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Based on observation, staff interview and review of maintenance records between 9/30 -10/03/13, the facility failed to construct, install, and maintain the building system to ensure safety to all patients, staff and visitors.

Building #01 Kohler, Center, Lucas and South buildings

1. One doorway of hazardous room not kept clear of an obstruction;
2. Lack of exit signs to direct occupants to exits;
3. One smoke barrier not extended to roof deck above, one cable penetration of smoke barrier not properly sealed and supported, and one HVAC duct penetration of smoke barrier sealed with an expandable foam;.
4. Inadequate clear widths provided by smoke barrier doors;
5. Inadequate clear widths provided by exit access doors;
6. Fire Alarm system was not installed to minimum standards of NFPA 72, trouble signals due to phone line failure not transmitted to and annunciated at a continuously attended location in accordance with NFPA 72 Chapters 1, 5 and 7;
7. Fire alarm system batteries not tested semiannually;
8. Sprinkler piping not maintained free of external loads that are not allowed by NFPA 25 standards, and missing sprinkler head on top of one stair shaft;
9. One corridor used as a return air plenum, and lack of smoke isolation dampers in two air-handling units;
10. Soiled linen/trash receptacles not stored in a room protected as a hazardous area;
11. Lack of medical gas and vacuum area alarm panel in three patient sleeping areas; and
12. Lack of adequate ventilation with proper airflow direction in four clean utility and clean supply storage spaces, and five soiled utility/housekeeping rooms.

See K18, K-22, K-25, K-28, K-40, K-51, K52, K56, K67, K75, K77, and A-726 for detail.


Building #03- Ambulatory Surgery Center, Plymouth

(i) lack of smoke detectors in the fire alarm control unit rooms;
(ii) lack of a remote annunciator to annunciate emergency generator fault conditions; and
(iii) lack of exit sign in one location to direct occupants to exits.

See K-130 for detail.

The cumulative effects of these environmental problems resulted in the hospital's inability to ensure a safe environment for the patients.


As a result of a verification visit on 12/03/13, surveyor determined that the facility was making a satisfactory progress toward correcting the deficiency Items 3, 4, 5, 9, 11 and 12 of Building #1, and Item (ii) of Building #3. The remaining deficiency items of Buildings #1 and #3 were verified as corrected.


While on a 2nd verification visit of the facility on 3/21/14, surveyor determined that the facility was making a satisfactory progress toward correcting the deficiency Items 3, 4, 5, 9 and 12 in Building #1. The remaining deficiency items in Buildings #1 and #3 were verified as corrected.

Based on observation and staff interview, the facility failed to ensure 'life safety from fire' for all patients, staff and visitors.

Findings include:

Building #01 Kohler, Center, Lucas and South buildings

1. Failed to protect the life safety of patients from fire due to one doorway of hazardous room not kept clear of obstruction;
2. Failed to protect the life safety of patients from fire due to lack of exit signs to direct occupants to exits;
3. Failed to protect the life safety of patients from fire due to one smoke barrier not extended to roof deck above, one cable penetration of smoke barrier not properly sealed and supported, and one HVAC duct penetration of smoke barrier sealed with an expandable foam;
4. Failed to protect the life safety of patients from fire due to clear widths provided by smoke barrier doors in two locations not being adequate;
5. Failed to protect the life safety of patients from fire due to clear widths provided by exit access doors not adequate in one location;
6. Failed to protect the life safety of patients from fire due to fire Alarm system not installed to minimum standards of NFPA 72, and trouble signals due to phone line failure not annunciated at a location where it can be easily heard in accordance with NFPA 72 Chapters 1, 5 and 7;
7. Failed to protect the life safety of patients from fire due to fire alarm system batteries not tested semiannually;
8. Failed to protect the life safety of patients from fire due to sprinkler piping not maintained free of external loads, and missing sprinkler head on top of one stair shaft;
9. Failed to protect the life safety of patients from fire due to one corridor used as a return air plenum, and lack of smoke isolation dampers in two air-handling units;
10. Failed to protect the life safety of patients from fire due to soiled linen/trash receptacles not stored in a room protected as a hazardous area; and
11. Failed to protect the life safety of patients due to lack of medical gas and vacuum area alarm panels in three patient sleeping areas.

See K18, K-22, K-25, K-28, K-40, K-51, K52, K56, K67, K75, and K77 for detail.


Building #03- Ambulatory Surgery Center, Plymouth

(i) lack of smoke detectors in the fire alarm control unit rooms;
(ii) lack of a remote annunciator to annunciate emergency generator fault conditions; and
(iii) lack of exit sign in one location to direct occupants to exits.

See K-130 for detail.


As a result of a verification visit on 12/03/13, surveyor determined that the facility was making a satisfactory progress toward correcting the deficiency Items 3, 4, 5, 9, and 11 of Building #1, and Item (ii) of Building #3. The remaining deficiency items of Buildings #1 and #3 were verified as corrected.


While on a 2nd verification visit of the facility on 3/21/14, surveyor determined that the facility was making a satisfactory progress toward correcting the deficiency Items 3, 4, 5, and 9 in Building #1. The remaining deficiencies in Buildings #1 and #3 were verified as corrected.

Based on observation and staff interview, the facility did not provide adequate ventilation due to (i) lack of positive pressure in 4 clean utility and clean supply storage spaces, and (ii) lack of negative pressure in 5 soiled utility/housekeeping rooms in accordance with CDC and AIA guidelines. This deficient practice had a potential of contaminating air in clean spaces with undesirable contaminants, and causing possible infection.

The CDC guidelines can be found in the website


Findings include:

(i) During a tour of the facility with Staff M1 (senior director of facilities operations), Staff M2 (director of facilities operations), Staff M3(director of facilities operations-south market), and Staff M4(manager of facilities operations), surveyor observed on 10/01/13 between 8:50 am and 12 pm that the 5th Floor clean supply storage room adjacent to the Operation Room 5 did not have ventilation and positive pressure.

(ii) During a tour of the facility with Staff M1, Staff M2, Staff M3, and Staff M4, surveyor observed on 10/01/13 between 8:50 am and 12 pm that the Biohazard/Soiled Utility room on the 5th Floor did not have adequate ventilation, even though the room was slightly under negative pressure when tested with a tissue paper at the door undercut.

(iii) During a tour of the facility with Staff M1, Staff M2, Staff M3, and Staff M4, surveyor observed on 10/01/13 between 8:50 am and 12 pm that the 4th Floor soiled utility room across from Patient Room 468 was not maintained in negative pressure relative to the adjacent spaces. The room was under positive pressure causing airflow in the wrong direction from dirty to a clean environment.

(iv) During a tour of the facility with Staff M1, Staff M2, Staff M3, and Staff M4, surveyor observed on 10/01/13 between 8:50 am and 12 pm that the 4th Floor Clean Utility Room 466 adjacent to the Nourishment Center was not maintained under positive pressure relative to adjacent paces. The room was under negative pressure causing airflow in the wrong direction from dirty to a clean environment.

(v) During a tour of the facility with Staff M1, Staff M2, Staff M3, and Staff M4, surveyor observed on 10/01/13 between 8:50 am and 12 pm that the 3rd Floor clean utility room across the Nurse Station was not maintained under positive pressure and allowed air to flow from the corridor (dirty environment) into the clean space.

(vi) During a tour of the facility with Staff M1, Staff M2, Staff M3, and Staff M4, surveyor observed on 10/01/13 at 1:58 pm that the 2nd Floor Housekeeping Closet across Room 266 in the Kohler building did not have exhaust ventilation, and was thus not maintained in a negative pressure relative to adjacent spaces.

(vii) During a tour of the facility with Staff M1, Staff M2, Staff M3, and Staff M4, surveyor observed on 10/02/13 between 10:45 am and 11:30 am that the Soiled Utility Room in the C-Section Suite on the 2nd Floor was not maintained in a negative pressure relative to the adjacent spaces. The pressure in the room was instead positive causing air flow in a wrong direction.

(viii) During a tour of the facility with Staff M1, Staff M2, Staff M3, and Staff M4, surveyor observed on 10/02/13 at 11:36 am that the Housekeeping Closet across Room 23 and adjacent to the stair in the emergency department on the 1st Floor did not have exhaust ventilation to maintain a negative pressure relationship.

(ix) During a tour of the facility with Staff M1, Staff M2, Staff M3, and Staff M4, surveyor observed on 10/02/13 at 2:05 pm that the Clean Utility room adjacent to the Nurse Station in the 1st Floor behavioral patient unit was not maintained under positive pressure. The space was under a negative pressure relationship to adjacent spaces.

This deficiency was acknowledged by the senior director of facilities operations, director of facilities operations, director of facilities operations-south market, and manager of facilities operations at the time of discovery, and confirmed with Staff JJ (chief nursing officer) at the exit conference on 10/03/13 at 4 pm.

As a result of a verification visit on 12/03/13, surveyor determined that the facility was making a satisfactory progress toward correcting the deficiency. When interviewed on 12/02/13 between 10:45 am and 11:30 am, Staff M3 (director of facilities operations-south market) stated that the hospital has hired the consulting firm Ring & duChateau to evaluate the existing HVAC system fan capacity, and distribution of air. Staff M3 further stated that the design firm was in the process of surveying the air pressure relationships in the affected buildings. Staff M3 stated that the hospital would most likely need a new air-handling unit of a larger capacity to provide enough air to correct the deficiency of air pressure relationships, and submit plans and specifications to the state for review and approval before alteration of the existing HVAC system.

The approved completion date is 6/1/2014.

When interviewed during the 2nd verification visit on 3/21/14 between 10 am and 12 pm, Staff M3 (director of facilities operations-south market) stated that the hospital has state approved construction plans for installation of a new replacement air-handling unit and associated ductworks to correct the deficiencies related to air pressure relationships, missing exhaust grilles in some dirty closets/rooms, and corridor used as supply/return air plenums. Staff M3 further stated that he anticipates completion of correction work before the approved due date of June 1, 2014.