour of the facility from 11:25 a.m. to 12:50 p.m. on 08/29/17, the portable ABC fire extinguisher in the service hall by Stair 1 was freestanding on the floor. There was no designated location on the wall in the service hall and was missing a hanger or supporting bracket. Based on interview at the time of the observations, the Manager of Emergency Preparedness stated the facility had completed a renovation recently and the fire extinguisher most likely belonged to a contractor who left it behind but agreed it should not have been left freestanding on the floor.

2. Based on observation and interview, the facility failed to ensure 1 of 4 portable fire extinguishers had documented annual maintenance in accordance with NFPA 10. LSC 39.3.5 states portable fire extinguishers shall be provided in every business occupancy in accordance with 9.7.4.1. LSC 9.7.4.1 states portable fire extinguishers shall be selected, installed, inspected and maintained in accordance with NFPA 10. NFPA 10, 2010 Edition, Section 7.3.1.1.1 states fire extinguishers shall be subject to maintenance at intervals of not more than one year, at the time of hydrostatic test, or when specifically indicated by an inspection or electronic notification. Section 7.3.3 states each fire extinguisher shall have a tag or label securely attached that indicates the month and year the maintenance was performed, identifies the person performing the work, and identifies the name of the agency performing the work. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observations with the SJRMC Manager of Emergency Preparedness and the Property Management Technician for Cressy & Everett during a tour of the facility from 11:25 a.m. to 12:50 p.m. on 08/29/17, the portable ABC fire extinguisher in the service hall by Stair 1 had an affixed tag indicating the most recent annual maintenance was performed in January 2015. Based on interview at the time of the observations, the Manager of Emergency Preparedness stated the facility had completed a renovation recently and the fire extinguisher most likely belonged to a contractor who left it behind but agreed the aforementioned portable fire extinguisher did not have annual maintenance documented within the most recent twelve month period.

3-1.19(b)

3. Based on observation and interview, the facility failed to ensure 1 of 4 portable fire extinguishers located in the facility were inspected at least monthly and the inspections were documented including the date and initials of the person performing the inspection in accordance with NFPA 10. LSC 39.3.5 states portable fire extinguishers shall be provided in every business occupancy in accordance with 9.7.4.1. LSC 9.7.4.1 states portable fire extinguishers shall be selected, installed, inspected and maintained in accordance with NFPA 10. NFPA 10, the Standard for Portable Fire Extinguishers, 2010 Edition, Section 7.2.1.2 states fire extinguishers shall be inspected either manually or by means of an electronic monitoring device/system at a minimum of 30-day intervals. Where monthly manual inspections are conducted, the date the manual inspection was performed and the initials of the person performing the inspection shall be recorded. Where manual inspections are conducted, records for manual inspections shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or by an electronic method. Records shall be kept to demonstrate that at least the last 12 monthly inspections have been performed. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observations with the SJRMC Manager of Emergency Preparedness and the Property Management Technician for Cressy & Everett during a tour of the facility from 11:25 a.m. to 12:50 p.m. on 08/29/17, the portable ABC fire extinguisher in the service hall by Stair 1 had an affixed maintenance tag lacking a monthly inspection for the most recent twelve month period. Based on interview at the time of the observations, the Manager of Emergency Preparedness stated the facility had completed a renovation recently and the fire extinguisher most likely belonged to a contractor who left it behind but agreed documentation of monthly inspections for the aforementioned portable fire extinguisher within the most recent twelve month period was not available for review.

Based on observation and interview, the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 1 of 3 4th floor and 1 of 4 2nd floor smoke barrier walls were protected to maintain the smoke resistance of each smoke barrier. LSC Section 19.3.7.5 requires smoke barriers to be constructed in accordance with LSC Section 8.5 and shall have a minimum ½ hour fire resistive rating. This deficient practice could affect staff and at least 39 residents.

Findings include:

Based on observations with the Director of Facility Resources on 08/29/17 at 2:26 p.m., a two inch unsealed penetration by the room A4409F smoke barrier above the drop ceiling.
Based on observations with the Director of Facility Resources on 08/30/17 at 12:00 p.m. then again at 1:57 p.m., a half inch unsealed penetration by the room A2248 smoke barrier above the drop ceiling. Then again, a one inch unsealed penetration by the room A0227 smoke barrier above the drop ceiling.
Based on interview at the time of each observation, the Director of Facility Resources acknowledged each aforementioned condition and provided the measurements.

Based on observation and interview, the facility failed to ensure 1 of 1 of room A4409 and 1 of 1 of room A2506 sets of corridor doors would close to form a smoke resistant barrier. Centers for Medicare & Medicaid Services (CMS) requires sets of smoke barrier doors which swing in the same direction and equipped with an astragal to have a coordinator to ensure the door which must close first always closes first. This deficient practice could affect staff and up to 39 patients.

Findings include:

Based on observation with the Director of Facility Resources on 08/29/17 at 2:23 p.m., the Mother/Baby by room A4409 corridor smoke doors swung in the same direction without an astragal or coordinating device.
Based on observation with the Director of Facility Resources on 08/30/17 at 9:26 a.m., the corridor smoke doors by room A2506 swung in the same direction without an astragal or coordinating device.
Based on interview at the time of each observation, the Director of Facility Resources acknowledged the smoke barrier doors swung in the same direction, was not covered by an astragal and lacked a coordinating device.

Based on observation and interview, the facility failed to ensure 1 of 1 2nd floor Surgery Scheduling A2236 room was maintained in accordance with 19.7.5.6. LSC 19.7.5.6 prohibits combustible decorations unless an exception was met. This deficient practice could affect staff and at least 7 patients.

Findings include:

Based on observation with the Director of Facility Resources on 08/29/17 at 10:46 a.m., the 2nd floor Surgery Scheduling A2236 room contained a candle with a wick. Based on interview at the time of observation, the Director of Facility Resources confirmed the candle contained a wick and was unware that an unburnt wick was considered a combustible decoration.

Based on observation and interview, the facility failed to ensure 1 of 1 Office room A6450 space heater was in accordance with 19.7.8. This deficient practice could affect staff only.

Findings include:

Based on observation with the Director of Facility Resources on 08/29/17 at 11:55 a.m., a space heater was discovered in the Office room A6450. Based on interview at the time of observation, the Director of Facility Resources was unaware the space heater was in the building and confirmed no documentation was available to provide the heating element does not exceed 212 degrees.

Based on observation, interview, and record review, the facility failed to ensure there were battery-powered lighting for 2 of 2 Mother/Baby C-section Operating Rooms using general anesthesia. NFPA 99 2012 edition 6.3.2.2.11.1 states one or more battery-powered lights shall be provide within locations where deep sedation and general anesthesia is administered. 6.3.2.2.11.2 The lighting level of each unit shall be sufficient to terminate procedures intended to be performed within the operating room. This deficient practice could affect staff and up to 14 patients.

Findings include:

Based on observation with the Director of Facility Resources on 08/29/17 at 3:09 p.m., operating room A4139 and A4150 in the Mother/Baby area battery operated emergency lighting was not obvious. Based on interview at the time of observation, the Director of Facility Resources was unable to locate which lighting fixture was battery powered. Based on record review, Director of Facility Resources confirmed that the facility's battery operated emergency lighting testing documentation does not indicate any testing for that area. Director of Facility Resources confirmed that battery operated emergency lighting is not provided for the Mother/Baby operating rooms.

1. Based on observation and interview, the facility failed to ensure 6 of 6 flexible cords were not used as a substitute for fixed wiring to provide power equipment with a high current draw according to 9.1.2. LSC 9.1.2 requires electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code. NFPA 70, 2011 Edition, Article 400.8 requires that, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice affects staff and up to 31 patients.

Findings include:

Based on observation with the Director of Facility Resources on 08/30/17 between 11:02 a.m. and 3:20 p.m., the following was discovered:
a) a surge protector was powering a microwave and a refrigerator in the 6th floor Case Manager's office A6407
b) a surge protector was powering a refrigerator in the 6th floor Office room A6415. Additionally, a surge protector was powering another surge protector powering computer components
c) a surge protector was powering two separate surge protectors mounted on ultrasound machines in the 6th floor IV Therapy OFC room A6419
d) a surge protector was powering a coffee pot, toaster, and refrigerator in the 5th floor Staff Office room A5441
e) a surge protector was powering a refridgerator in the 4th floor Staff Lounge room A4128
f) a surge protector was powering a microwave in the 4th floor Nurse's Supply room A4419
Based on interview at the time of each observation, the Director of Facility Resources acknowledged each surge protector was powering hi-amperage devices.

2. Based on observation and interview, the facility failed to ensure junction boxes were protected in 1 of 1 Room A2248 smoke barrier according to 9.1.2. LSC 9.1.2 requires electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code. NFPA 70, 2011 Edition, Article 314.28(c) requires all junction boxes shall be provided with covers compatible with the box. Additionally, Article 406.6, Receptacle Faceplates (Cover Plates), requires receptacle faceplates shall be installed so as to completely cover the opening and seat against the mounting surface. This deficient practice could affect staff only.

Findings include:

Based on observation with the Director of Facility Resources on 08/30/17 at 9:54 a.m., a junction box was missing a cover in the Room A2248 smoke barrier above the drop ceiling. Based on interview at the time of observation, the Director of Facility Resources acknowledged and confirmed the junction box was missing a cover.

Based on observation and interview, the facility failed to ensure 2 of 2 extension cords including power strips were not used as a substitute for fixed wiring. LSC 39.5.1 requires utilities to comply with Section 9.1. LSC 9.1.2 requires electrical wiring and equipment to comply with NFPA 70, National Electrical Code, 2011 Edition. NFPA 70, Article 400.8 requires that, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. LSC Section 4.5.7 states any building service equipment or safeguard provided for life safety shall be designed, installed and approved in accordance with all applicable NFPA standards. NFPA 99, Standard for Health Care Facilities, 2012 edition, 3.3.71 defines health care facilities as buildings or portions of buildings in which medical care is provided. NFPA 99 defines patient care areas as any portion of a health care facility wherein patients are intended to be examined or treated. Patient care vicinity is defined as a space, within a location intended for the examination and treatment of patients, extending 6 ft (1.8 m) beyond the normal location of the bed, chair, table, treadmill, or other device that supports the patient during examination and treatment. A patient care vicinity extends vertically to 7 ft 6 in. (2.3 m) above the floor. NFPA 99, Section 10.4.2.3 states household or office appliances not commonly equipped with grounding conductors in their power cords shall be permitted provided they are not located within the patient care vicinity. This deficient practice could affect two patients, staff and visitors.

Findings include:

Based on observations with the SJRMC Manager of Emergency Preparedness during a tour of the facility from 2:25 p.m. to 3:10 p.m. on 08/29/17, office equipment was plugged into a power strip mounted on the wall three feet from the hyperbaric chamber identified as Tank 2. Additional office equipment was plugged into a second power strip mounted on the wall five feet from Tank 2. The UL listing of each of the two power strips could not be determined. Based on interview at the time of the observations, the Manager of Emergency Preparedness agreed power strips were being used as a substitute for fixed wiring and in the patient care vicinity at the aforementioned location.

Based on observation and interview, the facility failed to ensure 1 of 1 cylinders in Post Op nurse's station of nonflammable gases such as carbon dioxide were properly chained or supported in a proper cylinder stand or cart. 2012 NFPA 99, Health Care Facilities Code, 11.6.2.3(11) requires freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart. This deficient practice could affect staff and up to 21 patients.

Findings include:

Based on observation with the Director of Facility Resources on 08/30/17 at 11:05 a.m., the Post Op nurse's station had one carbon dioxide cylinder that was freestanding on the floor. Based on interview at the time of observation, the Director of Facility Resources confirmed that nothing is preventing the cylinder from tipping over.