HospitalInspections.org

Evidence includes:

A) Based on observation and personnel interview on 9/20/11, the surveyor finds that the 1st Floor Main Lobby is not staff 24/7. It is also locked at night (see K038). This lobby is part of a required means of egress from the hospital (and is a primary required exit access corridor for much of the 1st Floor). The ceiling of this lobby has several levels. Smoke detection in accordance with 19.3.6.1 is not provided throughout this lobby, with smoke detection installed and spaced to protect the entire space in accordance with NFPA 72 and 19.3.6.1 of NFPA 101.

B) Based on observation and personnel interview on 9/20/11, the 1st Floor Patient Registration area (near the 1st Floor Lobby) has multiple spaces, all of which are open to the exit access corridor. The area is not staff at night. Although some smoke detection is provided, smoke detection is not installed and spaced to protect the entire space in accordance with NFPA 72 and 19.3.6.1 of NFPA 101.

C) Based on observation and personnel interview on 9/21/11, the surveyor finds that the Ground Floor Nurse's Station in the Outpatient Unit in the southwest portion of the building is open to multiple exit access corridors. The Nurse's Station is not staff at night. Smoke detection is provided in accordance with 19.3.6.1 of NFPA 101, exception # 1.

Failure to separate or protect spaces that are open to exit access corridors could allow fire or smoke to spread into corridors that are needed for patient movement or evacuation.

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20224


Based on random observation during the survey walk through on the morning of 9/21/2011, the surveyor accompanied by the Director of Facilities finds that use areas are not separated from exit access corridors to comply with 19-3.6.1. This condition may expose patients, staff and visitors to a fire emergency within the exit access corridor and impede movement to an exit discharge.

Findings include:

A). Ground floor MRI area (not a suite) Patient care areas, which are designated holding bays, are not separated from exit access corridors. This condition is not permitted by any of the exceptions for 19.3.6.1.


B). Ground floor Ultrasound area (not a suite) patient waiting area which is not supervised after the day shift, is open to exit access corridors which does not comply with 19.3.6.1.(c) due to the lack of smoke detection.

Findings include

A) From random observation and personnel interview on 9/21/11, the surveyor finds that there is a Ground Floor Nurse's Station for the Endoscopy and/or outpatient programs in this southwest portion of the building. The Nurse's Station is not staffed at night and the unit is closed at night. However, the Nurse's Station has a sliding pass-through window that opens to an exit access corridor. The opening does not comply with 19.3.6.5. The surveyor finds that there is a fire shutter above the opening. The provider indicates that they close this shutter at night.

Based upon personnel interview, the surveyor finds that this fire shutter has not been observed or tested to close up activation of the fire alarm system, activation of the sprinkler system and activation of the existing smoke detector located within five feet of the opening in the Nurse's Station.

Further, the provider lacks written procedures that require this shutter to be closed manually during any fire event or fire drill. The provider's staff does not close the shutter during fire drills and the surveyor notes that a special tool (rod with a hook) is required to close the shutter manually.

Failure to close all opening in accordance with the written fire plan will allow smoke and fire to spread unchecked in the exit access corridor.

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Evidence includes:

A) Based upon personnel interview and random observation during all three days of the survey, the surveyors find that vertical openings are not enclosure in accordance 19.3.1.1 and NFPA 90A:

1) The 2nd, 3rd and 4th Floor patient rooms have bathrooms that are back to back. The plumbing wall between each pair of bathrooms contains an exhaust duct that is continuous, vertically, from the 2nd Floor ceiling to the roof mounted exhaust fan. Each bathroom exhaust duct communicates to the 2nd, 3rd and 4th Floors, and penetrates two fire rated floor assemblies.

a) Each duct is not enclosed in a fire rated
shaft enclosure in accordance with
19.3.1.1 and NFPA 90A

b) Each exhaust duct lacks fire dampers
where the ducts branch out of a shaft at
each floor (above the ceiling).

c) Fire dampers have been installed at the
floor of each exhaust duct below the
plane of the 3rd Floor slab and th 4th
Floor slab. This installation does not
comply with NFPA 90A but was done in
conjunction with an FSES in 2007. The
installation does not comply with
current CMS policies which do not
allow an FSES for this condition.

d) The duct in each pair of bathrooms is
installed directly against the corridor
wall with only one layer of drywall
between the duct and the corridor. The
drywall is not secured at the top of this
wall and at the bottom of the wall at the
floor and the wall is not fire rated (as
part of a shaft enclosure).

2) The surveyors find from random observation and review of plans, that there are concrete block shaft enclosures at the west side of the West stair and at the east side of the East Stair on the 2nd, 3rd and 4th Floors. Duct penetrations through the floor and/or into these shaft enclosures lack fire dampers in accordance with NFPA 90A. Access to investigate this condition was limited by ceiling conditions and/or due to semi-sterile envirnonments with no access on some floors.

3) Bathroom at Room 2-246: A new fire damper has been installed in this bathroom. The penetration and fire damper appears to be caulked into the fire rated shaft enclosure and the fire damper is not installed in the plane of the barrier in accordance with NFPA 90A and/or a U L Tested damper installation detail.

4) There is an abandoned kitchen exhaust duct above the 1st Floor ceiling that penetrates the shaft adjacent to the West Stair (above the ceiling of Room 1-196). The duct no longer serves as a kitchen exhaust duct. The duct lacks a fire damper where it penetrates the fire rated shaft enclosure in accordance with NFPA 90A. Alternately, the duct has not been terminated before it penetrates the shaft and the shaft has not been repaired to maintain a two hour fire rated enclosure.

a. The surveyor finds that there is very
limited access above the ceiling for three
side of the above shaft. The surveyor
notes that in addition to the above duct,
there is also a pipe penetration into the
southeast side of the shaft with a large
void, above the ceiling.
Shaft integrity of three sides of this shaft
should be confirmed above the ceiling.

Failure to construct shaft enclosures in accordance with NFPA 90A and NFPA 101 and failure to install and maintain fire dampers could allow fire to spread from floor to floor and throughout patient areas. See also K067.

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20224


Based on random observation during the survey walk through on the afternoon of 9/20/2011, the surveyor accompanied by the Director of Facilities finds that vertical openings are not enclosed comply with 8.2.5.3. Unenclosed shafts may affect patient care areas on several floors and smoke compartments, preventing the safe movement of patients, visitors and staff during a fire emergency.

Finding as follows:

A). Shafts are open to the ceiling cavity's of adjacent spaces which is not permitted by NFPA 90A 3-3.2. These shafts extend up for an unknown height. These rooms constitute part of the shaft which does not comply with NFPA 101 8.2.5.3. Example locations observed:

1. Ground floor room G-193 Lab Waiting room, above the center of the room, close to the South wall.

2. Ground floor mechanical room G-169. Above the mechanical space approximately 25 feet in from the corridor entry doors.

3. 2nd floor, corridor # C-22 adjacent to Stair # 3 and to Cardinal Sleep Lab, several bathroom exhaust ducts extend up to the floor(s) above within a shaft that is open to this corridor.

B). On the morning of 09/19/2011, duct penetrations through the walls of 2 hour fire rated ventilation shafts were observed which lack fire dampers to comply with 8.2.3.2.4.1. and NFPA 90A 1999 3-3.4.1. Locations observed include:

1. 3rd floor, east compartment, shaft adjacent to unmanned nurse station.

2. 3rd floor, visitor's lobby # 344, shaft adjacent to toilet #310A

3. 4th floor, east compartment, Pharmacy shaft adjacent to West Stair #3

Based on random observation on the morning of 09/20/2011during the survey walk through, the surveyor accompanied by the Facility Director finds that not all stair shafts are constructed or maintained as fire resistive assemblies to comply with 8.2.5.4.

Findings include:

A. Stair enclosures were observed which are not separated from adjacent areas and do not provide an enclosed protected means of egress to an exit discharge. Location observed:

1. Required exit stair located near the main entry is an unenclosed stair on both levels. This condition does not comply with 39.3.1.1(3) and 8.2.5.8 for a vertical enclosure with a minumum 1-hour fire rating as a required component for a means of egress.

2. Required exit stair located within the 2010 addition is open to adjacent spaces due to a duct penetration to a wall louver on the upper floor which does not appear to have a damper.

3. Required exit stair located within the 2010 addition is open to adjacent spaces due to the entry door on the lower level which does not comply with 7.2.1 and 7.2.1.8 for the requirements of an exit door.

4. Exit stair located within the original part of the building (not sprinkler protected) does not provide the proper means of separation due to holes in the wall at the upper landing.




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Findings include

A) From random observation, the surveyor finds that fire doors and/or smoke doors are not installed to close automatically from activation of the fire alarm and sprinkler system in accordance with 19.2.2.2.6, 7.2.1.8 and NFPA 72:

1) The 1st Floor Kitchen has been evaluated as a hazardous area. The door between the Kitchen and the Servery is therefore required to be smoke tight, self closing and positive latching. The door is held open by a device that does not comply with 19.2.2.2.6 (it lacks a magnetic hold open device with smoke detection within five feet of the door).

2) The 1st Floor Medical Records area is a hazardous area. One or more doors to this space have hold open devices that do not comply with 7.2.1.8.

3) Ground Floor Soiled Linen Holding Room G-281. The corridor door is held open with an unapproved hold open device.

Failure to close fire doors in accordance with NFPA 101 could allow the spread of fire and smoke from designated hazardous areas to other areas of the building.

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Evidence includes:

A) Based upon random observation, the surveyor finds that hazardous areas are not enclosed in accordance with 19.3.2.1 or 18.3.2.1 (where applicable). The surveyor notes that the building is sprinklered and that existing hazardous areas only have to comply as a smoke tight enclosures with smoke tight, self closing doors.

1) 3 West Patient Room 325 has been converted into a storage room and lacks one hour fire rated walls to the deck above and a 3/4 hour fire rated corridor door with listed self closing and positive latching hardware in accordance with 18.3.2.1.

2) 2nd Floor C-Section Unit: The door to the Clean Supply Room does not close to latch.

3) The 1st Floor Kitchen is used for storage of combustibles and has several storage rooms with louvered doors. The Kitchen has been evaluated as a hazardous area. See also K021.

a) The Kitchen door to the tray return
alcove is self closing and positive
latching. It has a manual slide bolt on it
that is not permitted as a latching device
or locking device and the bolt is used to
keep the door from closing to a latched
condition.

b) The designated smoke door/corridor
door near the "dietech's" desk does not
close to latch.

4) Ground Floor General Storage Room - the doors near G-301 do not close to latch.

5) The pair of doors to General Stores has an inactive leaf that lacks positive latching hardware (it has manual flush bolts that were not engaged) and it has a hold open device that does not comply with 7.2.1.8. (it is not designed to release the door from activation of the fire alarm in accordance with 19.2.2.2.6.)

6) The Ground Floor Clean Linen Receiving/sorting Room has a pair of doors with an inactive leaf that has manual flush bolts instead of positive latching hardware.

7) G-250 Bio-Hazard Holding Room, The pair of corridor doors to this space have been damaged at the bottom of the doors, beyond the conditions where repair is possible. The doors no longer comply as fire doors in accordance with NFPA 80.

Failure to provide and maintain separation between hazardous areas and all other areas could result in spread of fire and smoke throughout the building.

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20224


Based on random observation during the survey walk-through while accompanied by the Director of Facilities the surveyor finds that not all hazardous areas are separated from the remainder of the building to comply with 19.3.2.1.

Findings include:

A). The lack of separation between a hazardous area and an exit access corridor may prevent the use of the corridor by staff, patients and visitors for safe egress to the nearest discharge. Locations and conditions observed include:

1. On the morning of 09/20/2011,Surgery Suite- Center Core located between all O.R.'s. This room which is greater than 100 square feet, is considered a hazardous area due to the amount of combustible storage. This room does not maintain a smoke tight separation from the corridor and adjacent rooms due to the following:

a. The doors do not appear to provide a
physical condition equivalent to a 20
minute smoke tight door installation due
to the following:

i. Doors display decay across the
bottom and at the latch side.

ii. Finish is delaminated in areas and
the interior core may be viewed.

iii. Several of these doors appear to be
out of plumb with the door frames
which does not maintain a resistance
to smoke.

2. On the morning of 09/22/2011, Ground floor, Mechanical Room G-169. The inactive leaf of a pair of egress doors no longer maintains the fire rating of the door due to a large rectangular hole in the latch side of this door. This condition compromises the protection of the corridor from the room.

3. On the morning of 09/22/2011, Corridor doors were observed which are not self closing to comply with 19.3.2.1 and therefore, do not maintain the separation between a designated hazardous area and an exit access corridor. Locations observed:

a. First floor, Frozen Section room #1-181.

b. Clean Utility room #1-133.

4. On the morning of 09/21/2011, Ground floor maintenance storage/paint shop #G-170 (designated on the Life Safety plan with a 2-hour enclosure) lacks separation from the exit access corridor due to a large duct penetration which lacks a fire damper installation.

B). The lack of separation between a hazardous area and an occupied room does not comply with 19.3.2.1, and 8.4.1 and does not maintain a safe protected environment for staff, patients and visitors. Locations and conditions observed include:

1. On the afternoon of 09/20/2011, Ground floor, Lab Waiting room # G-193 is not separated from both a shaft above (refer to K-tag 20) and the adjacent two storage rooms due to the lack of a wall to the underside of the floor above.


C). On the afternoon of 09/20/2011, a room which are not constructed as hazardous area is being used for storage of combustible materials which does not comply with 19.3.2.1, and 8.4.1. This condition may affect patients, staff and visitors in adjacent spaces during a fire emergency in the 3rd floor East smoke compartment. Location and condition observed:

1. 3rd floor room # 334 (actual room number) exit access corridor door is not self closing.

2. 3rd floor room # 334 (actual room number) vent louvers are located in the wall above the exit access door which do not appear to maintain the separation of a hazardous area from an exit access corridor.

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Findings include:

A) Based upon random observation the surveyor finds that required exit stairs are not maintained as fire rated enclosures in accordance with 19.3.1.1. The fire door from the 1st Floor Physical Therapy area to the East Exit Passageway does not always close to latch.

Failure to maintain opening protection in fire rated shaft enclosures could allow fire and smoke to spread from floor to floor.

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20224


Based on random observation during the survey walk-through, the surveyor accompanied by the Director of Facilities finds that not all exit stair shafts or other exit enclosures are constructed or maintained as fire resistive assemblies to comply with 19.3.1.1. These conditions may affect any patients, staff and visitors on the 2nd through 4th floors as well as those in the surgery area. Exit egress paths may become compromised under a fire condition.

Findings include:

A). On the afternoon of 09/20/2011 exit enclosures were observed in which utilities and materials unrelated to the enclosure have been installed. This condition does not comply with 7.1.3.2.1(e). Location and condition observed:

1. Exit Passageway for West Exit Stair( #1-on life safety floor plans) has a suspended acoustical tile ceiling. Above the ceiling are multiple pipe runs, a duct run, and multiple conduits and data cables. The installations of the dual pipe runs, data cables and some conduit do not appear to be original installations within the exit passageway.

2. Exit Passageway for East Exit Stair (#1) contains material not related to the exit passageway but serves only the adjacent surgery department. A wall mounted coat hook rack and container of scrub items was observed within the space.

3. Center Exit Stair (#2) on the 4th floor contains 3 electrical conduits which serve the master clock system and the exterior sign.


B). On the morning of 09/19/2011, exit stairs were observed in which the fire rated separation of the stair is not provided due to an exit door that does not maintain the fire rating of the stair enclosure. Location and condition observed:

1. Center Stair (# 2) Fourth floor, stair entry door appears warped on the latch side of the door. The top of the door when closed shows a 1/2 inch gap between the face of the door and the stop on the frame which does not comply with NFPA 80A.


C). On the afternoon of 09/19/2011 entry to a normally unoccupied room was observed within the stair enclosure that does not comply with 7.1.3.2.1(d). Location observed:

1. 4th Floor Center Stair (#2), there is a wall with an entry door used as a separation between the stair and unoccupied room for electronic equipment used for the master clock and exterior signs. The depth of the wall construction does not appear to be sufficient in order to qualify as a 2-hour fire rated separation.


D). On the afternoon of 09/19/2011 the 4th floor Center exit stair (#2) was observed to contains a hole through the corridor wall above the entry door which does not maintain the fire resistance of the stair enclosure.




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Evidence includes:

A) Uncorrected deficiencies that were transferred from the Complaint Survey of 06/22/11:

Based upon observation the surveyor finds that the facility has locked doors in identified paths of egress that do not comply with 7.2.1:

1) The 3rd Floor center portion of the building is not a psychiatric area and allows free access via elevators to this portion of the building. There are multiple paths of egress from the center portion of the 3rd Floor. The exit paths to the west are directed with illuminated exit signs into a locked psychiatric unit.

a) The south corridor has an illuminated
exit sign above a door with a sign that
indicates "Do Not Enter" The two signs
conflict.

b) The north corridor has a door with an
illuminated exit sign. The door has
electronic locking hardware that does
not allow release within 15 seconds in
accordance with the provisions of
7.2.1.6.

c) Modified 09/19/11: The above pair of
doors in both corridors has an exit
sign directing exit travel west to east
through this pair of opposite swinging
doors. The door that swings to the
east lacks any kind of hardware that
can be opened from the west side of the
door (it has concealed manual
flush bolts that can only be operated by
opening the other leaf ).

The doors do not comply with 7.2.1.5
and 7.2.1.6.

Exit signs identify a path that is not available to everyone. The confusing identification of exit paths from this floor could cause a delay of evacuation during a fire particularly for any staff, patients or visitor that are not intimately familiar with this floor.

B) 09/21/11: Based upon random observation, the surveyor finds that the facility has multiple locked doors in identified paths of egress that do not comply with 7.2.1 of NFPA 101:

1) 3rd Floor (see also item "A 1"): The center portion of the 3rd Floor and the south west corridor are accessible by the public via elevators. Also, this portion of the building has offices and it is not a designated locked psychiatric area.

The door to the West Exit Stair is a required exit for the public accessible corridor and is identified with an exit sign. The stair door has a locking device that does not comply with 7.2.1.6.1

a) The stair door lacks signage indicating
"Push until alarm sounds - Door can be
opened in 15 seconds" [7.2.1.6.1. (d)].

b) According to the provider, the door does
not release in 15 seconds.

c) The hardware on the door (a lever
handle latchset) requires two operations
and special knowledge to open the door
(turn handle in push on door) This
hardware does not comply with 7.2.1.6
does not comply with 7.2.1.5.

d) The door has a keyed switch and a
keypad in the stair that allows release of
the lock from the stair side and the
corridor side of the door. Once the
keyed switch has been used, the door
relocks and does not release again until a
code is entered from the keypad.

While the keyed switch and keypad may
be permitted for convenience functions,
the operation of the hardware and
locking functions fail to comply with
7.2.1.5 and 7.2.1.6.

2) 2nd Floor:

a) The 2nd Floor Level 1/Level II Nursery
has two doors. Both doors have magnetic
locking devices that require keypad entry
to leave the room. These locking
devices do not comply with 7.2.1.

b) The 2nd Floor has a pair of doors in the
north corridor and in the south corridor
roughly in the center of the building.
Each pair of doors swing west to east (in
one direction only). This complies with
19.3.7.6 of existing smoke doors but
does not comply with 18.3.7.5 for new
smoke doors.

The doors have exit signs on both sides
of the doors indicating the exit travel in
both directions is required. The doors
also have magnetic locking devices that
have delayed release in accordance with
7.2.1.6.1 in one direction only. The
pairs of doors of doors do not comply
with 7.2.1.6 because opposite swinging
doors are not provided and 7.2.1.6
cannot be used for doors that must be
pulled open.

The doors have lever handled latchsets.
This hardware is not permitted in
conjunction with delayed egress (it
requires two motions to release the
locking devices). The latchset and
hardware functions do not comply with
7.2.1.5 and 7.2.1.6.

c) The stair door to the West Exit Stair on
the 2nd Floor has a locking device that
does not comply with 7.2.1.6.1 It says
that it will release in 15 seconds but it
does not (based on testing on 9/20/11).

3) 1st Floor

a) The Cafeteria has a door to an outside
patio area. The door back into the
building is locked at night and requires
operation of a push paddle to release the
lock. This arrangement does not comply
with 7.2.1.5 or 7.2.1.6. The only other
path off of the patio is a partially paved
path to a gate in a fence. The path is not
paved all the way to the gate and there is
a bush that blocks access to the gate.

b) The Main Entry Lobby foyer has two
pairs of sliding doors with "break and
swing" functions. These door are part of
the required means of egress for the
Hospital. One pair of doors has a
magnetic locking device that is locked
at night. Signs on the inside and outside
indicate that the doors are locked at
night. The locking devices do not
comply with 7.2.1.5 and 7.2.1.6.

c) The Cafeteria Serving area has a security
shutter and a single swinging door as a
path out of this space. The security
shutter is closed after hours. The single
door has a double cylinder dead bolt lock
that requires a key or special knowledge
to get out of the serving area. This lock
does not comply with 7.2.1.5.

4) Ground Floor Infusion/Endoscopy/ED Registration/EKG/etc. This has been evaluated as a mixture of inpatient and outpatient treatment. Three of four exit paths do not comply.

a) The corridor near G-270 has a door to the
north with an exit sign and a magnetic
locking device. This door is locked at
night and does not comply with 7.2.1.6.
Further, the surveyor finds that this path
to the north leads to the same exit path
as the exit path from Corridor G-111 and
as such does not constitute a second
remote path of egress. It is not clear
how this exit path can serve as an
additional exit path without another
complying exit path that can be
considered to be remote. see below

b) There is a pair of auto-open, opposite
swinging doors near the G-301. These
doors have exit signs on both sides of the
doors and magnetic locking devices on
both sides of the doors. The provider
indicates that the doors are locked at
night. The locking devices do not
comply with 7.2.1.5 or 7.2.1.6. With this
door locked, Corridor G-286 is a dead
end corridor in excess of 50' and G-287
is a dead end more than 30' in length

c) There is a single door to the north, next
to the OP Nurses Station, with an exit
sign. This door directs that exit path into
a waiting room. The exit path from the
corridors is not directed into an exit
access corridor or to another corridor
without passing through an intervening
space and the door does not swing in the
direction of exit travel.

C) 9/21/11: Based on random observation, the surveyor finds that a safe path to a public way is not provided and maintained.

1) The East Exit Passageway from the East Stair discharges to an exterior sidewalk. There is a curb (change in elevation) in this path near the discharge door constitutes a tripping hazard in a means of egress and does not comply with 7.1.6.2.

2) The West Exit Passageway from the West Stair discharges to an exterior sidewalk. Several depressed concrete sidewalk panels and a drop-off at the edge of the walk, near the exterior stair leading down, constitute tripping hazards in a means of egress that do not comply with 7.1.6.

3) The exit stair from the 1st Floor to the Ground Floor discharges into the Ground Floor corridor (in accordance with 7.7.2). However, the exit path is then directed through the Loading Dock to the east. The Loading Dock has unprotected drop offs, in the path of egress at the dock and at the lift. Further the corridor just outside the stair is used as a holding area for received materials. This use of the corridor does not comply with 19.3.2.1 or 19.3.6.1.

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Findings include:

A. The surveyors find from personnel interview and document review on 9/21/11, that the facility has emergency lighting with battery back-up in multiple locations throughout the building, including multiple exit stairs. The surveyors find that the provider has documentation that demonstrates monthly testing but finds that the provider lacks documentation of annual testing in accordance with 7.9.3. The surveyors also find that replacement of the batteries every year or every other year is not equivalent to the annual testing that is required.

Failure to maintain these systems could result in loss of means of egress lighting for both patients and staff.

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Findings include

A) Based upon random observation, the surveyor finds that illuminated exit signs are not provided in accordance with 19.2.10.1: The Ground Floor Emergency Department Registration area has a pair of auto opening, opposite swinging doors. An exit sign is not provided above these doors for the exit path running east to west.

B) The 2nd Floor C-section Suite lacks illuminated exit signs identifying the path out of this unit in accordance with 7.10.

Failure to provide proper identification of exit paths could result in confusion and delay in exiting during an emergency.

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Evidence includes:

A) Based on random observation during testing of the fire alarm system on the afternoon of 09/20/11, the surveyors find that the fire alarm system is not installed and maintained in accordance with NFPA 72 and NFPA 101.

The surveyors find that the fire alarm system is not audible throughout all portions of the building and particularly in all personnel work areas. The fire alarm system does not comply with the 5db/10db/15db audibility requirements of NFPA 72 -1999 (Sections 4-3, 4-3.2, 4-3.3 and 4-3.4). No audible devices are provided in many locations, most of these locations do not comply with the exceptions where visible devices (fire alarm strobes) can take the place of audible devices. Locations include but are not limited to:

4th Floor Pharmacy

Room 427

Multiple patient rooms and staff work areas
on Floors 2, 3 and 4

1st Floor:

Administrative Offices

Kitchen, Servery, and Dining Rooms

Main Lobby, Gift Shop and Chapel

The fire alarm system is barely audible
throughout the 1st Floor Registration
area

Based upon the above and the K051 citation on other floors, the surveyors find that staff may be responding to manually announced overhead pages during activation of the fire alarm system. Staff does not respond to the activation of the fire alarm system in accordance with their written plan because they cannot hear the fire alarm system. This results in a delayed response. If staff cannot hear the fire alarm system or see it activate from strobes (where such is permitted in NFPA 72), the staff response to patient safety will be delayed and could result in limited or no response if the switchboard operate misinterprets the information provided announces the wrong location.

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20224


Based on random observation during the survey walk-through the surveyor accompanied by the Director of Facilities finds that not all portions of the building fire alarm system are installed to comply with 19.3.4. This condition may prevent emergency egress from the location of fire origin to an adjacent compartment. This condition may affect patients, staff and visitors on the second floor East smoke compartment.

Findings include:

A). On the afternoon of 9/20/11 during testing of the fire alarm system, the visual and audible notification devices did not operate in a manner to give warning in accordance with NFPA 72 4-4. Locations and conditions include:

1. Second floor C-Section suite, surveyor was unable to locate a strobe device and did not hear any audible devices anywhere within this suite.

2. Second floor Nursery, surveyor was unable to hear an audible device anywhere including the work room. The strobe device (located in the North side corridor) could not be viewed except from one location - the South west corner of nursery adjacent to the work room.

3. Second floor LDRs, surveyor was unable to hear an audible device within the area.

4. First floor Surgery on call room lacks a visual notification device.

A). Documentation to indicate the annual testing and maintenance of the building fire alarm and detection system in accordance with NFPA 101, 9.6 and NFPA 72, 7-3 was requested on the afternoon of September 21, 2011. The Surveyor requested documentation on the Radiolody Unit and the building, however, the surveyor was informed that there was no documentation available.


B). Documentation to indicate the conducting of fire drills to comply with 39.7.1 and 4.7 was requested. The Surveyor requested documentation on the Radiolody Unit and the building, however, the surveyor was informed that there was no documentation available.


.

Evidence includes:

A) This uncorrected deficiency was transferred from the Complaint Survey of 06/22/11:

Sprinkler systems are not installed and maintained in accordance with NFPA 25: There is a vestibule between the Emergency Room and the Ambulance Bay. The vestibule is sprinklered and has lay-in ceiling tiles. The ceiling tiles are displaced by wind or air pressure when a door is opened. This creates multiple voids in the ceiling and compromises the sprinkler protection in this space. The ceiling lacks adequate hold-down clips to prevent displacement or the room lacks a ceiling that cannot be moved by wind or air pressure.

B) 9/21/11: From random observation throughout the building, the surveyors find that the sprinkler system is installed with metal pipe in some areas and plastic pipe in other areas. Arm-over and/or end of branch bracing is not provided for sprinkler heads on all five floors throughout the building in accordance with Section 6-2.3.3 of NFPA 13 - 1999.

Note: This deficiency does not occur in everywhere because sidewall heads are used in many locations. Examples of where arm-over bracing for uplift is not provided include but is not nearly limited to 3rd Floor Group Therapy Room and the Ground Floor E R Registration area.

C) Based upon observation and personnel interview, the surveyors find that inspector's test valve installed on the 2nd, 3rd and 4th Floors are not permanently piped to a drain or to the outside in accordance with NFPA 13.

The provider indicates that they hook up hoses in order to test these floors.

D) The 1st Floor Kitchen has sprinkler heads that are spaced as much as 18' or more apart. The provider lacks documentation that indicate that these sprinkler heads are extended throw heads. If regular heads are installed, they are installed too far apart to comply with NFPA 13.

Failure to install and maintain the sprinkler system could result in failure of the sprinkler system and uncontrolled fires. The exceptions used in this building for sprinkler protection do not apply if the sprinkler system is not installed in accordance with NFPA 13. (Example: smoke dampers would be required at duct penetrations through smoke barriers and the Center Exit Stair cannot comply with 76.7.2 without full sprinkler protection).

.

A). Documentation to indicate the inspection and testing of the sprinkler system to comply with 39.7.1 NFPA 13 was requested. The Surveyor requested documentation on the Radiolody Unit and the building, however, the surveyor was informed that there was no documentation available.

By direct observation on the afternoon of 9/19/11 the surveyor finds:
Monthly inspections of the kitchen hood suppression systems are not conducted to comply with NFPA 17, 1998, 9-2. Failure to inspect that all components are functioning and not impaired could contribute to failure of the suppression system during a fire emergency and affect the safety of kitchen staff.

Evidence includes:

A. The surveyors find from document review and personnel interview that fire dampers are not maintained in accordance with NFPA 90A and CMS Requirements (maintenance of fire dampers and smoke dampers every six years):

1. The provider has documentation with a list fire dampers identified and several dates in 2009. The documentation does not clearly indicate that the fire dampers identified were inspected and maintained in accordance with NFPA 90A (including inspection, cleaning, removal of fusible link, exercise of damper, repair as necessary and replacement of fusible link where necessary). The documentation does not indicate what as done in 2009.

2. All fire dampers that are listed on the above referenced documentation were not tested in 2009. The provider lacks documentation that identifies when all fire dampers were tested since September of 2005.

3. Multiple fire dampers are missing from the documentation. The surveyor observed two fire dampers above the ceiling on 4 West (Fire Damper FD4.7 and FD4.8). Access to these fire damper could not be provided due to conduit installed directly under the access panels. These fire dampers were not identified on the above documentation.

Failure to test and maintain fire dampers will result in failure of fire dampers during non-emergency conditions which will disrupt air distribution and failure of fire dampers in a fire emergency which could allow migration of fire and smoke to spread throughout patient areas and to multiple patient floors.

B) Based on random observation the surveyor finds that HVAC systems are not maintained in accordance with ASHRAE Guidelines (as referenced by NFPA 90AZ).

3rd Floor Northwest: This Psychiatric area has two shower rooms off of the corridor in one shower room the exhaust ventilation louver in the ceiling was totally blocked by dist and lint. In the other shower room, the louver was about 50% blocked.

Failure to clean and maintain the ventilation system is wet areas will allow moisture laden air to remain in the space and contribute to any mold problems in the building.

.

Evidence includes:

A) The surveyor observes that a large commercial gas fire grill has been installed on a patio just outside of the 1st Floor Dining Room. The grills is installed against one wall of the Hospital and it is less than 15' from an unprotected glass wall between the patio and the Main Lobby.

A kitchen hood suppression system is not installed in accordance with NFPA 17A. This condition is not mitigated by horizontal distance from the building. The surveyor also notes that there is a fuel shut off that cannot be reached under the grill in an emergency and there is a fuel shut off in the Ground Floor Level, inside the building

Alternately, the provider lacks written procedures that include the following:

1. The fuel shut off will remain turned off at the Lower Level and may be turned on only when the grill is in use and in constant attendance. The status of this fuel shut off is to be checked frequently and documented.

2. There is a written procedure at shut the fuel off in an emergency

3. Any time the grill is in use, Type K fire extinguishers are maintained in the immediate area. The written procedures need to clearly indicate that using a fire extinguisher without shut the fuel off will not likely be effective.

Any fire in this grill if not controlled or suppressed could easily spread to the building.

.

Based on random observation during the survey walk-through, the surveyor accompanied by the Director of Facilities finds that not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency to comply with 19.2.3.3. This condition may affect patients staff and visitors on the Ground floor East compartment and the 3rd floor East compartment.

Findings include:

A. Means of egress corridors are not maintained free of obstructions to comply with 7.1.10. Locations/conditions observed include:

1. On the afternoon of 09/20/2011 Ground floor exit access corridor G-157 is utilized for storage of equipment/wheelchairs. Although an alcove space is provided, the amount of equipment stationed open to the corridors exceeds the available space of the alcoves, and the corridor is obstructed.

2. On the afternoon of 09/20/2011, Ground floor exit access corridor G-103 near entry to Stair is utilized for storage of cardboard boxes piled up behind a privacy curtain. Although an alcove space is provided, the amount of equipment stationed open to the corridors exceeds the available space of the alcoves. Use of this space does not comply with 19.3.2.1 and 19.3.6.1.

3. On the morning of 09/19/2011, Third floor exit access corridor # 342 adjacent to the pair of cross corridor doors of the smoke barrier - a suggestion box attached to the wall extends more than 7" into the required width of the corridor.

Findings include

A) Ground Floor Loading Dock Area - there is a dedicated Nitrous Oxide Manifold Room and Storage Room that is accessed from the exterior Loading Dock. On 9/20/11 an acetylene tank was found in this room. Immediate removal was required. The provider lacks adequate means to prevent re-occurrence.

Storage of flammable gasses with oxidizing agents does not comply with NFPA 99 and constitutes a significant fire and explosion hazard.

B) The 2nd Floor C-section Unit has a Recovery Room with piped in medical gas systems. The provider was not able to locate the medical gas alarm panel for this space, in a constantly attended location in accordance with NFPA 99-1999.

Failure to install and maintained medical gas systems in accordance with referenced standard could result in failure of those systems, while in use or needed for critical patients.

.

A. Based on random observation the survey walk-through the generator equipment does not meet all requirements of NFPA-110.

Findings include:

1. Switchboard Room G-309 is the 24 hour monitoring location for the generator annunciator panels. The remote annunciator for one of the emergency generator was missing and did not meet the requirements of NFPA-99, Section 3-4.1.1.15 and NFPA-110, Section 3-5.5.2(d).

2. Two of the four generators did not have remote shut down switches to comply with NFPA-110, Section 3-5.5.6.

3. Battery pack lighting units to meet the requirements of NFPA-110, Section 5-3.1 were missing from the 750 KW and the 800 KW generating units .

These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised without the facility being aware that the emergency generators are not functioning properly.

.
Housekeeping/Sanitation: The facility failed to provide and maintain a safe and sanitary environment for staff and patients. The following are referenced as standards for this citation:

State and/or Federal Regulations for
Food Service and Sanitation

CMS 482.41 (a), 482. 41 (c)(2) and
48.41 (C)

A) Based on observation and interview the facility failed to maintain the floors of the General Storeroom in a clean sanitary condition and failed to prevent liquid waste discharge to the floor surface of the Medical Waste Storeroom.

Findings include the following:

1. On 9-20-11 at 11:30 a.m. unidentified liquid was pooling on the concrete floor beneath and adjacent to the Medical Waste Sterilizer in the Compactor Room (G282). Liquid waste was present on the floor covering approximately 50 square feet (10 by 5 feet). At this time the Sterilizer was in operation and was discharging liquid waste to the floor drain beneath the unit. Maintenance staff was present and stated that the source of the liquid was unknown.

2. On 9-20-11 at 11:40 a.m. accumulated paper items including medical supply wrappers, paper souffle cups, dust, and lint was present on the floor between and along the metal rails of the Rollable Storage System and floor/wall junctures adjacent to storage cabinets within the General Store Room (G303). Accumulations of debris was present beneath each of the Rollable Storage cabinets.

B. Based on observation and interview the facility failed to maintain food preparation equipment in a clean, sanitary condition between used so as to prevent conditions favorable for the growth of pathogens and potential subsequent foodborne illness. This has the potential to affect all 40 patients, visitors, and employees consuming food prepared by the kitchen.

Findings include the following:

1. On 9-20-11 at 2:00 p.m. the meat slicer, covered with plastic and designated as clean and ready to use, was soiled with greasy residues on the front and rear blade surfaces. Small fragments of food and congealed fat was present on the recessed hole of the slicing blade and other recesses and crevices of the meat slicing platform and slicing armature. Food fragments were present in other hard to reach food contact surfaces and areas of the slicer. The Food Service Supervisor stated at this time that the slicer is used regularly to process pre-cooked, ready to eat meats including roast beef, ham, and turkey.

2. On 9-20-11 at 2:10 p.m. one food processing blender designated as clean and ready to use, had clear liquid remaining in it from dishwashing. The blender pitcher was covered tightly with a lid. Upon disassembly of the pitcher and blade assembly remnants of food matter was present on the food contact surfaces of the blade, blade assembly, and threaded neck of the pitcher.

Similar conditions were present on food contact surfaces in one of the small covered food processor basins (liquid and moist food deposits present on blade assembly).

Dried food deposits were present on food contact surfaces inside of two small food processor basins and blade assemblies.

The Food Service Supervisor stated that these devices are used to prepare mechanically altered diets for 1 to 2 patients on a daily basis.

3. On 9-20-11 at 2:15 p.m. the large commercial table-mounted mixer, covered with plastic and designated as ready to use, had accumulations of dried food food present on its rotating spindle and upper splash area. Food deposits were also present on the upper armature and recessed areas of metal hardware. Dried food matter was also present inside of the attached metal mixing bowl. Food prepared in the mixer is subject to cross contamination from accumulated dried food that detaches from vibration of the mixer. The Food Service Supervisor stated that the mixer is seldom used and has not been used for approximately one year.









07113


A. Uncorrected deficiencies were transferred from the Complaint Survey of 06/22/11: The provider failed to provide and maintain a safe and sanitary environment for patients and staff.

4. The 1st Floor Kitchen and Cafeteria is not maintained in accordance with the Illinois Hospital Licensing Requirements and the State of Illinois Plumbing Code:

b. The only Janitor's Closet in Dietary
lacks a mop sink. The mop
sink in this space has been removed and
there is no dedicated mop sink for
Dietary.

c. The floor in Dietary is a wet location
that requires watertight joints and cove
bases. The cove bases are separated
from the walls in places and the cove
bases are cracked, chipped or missing
in multiple locations.

The above item was not investigate
on 9/21/11 to determine whether
corrections have been made

5. 06/21/11: Wall mounted toilets throughout the facility are not installed in accordance with the Plumbing Code and/or the manufacturer's requirements. The joint between the finish wall and the toilet is open and not sealed with a water resistant material. This allows moisture, cleaning fluids and debris to fall between the toilet and into the chase behind the toilet.

Modified 9/21/11: The surveyors observed that most bathrooms, dietary, and other areas identified in the compliant survey had been cleaned and visible evidence of housekeeping deficiencies, stains and possible surface mold was cleaned up. The condition of the joints between the toilets and the wall was not re-investigated. Based upon interviews of Hospital personnel and the onsite outside contractor's personnel, the surveyor finds that the Hospital believes that many of the hidden mold problems and some of the surface conditions were caused by the failure of the plumbing seal for the waste of the wall mounted toilets. These toilets are installed throughout the facility. Further, it is required, based on the information provided from thr facility, that corrective actions will be necessary.

C. New deficiencies based upon the 9/21/11 Survey:

Interim Life Safety Measures as an alternative to full compliance with NFPA 101 - 2000: Due to the severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

1. The provider failed to implement interim life safety measures for deficiencies cited under the survey dated 9/21/11.

E. (New deficiencies based upon 9/21/11 Survey): Based upon the conditions observed on 6/22/11 and observed on 9/21/11 and based upon personnel interview and document review, the surveyors find that mold has been found in the concealed spaces between bathrooms. Hospital personnel indicated that they expect to find this condition in most if not all bathrooms on all floors (see also Item "B 5" above).

1. On the morning of 9/19/20 and on the afternoon of 9/21/11, the Hospital provided access to two bathrooms on the 3rd Floor for rooms that were no longer used as patient rooms (Rooms 309A and 310A). The two back to back bathrooms have been partially demolished by an outside contractor (that was also present). The floor and ceiling finishes of the two bathrooms were removed. The sinks and toilets were removed. The wall finishes and wall (studs and drywall) between the two bathrooms were completely removed.. The Hospital's representative and the contractor were both interviewed on 9/19/11 and 9/21/11 with the following results:

a. The contractor indicated that the
demolition and removal was conducted
in accordance with the Hospital's rules
for projects, infection control and for
mold abatement. This included negative
ventilation of the project area and double
bagging of the demo materials being
removed.

b. The contractor indicated that no mold
was found under the floor finishes.

c. The contractor indicated that mold was
found on the inside portions of the
drywall as much as 12" above the floor.
The contractor also indicated that the
lower portion or drywall was soggy or
soft. No samples of this material were
save and no testing was conducted to
determine what type of mold was
present, whether it was active or inert,
and/or if the substances observed were
mold.

d. The contractor indicated that the stud
track at the floor was rusted away and
that the lower portion of the wall studs
were significantly deteriorated. Again,
none of this material was saved for
testing or later examination.

e. The Hospital's representative indicated
that the Hospital expects to find this
same condition in most of the bathrooms
in the facility.

From observation the surveyor also finds:

f. The plumbing wastes, including two
toilets were capped off with rags.

g. The sprinkler heads in each space were
not turned up to the deck when the
ceilings were removed; this condition
requires interim life safety measures.

The above findings support that findings from the complaint survey of 6/22/11, which concluded that there is mold in the bathrooms of the building on multiple patient floors. Based upon multiple interviews, the surveyors find that the Hospital expects to find mold and deteriorating wall conditions in bathrooms. The scope of this condition is expected throughout the building. The severity of this condition has not been determined; see below

2. The bathroom mirror in Room 416 was removed on the afternoon of 9/20/11, to allow viewing of the plumbing cavity behind the bathroom. This room is an example of a project that took place recently in which the 4th Floor bathrooms were renovated. In the bathroom of 416, the surveyors observed no mold. The surveyors observed that the drywall on both sides of the wall had been replaced from the floor to about four feet above the floor. The light gage steel wall studs were partially removed from the floor to about four feet above the floor and were replaced with new studs. However, the existing studs were cut off at roughly four feet above the floor and the new studs were not spliced into the existing studs and were not run from deck to deck. The drywall in the bathroom (5' x 8') on each side of the plumbing wall was is stiffened only by steel stud with a break in the middle of each wall.

The corridor wall has about 12" of drywall at the floor that is not supported by studs or a stud track. This portion of the corridor wall is also part of an unrated shaft that is also cited under K 020. This condition is typical of many of the 4th Floor bathrooms

3. The Hospital has indicated that some form of outside testing was conducted. The information about who did the testing, what testing was conducted, where the testing conducted, the results of the testing and the qualifications of the testing agency was not available. There is no evidence that indicates that the Hospital has engaged the services of an industrial hygienist, a mold or moisture abatement consultant and/or contractor that specializes in abatement.

4. The Hospital has adopted a management plan for investigation, containment and abatement of mold that is based upon OSHA and/or EPA references. This plan contains four levels of contamination with Level I being the lowest level and Level IV the highest. Level III and Level IV includes recommendations for consultation with an industrial hygienist, or environmental health and safe professionals.

a. The provider was not able to identify
which Level of contamination has been
found at their facility and how this was
determined. There is no evidence or
report that identifies that source(s) of
mold that may be found in the bathroom
plumbing walls.

b. A project architect was also present for
the survey on all three days. The project
architect has identified a project that is
proposed to repair bathrooms walls,
abate any mold or deteriorating
conditions, replace shaft enclosures and
replace bathroom toilets in every
bathroom in the facility.

The shaft correction in many bathrooms
(but not all) will necessitate demolition
and removal of bathroom walls. In
other bathrooms, demolition is proposed
to install new floor mounted toilets and
to abate deteriorated wall conditions.
There is no indication of what Level of
abatement is necessary for all portions of
this project, based upon the Hospital
policies.

The following conditions are cited on the Complaint Survey dated 6/22/11 under tag A 700 and are repeated herein. They support the findings above. No attempt was made to determine whether portions of the findings below have been corrected as of 9/21/11.

The informatoin below are based upon random observation, personnel interview and limited document review during the complaint survey of 6/22/11. The following citations are also based upon observations throughout the hospital by looking; at wall and floor finishes, above ceilings and using existing access panels to view concealed spaces. Rooms with patients were not inspected with the exception of one Room on the 4th Floor . The investigation was mostly confined to toilet and shower rooms on Floors 2, 3 and 4. Random inspections were conducted on the 1st Floor and Ground Floor. No destructive demolition was conducted and no special means (pin hole cameras, etc) were used to observe concealed spaces.

Findings include:

A. The presence of what appears to be molds in patient bathrooms was confirmed by the surveyor. Based upon the following, the surveyor expects to find mold and moisture problems throughout toilet rooms (and/or in the plumbing chases for toilet rooms) on every floor.

1. There is a plumbing chase between patient room 404 and 403 with wall mounted sinks and wall mounted toilets installed back to back. The wall finishes, cove base and floor finishes are ceramic tile. The ceramic tile on the wall is new and has white grout. The ceramic cove base and floor tiles are older and the grout in the joint work is stained, discolored and damaged.

Access into the plumbing chase is limited to a small access panel under the sink. This access panel allows very little access (not enough to view into the space and not enough room for a camera. The surveyor reached into the cavity near the floor to feel the wall surface that the toilet is mounted to. The wall surface in the chase was soft and mushy (as opposed to hard drywall) near the floor. The surveyor's fingers were coated with a gray/blue/black residue after touching the wall in the chase. The surveyor finds that the lower portions of the wall are damaged by moisture problems in the wall and the residue is most likely mold growing on the wall. The extent of this problem in this room could not be determined further without demolition to expose the chase.

However, the surveyor observed the joint work in the ceramic tile at the plumbing wall was broken and discolored with a yellow material. There is waste water brown stain under the wall mounted toilet that appears to be a leak from the toilet. Much of the grout work in the floor tile around the toilet is stained or discolored.

Further, the surveyor observed a slight hump in the corridor wall along the outside of this bathroom. The wall surface and base moves slighting when pressed upon. This indicates that the wall is not attached to the floor track or floor plate at the base of the wall or it indicates that the steel track or plate inside the wall has deteriorated from moisture.

2. Patient Room 415: The surveyor observed a plastic barrier in the corridor in front of this room and observed that the toilet room was being renovated. A contractor was in the bathroom working on new ceramic tile wall finishes and ceramic tile floor finishes. It was readily obvious that portions of the drywall had been replaced. The demolished materials were not found in the room. The surveyor interviewed the contractor working on the toilet room. The contractor indicated that the old ceramic tile finishes had been removed. He indicated that the drywall on three walls was removed and replace to about four feet above the floor. When asked, he indicated that the drywall that was removed had mold on it. When asked, the contractor indicated that the steel floor track had to be replaced because it had rusted away.

The Director of Plant Operations indicated that the ceramic floor tile had mold under the tile and that the substrate was removed.

Patient Room 416: The surveyor found that the adjacent patient room was occupied. Staff asked for and received the patient's permission to look in the bathroom. The bathroom is back to back with Patient Room 415 and shares a plumbing chase. The bathroom has no access panel to the plumbing chase. The room has similar conditions, visually, to most of the bathrooms on this floor. The surveyor observed no evidence of any repair to wall or floor finishes or substrates.

3. 3rd Floor Shower Room near Room 318. This shower room is typical for most shower rooms in the building. Most but not all patients rooms have no showers in the patient bathrooms. Instead patient showers are provided off the corridors on each floor. The shower room near Room 318 has no ventilation and was much more humid that other showers observed. The shower was not clean. The ceramic tile finishes were discolored and coated with grime.

4. Patient Room 318 has a toilet room with back to back fixtures and a shared plumbing chase with the adjacent patient room.

The corridor wall surface is loose near the floor along the bathroom wall.

The wall and floor finishes are heavily discolored and the wall and cove base are loose at the toilet. The joints are not watertight. The surveyor observed wood blocking in the plumbing chase.

5. Dietitian's Office 314 (formerly a patient room and typical of many): The toilet room is typical of most patient toilet rooms on this floor.

There is no water tight seal between the toilet and the wall. The ceramic tile wall finishes have failed and the joints between the water and the floor are buckled. There are heavy stains on the wall under the toilet

6. Office 2-211 (with a typical patient toilet room): The cove base is vinyl and it is ripped and buckled. The toilet is not sealed to the wall finish.

7. Room 2-253: The ceramic tile joints in this room were originally white but have turned brown and black. The discoloration does not come out with rubbing or scraping. This is typical of many patient toilet rooms.

8. Room 2-214: Sheet vinyl flooring and a vinyl cover based have been installed directly over the ceramic tile. Some of the joints have failed at the vinyl cove base. There is discoloration at the joints and along the top of the cover based.

9. From random observation via access panels in patient toilet rooms the surveyor finds that plumbing chases to be full of debris and rags.

10. Ground Floor patient toilet room near an X-ray Room: The wall mounted toiled in this bathroom is not sealed to the wall with a water resistant seal or caulking material. This allows dirt, soiled materials and moisture behind the toilet and possibly into the plumbing chase.

End

.

A.) Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and reference therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

1. The provider failed to implement interim life safety measures for deficiencies cited under the survey dated 9/21/11.

A) Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517.

Findings include:

1. The following Life Safety Panels are serving loads other than those allowed by NFPA-70, Section 517-32 and NFPA-99, Section 3-4.2.2.2(b) .

a. Life Safety panel 4LSP is feeding
receptacles.

b. Panel 2LSP circuit 5 is serving the nurse
call .

c. Panel 1LSP has several circuits serving
loads such as nurse call and room
receptacles.

d. The only generator loads allowed to be
served by the Life Safety Branch are
selected lighting and receptacles at the
generator set location. Several Life
Safety Panels had circuits serving battery
chargers, heaters, louvers and other
generator loads.

e. Life Safety Panel GEL1 had several
circuits serving non Life Safety loads,
including a welder.

2. Panel 1CRP circuit 20 is serving a fire alarm load that should be fed from a Life Safety panel in accordance with NFPA-70, Section 517-32 and NFPA-99, Section 3-4.2.2.2(b) .

3. The fire alarm circuit breakers in the Life Safety Panels are not marked red and do nothave a locking device on the breakers to comply with NFPA-72, Section 1-5.2.5.

These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised by the loss of a single transfer switch.

Evidence includes:

A) From random observation, the surveyors find that electrical installations and materials do not comply with NFPA 70 -1999.

1) The surveyor finds the electrical extension cords and plug strips plugged in in series are in permanent use throughout the facility. Locations include but are not limited to:

a) Nourishment Room 366 - refrigerator on
extension cord

b) 3-236 Staff Break Room with extension
cord at radio near window

c) 1st Floor Dining Room Vending Room

d) 1st Floor Cafeteria (light at salad table
is on an extension cord, the soup
kettles are connected to a large yellow
extension cord

e) 1st Floor Kitchen - dietatechs desk

f) 1st Floor Human Resources - back
office area has multiple extension
cords along with plug strips that are
plugged in in series.

g) Ground Floor Communication Room
(accessed through Electrical Room)

2) Electrical circuits in electrical panels are not installed and maintained

a) A 3rd Floor Electrical Closet has several
circuits that are "tagged out." The
provider does not know why or what
these are. There is also a junction box in
this closet that lacks a cover.

b) Electrical Closet 2-240; Panel 2L-2 has
ten circuits that are labeled as
"unknown" all ten circuits were "on".
The provider was not able to explain the
black electricians tape that was found
over some of the circuit breakers.

3) Business Office 1-197 (near former storage room that is now an office) multiple cables and data wires above the ceiling are supported by conduit and arm-a-flex and are not supported in accordance with NFPA 70.

4) G-250 Bio-Hazard Holding Room: access to switchgear or electrical panels in this area is blocked by carts. A 3'-0" clear space in front of the panels is not maintained in accordance with NFPA 70..

Failure to maintain and identify devices and equipment in accordance with NFPA 70 could result: in failure of devices and systems, delayed response by staff or fire personnel and/or fires in devices that are not installed in accordance with NFPA 70.

.


17659


Based on random observation during the survey walk-through not all portions of the building systems are installed in accordance with NFPA 70 (1999).

Findings include:

1. Rooftop mechanical equipment does not have a GFCI receptacle within 25' of equipment as required by NFPA-70, Section 210-63.

2. Duplex receptacles served by emergency power in patient rooms and several critical care areas are not color coded as required by NFPA-70, Section 517-33(c).

3. Two of the three operating rooms were not equipped with battery operated emergency lighting as required by NFPA-99, Section 3-3.2.1.2(a)5e.

4. Normal power receptacles were not provided in C-section rooms, operating rooms, emergency rooms G-184 and G-185, and ICU rooms as required by NFPA-70, Section 517-19, and NFPA-99, Section 3-3.2.1.2(a)1. In the event of a transfer switch failure upon return to normal power, the operating rooms could be left with no power.

Evidence includes:

A) The provider lacks documentation of monthly testing of fire fighter service on all elevators in accordance with 9.4.6. of NFPA 101 and ASME/ANSI A17.3.

B) Documentation for annual testing of automatic elevator recall functions, for all elevators in accordance with ASME/ANSI A17.3, that includes the designated primary floor of recall and alternate floor of recall) was not available on site.

Failure to test and maintain elevators could result in failure of elevator functions in an emergency.

.


17659


Based on random observation during the survey walk-through portions of the elevator control system are not installed in accordance with ASME A17.1.

Findings include:

1. The surveyor did not find that the hydraulic elevator machine rooms were equipped with shunt trip devices to meet the requirements of ASME A17.1-102.2.c.3

2. The surveyor did not find that the disconnect for the emergency lighting and controls for the hydraulic elevators were properly labeled in accordance with NFPA-70, Section 620-53.

Failure to install and maintain required devices and systems for elevators could result in failure.

.

Evidence includes:

A) Based on observation and personnel interview on 9/20/11, the surveyor finds that the 1st Floor Main Lobby is not staff 24/7. It is also locked at night (see K038). This lobby is part of a required means of egress from the hospital (and is a primary required exit access corridor for much of the 1st Floor). The ceiling of this lobby has several levels. Smoke detection in accordance with 19.3.6.1 is not provided throughout this lobby, with smoke detection installed and spaced to protect the entire space in accordance with NFPA 72 and 19.3.6.1 of NFPA 101.

B) Based on observation and personnel interview on 9/20/11, the 1st Floor Patient Registration area (near the 1st Floor Lobby) has multiple spaces, all of which are open to the exit access corridor. The area is not staff at night. Although some smoke detection is provided, smoke detection is not installed and spaced to protect the entire space in accordance with NFPA 72 and 19.3.6.1 of NFPA 101.

C) Based on observation and personnel interview on 9/21/11, the surveyor finds that the Ground Floor Nurse's Station in the Outpatient Unit in the southwest portion of the building is open to multiple exit access corridors. The Nurse's Station is not staff at night. Smoke detection is provided in accordance with 19.3.6.1 of NFPA 101, exception # 1.

Failure to separate or protect spaces that are open to exit access corridors could allow fire or smoke to spread into corridors that are needed for patient movement or evacuation.

.


20224


Based on random observation during the survey walk through on the morning of 9/21/2011, the surveyor accompanied by the Director of Facilities finds that use areas are not separated from exit access corridors to comply with 19-3.6.1. This condition may expose patients, staff and visitors to a fire emergency within the exit access corridor and impede movement to an exit discharge.

Findings include:

A). Ground floor MRI area (not a suite) Patient care areas, which are designated holding bays, are not separated from exit access corridors. This condition is not permitted by any of the exceptions for 19.3.6.1.


B). Ground floor Ultrasound area (not a suite) patient waiting area which is not supervised after the day shift, is open to exit access corridors which does not comply with 19.3.6.1.(c) due to the lack of smoke detection.

Findings include

A) From random observation and personnel interview on 9/21/11, the surveyor finds that there is a Ground Floor Nurse's Station for the Endoscopy and/or outpatient programs in this southwest portion of the building. The Nurse's Station is not staffed at night and the unit is closed at night. However, the Nurse's Station has a sliding pass-through window that opens to an exit access corridor. The opening does not comply with 19.3.6.5. The surveyor finds that there is a fire shutter above the opening. The provider indicates that they close this shutter at night.

Based upon personnel interview, the surveyor finds that this fire shutter has not been observed or tested to close up activation of the fire alarm system, activation of the sprinkler system and activation of the existing smoke detector located within five feet of the opening in the Nurse's Station.

Further, the provider lacks written procedures that require this shutter to be closed manually during any fire event or fire drill. The provider's staff does not close the shutter during fire drills and the surveyor notes that a special tool (rod with a hook) is required to close the shutter manually.

Failure to close all opening in accordance with the written fire plan will allow smoke and fire to spread unchecked in the exit access corridor.

.

Evidence includes:

A) Based upon personnel interview and random observation during all three days of the survey, the surveyors find that vertical openings are not enclosure in accordance 19.3.1.1 and NFPA 90A:

1) The 2nd, 3rd and 4th Floor patient rooms have bathrooms that are back to back. The plumbing wall between each pair of bathrooms contains an exhaust duct that is continuous, vertically, from the 2nd Floor ceiling to the roof mounted exhaust fan. Each bathroom exhaust duct communicates to the 2nd, 3rd and 4th Floors, and penetrates two fire rated floor assemblies.

a) Each duct is not enclosed in a fire rated
shaft enclosure in accordance with
19.3.1.1 and NFPA 90A

b) Each exhaust duct lacks fire dampers
where the ducts branch out of a shaft at
each floor (above the ceiling).

c) Fire dampers have been installed at the
floor of each exhaust duct below the
plane of the 3rd Floor slab and th 4th
Floor slab. This installation does not
comply with NFPA 90A but was done in
conjunction with an FSES in 2007. The
installation does not comply with
current CMS policies which do not
allow an FSES for this condition.

d) The duct in each pair of bathrooms is
installed directly against the corridor
wall with only one layer of drywall
between the duct and the corridor. The
drywall is not secured at the top of this
wall and at the bottom of the wall at the
floor and the wall is not fire rated (as
part of a shaft enclosure).

2) The surveyors find from random observation and review of plans, that there are concrete block shaft enclosures at the west side of the West stair and at the east side of the East Stair on the 2nd, 3rd and 4th Floors. Duct penetrations through the floor and/or into these shaft enclosures lack fire dampers in accordance with NFPA 90A. Access to investigate this condition was limited by ceiling conditions and/or due to semi-sterile envirnonments with no access on some floors.

3) Bathroom at Room 2-246: A new fire damper has been installed in this bathroom. The penetration and fire damper appears to be caulked into the fire rated shaft enclosure and the fire damper is not installed in the plane of the barrier in accordance with NFPA 90A and/or a U L Tested damper installation detail.

4) There is an abandoned kitchen exhaust duct above the 1st Floor ceiling that penetrates the shaft adjacent to the West Stair (above the ceiling of Room 1-196). The duct no longer serves as a kitchen exhaust duct. The duct lacks a fire damper where it penetrates the fire rated shaft enclosure in accordance with NFPA 90A. Alternately, the duct has not been terminated before it penetrates the shaft and the shaft has not been repaired to maintain a two hour fire rated enclosure.

a. The surveyor finds that there is very
limited access above the ceiling for three
side of the above shaft. The surveyor
notes that in addition to the above duct,
there is also a pipe penetration into the
southeast side of the shaft with a large
void, above the ceiling.
Shaft integrity of three sides of this shaft
should be confirmed above the ceiling.

Failure to construct shaft enclosures in accordance with NFPA 90A and NFPA 101 and failure to install and maintain fire dampers could allow fire to spread from floor to floor and throughout patient areas. See also K067.

.


20224


Based on random observation during the survey walk through on the afternoon of 9/20/2011, the surveyor accompanied by the Director of Facilities finds that vertical openings are not enclosed comply with 8.2.5.3. Unenclosed shafts may affect patient care areas on several floors and smoke compartments, preventing the safe movement of patients, visitors and staff during a fire emergency.

Finding as follows:

A). Shafts are open to the ceiling cavity's of adjacent spaces which is not permitted by NFPA 90A 3-3.2. These shafts extend up for an unknown height. These rooms constitute part of the shaft which does not comply with NFPA 101 8.2.5.3. Example locations observed:

1. Ground floor room G-193 Lab Waiting room, above the center of the room, close to the South wall.

2. Ground floor mechanical room G-169. Above the mechanical space approximately 25 feet in from the corridor entry doors.

3. 2nd floor, corridor # C-22 adjacent to Stair # 3 and to Cardinal Sleep Lab, several bathroom exhaust ducts extend up to the floor(s) above within a shaft that is open to this corridor.

B). On the morning of 09/19/2011, duct penetrations through the walls of 2 hour fire rated ventilation shafts were observed which lack fire dampers to comply with 8.2.3.2.4.1. and NFPA 90A 1999 3-3.4.1. Locations observed include:

1. 3rd floor, east compartment, shaft adjacent to unmanned nurse station.

2. 3rd floor, visitor's lobby # 344, shaft adjacent to toilet #310A

3. 4th floor, east compartment, Pharmacy shaft adjacent to West Stair #3

Based on random observation on the morning of 09/20/2011during the survey walk through, the surveyor accompanied by the Facility Director finds that not all stair shafts are constructed or maintained as fire resistive assemblies to comply with 8.2.5.4.

Findings include:

A. Stair enclosures were observed which are not separated from adjacent areas and do not provide an enclosed protected means of egress to an exit discharge. Location observed:

1. Required exit stair located near the main entry is an unenclosed stair on both levels. This condition does not comply with 39.3.1.1(3) and 8.2.5.8 for a vertical enclosure with a minumum 1-hour fire rating as a required component for a means of egress.

2. Required exit stair located within the 2010 addition is open to adjacent spaces due to a duct penetration to a wall louver on the upper floor which does not appear to have a damper.

3. Required exit stair located within the 2010 addition is open to adjacent spaces due to the entry door on the lower level which does not comply with 7.2.1 and 7.2.1.8 for the requirements of an exit door.

4. Exit stair located within the original part of the building (not sprinkler protected) does not provide the proper means of separation due to holes in the wall at the upper landing.




.

Findings include

A) From random observation, the surveyor finds that fire doors and/or smoke doors are not installed to close automatically from activation of the fire alarm and sprinkler system in accordance with 19.2.2.2.6, 7.2.1.8 and NFPA 72:

1) The 1st Floor Kitchen has been evaluated as a hazardous area. The door between the Kitchen and the Servery is therefore required to be smoke tight, self closing and positive latching. The door is held open by a device that does not comply with 19.2.2.2.6 (it lacks a magnetic hold open device with smoke detection within five feet of the door).

2) The 1st Floor Medical Records area is a hazardous area. One or more doors to this space have hold open devices that do not comply with 7.2.1.8.

3) Ground Floor Soiled Linen Holding Room G-281. The corridor door is held open with an unapproved hold open device.

Failure to close fire doors in accordance with NFPA 101 could allow the spread of fire and smoke from designated hazardous areas to other areas of the building.

.

Evidence includes:

A) Based upon random observation, the surveyor finds that hazardous areas are not enclosed in accordance with 19.3.2.1 or 18.3.2.1 (where applicable). The surveyor notes that the building is sprinklered and that existing hazardous areas only have to comply as a smoke tight enclosures with smoke tight, self closing doors.

1) 3 West Patient Room 325 has been converted into a storage room and lacks one hour fire rated walls to the deck above and a 3/4 hour fire rated corridor door with listed self closing and positive latching hardware in accordance with 18.3.2.1.

2) 2nd Floor C-Section Unit: The door to the Clean Supply Room does not close to latch.

3) The 1st Floor Kitchen is used for storage of combustibles and has several storage rooms with louvered doors. The Kitchen has been evaluated as a hazardous area. See also K021.

a) The Kitchen door to the tray return
alcove is self closing and positive
latching. It has a manual slide bolt on it
that is not permitted as a latching device
or locking device and the bolt is used to
keep the door from closing to a latched
condition.

b) The designated smoke door/corridor
door near the "dietech's" desk does not
close to latch.

4) Ground Floor General Storage Room - the doors near G-301 do not close to latch.

5) The pair of doors to General Stores has an inactive leaf that lacks positive latching hardware (it has manual flush bolts that were not engaged) and it has a hold open device that does not comply with 7.2.1.8. (it is not designed to release the door from activation of the fire alarm in accordance with 19.2.2.2.6.)

6) The Ground Floor Clean Linen Receiving/sorting Room has a pair of doors with an inactive leaf that has manual flush bolts instead of positive latching hardware.

7) G-250 Bio-Hazard Holding Room, The pair of corridor doors to this space have been damaged at the bottom of the doors, beyond the conditions where repair is possible. The doors no longer comply as fire doors in accordance with NFPA 80.

Failure to provide and maintain separation between hazardous areas and all other areas could result in spread of fire and smoke throughout the building.

.


20224


Based on random observation during the survey walk-through while accompanied by the Director of Facilities the surveyor finds that not all hazardous areas are separated from the remainder of the building to comply with 19.3.2.1.

Findings include:

A). The lack of separation between a hazardous area and an exit access corridor may prevent the use of the corridor by staff, patients and visitors for safe egress to the nearest discharge. Locations and conditions observed include:

1. On the morning of 09/20/2011,Surgery Suite- Center Core located between all O.R.'s. This room which is greater than 100 square feet, is considered a hazardous area due to the amount of combustible storage. This room does not maintain a smoke tight separation from the corridor and adjacent rooms due to the following:

a. The doors do not appear to provide a
physical condition equivalent to a 20
minute smoke tight door installation due
to the following:

i. Doors display decay across the
bottom and at the latch side.

ii. Finish is delaminated in areas and
the interior core may be viewed.

iii. Several of these doors appear to be
out of plumb with the door frames
which does not maintain a resistance
to smoke.

2. On the morning of 09/22/2011, Ground floor, Mechanical Room G-169. The inactive leaf of a pair of egress doors no longer maintains the fire rating of the door due to a large rectangular hole in the latch side of this door. This condition compromises the protection of the corridor from the room.

3. On the morning of 09/22/2011, Corridor doors were observed which are not self closing to comply with 19.3.2.1 and therefore, do not maintain the separation between a designated hazardous area and an exit access corridor. Locations observed:

a. First floor, Frozen Section room #1-181.

b. Clean Utility room #1-133.

4. On the morning of 09/21/2011, Ground floor maintenance storage/paint shop #G-170 (designated on the Life Safety plan with a 2-hour enclosure) lacks separation from the exit access corridor due to a large duct penetration which lacks a fire damper installation.

B). The lack of separation between a hazardous area and an occupied room does not comply with 19.3.2.1, and 8.4.1 and does not maintain a safe protected environment for staff, patients and visitors. Locations and conditions observed include:

1. On the afternoon of 09/20/2011, Ground floor, Lab Waiting room # G-193 is not separated from both a shaft above (refer to K-tag 20) and the adjacent two storage rooms due to the lack of a wall to the underside of the floor above.


C). On the afternoon of 09/20/2011, a room which are not constructed as hazardous area is being used for storage of combustible materials which does not comply with 19.3.2.1, and 8.4.1. This condition may affect patients, staff and visitors in adjacent spaces during a fire emergency in the 3rd floor East smoke compartment. Location and condition observed:

1. 3rd floor room # 334 (actual room number) exit access corridor door is not self closing.

2. 3rd floor room # 334 (actual room number) vent louvers are located in the wall above the exit access door which do not appear to maintain the separation of a hazardous area from an exit access corridor.

.

Findings include:

A) Based upon random observation the surveyor finds that required exit stairs are not maintained as fire rated enclosures in accordance with 19.3.1.1. The fire door from the 1st Floor Physical Therapy area to the East Exit Passageway does not always close to latch.

Failure to maintain opening protection in fire rated shaft enclosures could allow fire and smoke to spread from floor to floor.

.


20224


Based on random observation during the survey walk-through, the surveyor accompanied by the Director of Facilities finds that not all exit stair shafts or other exit enclosures are constructed or maintained as fire resistive assemblies to comply with 19.3.1.1. These conditions may affect any patients, staff and visitors on the 2nd through 4th floors as well as those in the surgery area. Exit egress paths may become compromised under a fire condition.

Findings include:

A). On the afternoon of 09/20/2011 exit enclosures were observed in which utilities and materials unrelated to the enclosure have been installed. This condition does not comply with 7.1.3.2.1(e). Location and condition observed:

1. Exit Passageway for West Exit Stair( #1-on life safety floor plans) has a suspended acoustical tile ceiling. Above the ceiling are multiple pipe runs, a duct run, and multiple conduits and data cables. The installations of the dual pipe runs, data cables and some conduit do not appear to be original installations within the exit passageway.

2. Exit Passageway for East Exit Stair (#1) contains material not related to the exit passageway but serves only the adjacent surgery department. A wall mounted coat hook rack and container of scrub items was observed within the space.

3. Center Exit Stair (#2) on the 4th floor contains 3 electrical conduits which serve the master clock system and the exterior sign.


B). On the morning of 09/19/2011, exit stairs were observed in which the fire rated separation of the stair is not provided due to an exit door that does not maintain the fire rating of the stair enclosure. Location and condition observed:

1. Center Stair (# 2) Fourth floor, stair entry door appears warped on the latch side of the door. The top of the door when closed shows a 1/2 inch gap between the face of the door and the stop on the frame which does not comply with NFPA 80A.


C). On the afternoon of 09/19/2011 entry to a normally unoccupied room was observed within the stair enclosure that does not comply with 7.1.3.2.1(d). Location observed:

1. 4th Floor Center Stair (#2), there is a wall with an entry door used as a separation between the stair and unoccupied room for electronic equipment used for the master clock and exterior signs. The depth of the wall construction does not appear to be sufficient in order to qualify as a 2-hour fire rated separation.


D). On the afternoon of 09/19/2011 the 4th floor Center exit stair (#2) was observed to contains a hole through the corridor wall above the entry door which does not maintain the fire resistance of the stair enclosure.




.

Evidence includes:

A) Uncorrected deficiencies that were transferred from the Complaint Survey of 06/22/11:

Based upon observation the surveyor finds that the facility has locked doors in identified paths of egress that do not comply with 7.2.1:

1) The 3rd Floor center portion of the building is not a psychiatric area and allows free access via elevators to this portion of the building. There are multiple paths of egress from the center portion of the 3rd Floor. The exit paths to the west are directed with illuminated exit signs into a locked psychiatric unit.

a) The south corridor has an illuminated
exit sign above a door with a sign that
indicates "Do Not Enter" The two signs
conflict.

b) The north corridor has a door with an
illuminated exit sign. The door has
electronic locking hardware that does
not allow release within 15 seconds in
accordance with the provisions of
7.2.1.6.

c) Modified 09/19/11: The above pair of
doors in both corridors has an exit
sign directing exit travel west to east
through this pair of opposite swinging
doors. The door that swings to the
east lacks any kind of hardware that
can be opened from the west side of the
door (it has concealed manual
flush bolts that can only be operated by
opening the other leaf ).

The doors do not comply with 7.2.1.5
and 7.2.1.6.

Exit signs identify a path that is not available to everyone. The confusing identification of exit paths from this floor could cause a delay of evacuation during a fire particularly for any staff, patients or visitor that are not intimately familiar with this floor.

B) 09/21/11: Based upon random observation, the surveyor finds that the facility has multiple locked doors in identified paths of egress that do not comply with 7.2.1 of NFPA 101:

1) 3rd Floor (see also item "A 1"): The center portion of the 3rd Floor and the south west corridor are accessible by the public via elevators. Also, this portion of the building has offices and it is not a designated locked psychiatric area.

The door to the West Exit Stair is a required exit for the public accessible corridor and is identified with an exit sign. The stair door has a locking device that does not comply with 7.2.1.6.1

a) The stair door lacks signage indicating
"Push until alarm sounds - Door can be
opened in 15 seconds" [7.2.1.6.1. (d)].

b) According to the provider, the door does
not release in 15 seconds.

c) The hardware on the door (a lever
handle latchset) requires two operations
and special knowledge to open the door
(turn handle in push on door) This
hardware does not comply with 7.2.1.6
does not comply with 7.2.1.5.

d) The door has a keyed switch and a
keypad in the stair that allows release of
the lock from the stair side and the
corridor side of the door. Once the
keyed switch has been used, the door
relocks and does not release again until a
code is entered from the keypad.

While the keyed switch and keypad may
be permitted for convenience functions,
the operation of the hardware and
locking functions fail to comply with
7.2.1.5 and 7.2.1.6.

2) 2nd Floor:

a) The 2nd Floor Level 1/Level II Nursery
has two doors. Both doors have magnetic
locking devices that require keypad entry
to leave the room. These locking
devices do not comply with 7.2.1.

b) The 2nd Floor has a pair of doors in the
north corridor and in the south corridor
roughly in the center of the building.
Each pair of doors swing west to east (in
one direction only). This complies with
19.3.7.6 of existing smoke doors but
does not comply with 18.3.7.5 for new
smoke doors.

The doors have exit signs on both sides
of the doors indicating the exit travel in
both directions is required. The doors
also have magnetic locking devices that
have delayed release in accordance with
7.2.1.6.1 in one direction only. The
pairs of doors of doors do not comply
with 7.2.1.6 because opposite swinging
doors are not provided and 7.2.1.6
cannot be used for doors that must be
pulled open.

The doors have lever handled latchsets.
This hardware is not permitted in
conjunction with delayed egress (it
requires two motions to release the
locking devices). The latchset and
hardware functions do not comply with
7.2.1.5 and 7.2.1.6.

c) The stair door to the West Exit Stair on
the 2nd Floor has a locking device that
does not comply with 7.2.1.6.1 It says
that it will release in 15 seconds but it
does not (based on testing on 9/20/11).

3) 1st Floor

a) The Cafeteria has a door to an outside
patio area. The door back into the
building is locked at night and requires
operation of a push paddle to release the
lock. This arrangement does not comply
with 7.2.1.5 or 7.2.1.6. The only other
path off of the patio is a partially paved
path to a gate in a fence. The path is not
paved all the way to the gate and there is
a bush that blocks access to the gate.

b) The Main Entry Lobby foyer has two
pairs of sliding doors with "break and
swing" functions. These door are part of
the required means of egress for the
Hospital. One pair of doors has a
magnetic locking device that is locked
at night. Signs on the inside and outside
indicate that the doors are locked at
night. The locking devices do not
comply with 7.2.1.5 and 7.2.1.6.

c) The Cafeteria Serving area has a security
shutter and a single swinging door as a
path out of this space. The security
shutter is closed after hours. The single
door has a double cylinder dead bolt lock
that requires a key or special knowledge
to get out of the serving area. This lock
does not comply with 7.2.1.5.

4) Ground Floor Infusion/Endoscopy/ED Registration/EKG/etc. This has been evaluated as a mixture of inpatient and outpatient treatment. Three of four exit paths do not comply.

a) The corridor near G-270 has a door to the
north with an exit sign and a magnetic
locking device. This door is locked at
night and does not comply with 7.2.1.6.
Further, the surveyor finds that this path
to the north leads to the same exit path
as the exit path from Corridor G-111 and
as such does not constitute a second
remote path of egress. It is not clear
how this exit path can serve as an
additional exit path without another
complying exit path that can be
considered to be remote. see below

b) There is a pair of auto-open, opposite
swinging doors near the G-301. These
doors have exit signs on both sides of the
doors and magnetic locking devices on
both sides of the doors. The provider
indicates that the doors are locked at
night. The locking devices do not
comply with 7.2.1.5 or 7.2.1.6. With this
door locked, Corridor G-286 is a dead
end corridor in excess of 50' and G-287
is a dead end more than 30' in length

c) There is a single door to the north, next
to the OP Nurses Station, with an exit
sign. This door directs that exit path into
a waiting room. The exit path from the
corridors is not directed into an exit
access corridor or to another corridor
without passing through an intervening
space and the door does not swing in the
direction of exit travel.

C) 9/21/11: Based on random observation, the surveyor finds that a safe path to a public way is not provided and maintained.

1) The East Exit Passageway from the East Stair discharges to an exterior sidewalk. There is a curb (change in elevation) in this path near the discharge door constitutes a tripping hazard in a means of egress and does not comply with 7.1.6.2.

2) The West Exit Passageway from the West Stair discharges to an exterior sidewalk. Several depressed concrete sidewalk panels and a drop-off at the edge of the walk, near the exterior stair leading down, constitute tripping hazards in a means of egress that do not comply with 7.1.6.

3) The exit stair from the 1st Floor to the Ground Floor discharges into the Ground Floor corridor (in accordance with 7.7.2). However, the exit path is then directed through the Loading Dock to the east. The Loading Dock has unprotected drop offs, in the path of egress at the dock and at the lift. Further the corridor just outside the stair is used as a holding area for received materials. This use of the corridor does not comply with 19.3.2.1 or 19.3.6.1.

.

Findings include:

A. The surveyors find from personnel interview and document review on 9/21/11, that the facility has emergency lighting with battery back-up in multiple locations throughout the building, including multiple exit stairs. The surveyors find that the provider has documentation that demonstrates monthly testing but finds that the provider lacks documentation of annual testing in accordance with 7.9.3. The surveyors also find that replacement of the batteries every year or every other year is not equivalent to the annual testing that is required.

Failure to maintain these systems could result in loss of means of egress lighting for both patients and staff.

.

Findings include

A) Based upon random observation, the surveyor finds that illuminated exit signs are not provided in accordance with 19.2.10.1: The Ground Floor Emergency Department Registration area has a pair of auto opening, opposite swinging doors. An exit sign is not provided above these doors for the exit path running east to west.

B) The 2nd Floor C-section Suite lacks illuminated exit signs identifying the path out of this unit in accordance with 7.10.

Failure to provide proper identification of exit paths could result in confusion and delay in exiting during an emergency.

.

Evidence includes:

A) Based on random observation during testing of the fire alarm system on the afternoon of 09/20/11, the surveyors find that the fire alarm system is not installed and maintained in accordance with NFPA 72 and NFPA 101.

The surveyors find that the fire alarm system is not audible throughout all portions of the building and particularly in all personnel work areas. The fire alarm system does not comply with the 5db/10db/15db audibility requirements of NFPA 72 -1999 (Sections 4-3, 4-3.2, 4-3.3 and 4-3.4). No audible devices are provided in many locations, most of these locations do not comply with the exceptions where visible devices (fire alarm strobes) can take the place of audible devices. Locations include but are not limited to:

4th Floor Pharmacy

Room 427

Multiple patient rooms and staff work areas
on Floors 2, 3 and 4

1st Floor:

Administrative Offices

Kitchen, Servery, and Dining Rooms

Main Lobby, Gift Shop and Chapel

The fire alarm system is barely audible
throughout the 1st Floor Registration
area

Based upon the above and the K051 citation on other floors, the surveyors find that staff may be responding to manually announced overhead pages during activation of the fire alarm system. Staff does not respond to the activation of the fire alarm system in accordance with their written plan because they cannot hear the fire alarm system. This results in a delayed response. If staff cannot hear the fire alarm system or see it activate from strobes (where such is permitted in NFPA 72), the staff response to patient safety will be delayed and could result in limited or no response if the switchboard operate misinterprets the information provided announces the wrong location.

.


20224


Based on random observation during the survey walk-through the surveyor accompanied by the Director of Facilities finds that not all portions of the building fire alarm system are installed to comply with 19.3.4. This condition may prevent emergency egress from the location of fire origin to an adjacent compartment. This condition may affect patients, staff and visitors on the second floor East smoke compartment.

Findings include:

A). On the afternoon of 9/20/11 during testing of the fire alarm system, the visual and audible notification devices did not operate in a manner to give warning in accordance with NFPA 72 4-4. Locations and conditions include:

1. Second floor C-Section suite, surveyor was unable to locate a strobe device and did not hear any audible devices anywhere within this suite.

2. Second floor Nursery, surveyor was unable to hear an audible device anywhere including the work room. The strobe device (located in the North side corridor) could not be viewed except from one location - the South west corner of nursery adjacent to the work room.

3. Second floor LDRs, surveyor was unable to hear an audible device within the area.

4. First floor Surgery on call room lacks a visual notification device.

A). Documentation to indicate the annual testing and maintenance of the building fire alarm and detection system in accordance with NFPA 101, 9.6 and NFPA 72, 7-3 was requested on the afternoon of September 21, 2011. The Surveyor requested documentation on the Radiolody Unit and the building, however, the surveyor was informed that there was no documentation available.


B). Documentation to indicate the conducting of fire drills to comply with 39.7.1 and 4.7 was requested. The Surveyor requested documentation on the Radiolody Unit and the building, however, the surveyor was informed that there was no documentation available.


.

Evidence includes:

A) This uncorrected deficiency was transferred from the Complaint Survey of 06/22/11:

Sprinkler systems are not installed and maintained in accordance with NFPA 25: There is a vestibule between the Emergency Room and the Ambulance Bay. The vestibule is sprinklered and has lay-in ceiling tiles. The ceiling tiles are displaced by wind or air pressure when a door is opened. This creates multiple voids in the ceiling and compromises the sprinkler protection in this space. The ceiling lacks adequate hold-down clips to prevent displacement or the room lacks a ceiling that cannot be moved by wind or air pressure.

B) 9/21/11: From random observation throughout the building, the surveyors find that the sprinkler system is installed with metal pipe in some areas and plastic pipe in other areas. Arm-over and/or end of branch bracing is not provided for sprinkler heads on all five floors throughout the building in accordance with Section 6-2.3.3 of NFPA 13 - 1999.

Note: This deficiency does not occur in everywhere because sidewall heads are used in many locations. Examples of where arm-over bracing for uplift is not provided include but is not nearly limited to 3rd Floor Group Therapy Room and the Ground Floor E R Registration area.

C) Based upon observation and personnel interview, the surveyors find that inspector's test valve installed on the 2nd, 3rd and 4th Floors are not permanently piped to a drain or to the outside in accordance with NFPA 13.

The provider indicates that they hook up hoses in order to test these floors.

D) The 1st Floor Kitchen has sprinkler heads that are spaced as much as 18' or more apart. The provider lacks documentation that indicate that these sprinkler heads are extended throw heads. If regular heads are installed, they are installed too far apart to comply with NFPA 13.

Failure to install and maintain the sprinkler system could result in failure of the sprinkler system and uncontrolled fires. The exceptions used in this building for sprinkler protection do not apply if the sprinkler system is not installed in accordance with NFPA 13. (Example: smoke dampers would be required at duct penetrations through smoke barriers and the Center Exit Stair cannot comply with 76.7.2 without full sprinkler protection).

.

A). Documentation to indicate the inspection and testing of the sprinkler system to comply with 39.7.1 NFPA 13 was requested. The Surveyor requested documentation on the Radiolody Unit and the building, however, the surveyor was informed that there was no documentation available.

By direct observation on the afternoon of 9/19/11 the surveyor finds:
Monthly inspections of the kitchen hood suppression systems are not conducted to comply with NFPA 17, 1998, 9-2. Failure to inspect that all components are functioning and not impaired could contribute to failure of the suppression system during a fire emergency and affect the safety of kitchen staff.

Evidence includes:

A. The surveyors find from document review and personnel interview that fire dampers are not maintained in accordance with NFPA 90A and CMS Requirements (maintenance of fire dampers and smoke dampers every six years):

1. The provider has documentation with a list fire dampers identified and several dates in 2009. The documentation does not clearly indicate that the fire dampers identified were inspected and maintained in accordance with NFPA 90A (including inspection, cleaning, removal of fusible link, exercise of damper, repair as necessary and replacement of fusible link where necessary). The documentation does not indicate what as done in 2009.

2. All fire dampers that are listed on the above referenced documentation were not tested in 2009. The provider lacks documentation that identifies when all fire dampers were tested since September of 2005.

3. Multiple fire dampers are missing from the documentation. The surveyor observed two fire dampers above the ceiling on 4 West (Fire Damper FD4.7 and FD4.8). Access to these fire damper could not be provided due to conduit installed directly under the access panels. These fire dampers were not identified on the above documentation.

Failure to test and maintain fire dampers will result in failure of fire dampers during non-emergency conditions which will disrupt air distribution and failure of fire dampers in a fire emergency which could allow migration of fire and smoke to spread throughout patient areas and to multiple patient floors.

B) Based on random observation the surveyor finds that HVAC systems are not maintained in accordance with ASHRAE Guidelines (as referenced by NFPA 90AZ).

3rd Floor Northwest: This Psychiatric area has two shower rooms off of the corridor in one shower room the exhaust ventilation louver in the ceiling was totally blocked by dist and lint. In the other shower room, the louver was about 50% blocked.

Failure to clean and maintain the ventilation system is wet areas will allow moisture laden air to remain in the space and contribute to any mold problems in the building.

.

Evidence includes:

A) The surveyor observes that a large commercial gas fire grill has been installed on a patio just outside of the 1st Floor Dining Room. The grills is installed against one wall of the Hospital and it is less than 15' from an unprotected glass wall between the patio and the Main Lobby.

A kitchen hood suppression system is not installed in accordance with NFPA 17A. This condition is not mitigated by horizontal distance from the building. The surveyor also notes that there is a fuel shut off that cannot be reached under the grill in an emergency and there is a fuel shut off in the Ground Floor Level, inside the building

Alternately, the provider lacks written procedures that include the following:

1. The fuel shut off will remain turned off at the Lower Level and may be turned on only when the grill is in use and in constant attendance. The status of this fuel shut off is to be checked frequently and documented.

2. There is a written procedure at shut the fuel off in an emergency

3. Any time the grill is in use, Type K fire extinguishers are maintained in the immediate area. The written procedures need to clearly indicate that using a fire extinguisher without shut the fuel off will not likely be effective.

Any fire in this grill if not controlled or suppressed could easily spread to the building.

.

Based on random observation during the survey walk-through, the surveyor accompanied by the Director of Facilities finds that not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency to comply with 19.2.3.3. This condition may affect patients staff and visitors on the Ground floor East compartment and the 3rd floor East compartment.

Findings include:

A. Means of egress corridors are not maintained free of obstructions to comply with 7.1.10. Locations/conditions observed include:

1. On the afternoon of 09/20/2011 Ground floor exit access corridor G-157 is utilized for storage of equipment/wheelchairs. Although an alcove space is provided, the amount of equipment stationed open to the corridors exceeds the available space of the alcoves, and the corridor is obstructed.

2. On the afternoon of 09/20/2011, Ground floor exit access corridor G-103 near entry to Stair is utilized for storage of cardboard boxes piled up behind a privacy curtain. Although an alcove space is provided, the amount of equipment stationed open to the corridors exceeds the available space of the alcoves. Use of this space does not comply with 19.3.2.1 and 19.3.6.1.

3. On the morning of 09/19/2011, Third floor exit access corridor # 342 adjacent to the pair of cross corridor doors of the smoke barrier - a suggestion box attached to the wall extends more than 7" into the required width of the corridor.

Findings include

A) Ground Floor Loading Dock Area - there is a dedicated Nitrous Oxide Manifold Room and Storage Room that is accessed from the exterior Loading Dock. On 9/20/11 an acetylene tank was found in this room. Immediate removal was required. The provider lacks adequate means to prevent re-occurrence.

Storage of flammable gasses with oxidizing agents does not comply with NFPA 99 and constitutes a significant fire and explosion hazard.

B) The 2nd Floor C-section Unit has a Recovery Room with piped in medical gas systems. The provider was not able to locate the medical gas alarm panel for this space, in a constantly attended location in accordance with NFPA 99-1999.

Failure to install and maintained medical gas systems in accordance with referenced standard could result in failure of those systems, while in use or needed for critical patients.

.

A. Based on random observation the survey walk-through the generator equipment does not meet all requirements of NFPA-110.

Findings include:

1. Switchboard Room G-309 is the 24 hour monitoring location for the generator annunciator panels. The remote annunciator for one of the emergency generator was missing and did not meet the requirements of NFPA-99, Section 3-4.1.1.15 and NFPA-110, Section 3-5.5.2(d).

2. Two of the four generators did not have remote shut down switches to comply with NFPA-110, Section 3-5.5.6.

3. Battery pack lighting units to meet the requirements of NFPA-110, Section 5-3.1 were missing from the 750 KW and the 800 KW generating units .

These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised without the facility being aware that the emergency generators are not functioning properly.

.
Housekeeping/Sanitation: The facility failed to provide and maintain a safe and sanitary environment for staff and patients. The following are referenced as standards for this citation:

State and/or Federal Regulations for
Food Service and Sanitation

CMS 482.41 (a), 482. 41 (c)(2) and
48.41 (C)

A) Based on observation and interview the facility failed to maintain the floors of the General Storeroom in a clean sanitary condition and failed to prevent liquid waste discharge to the floor surface of the Medical Waste Storeroom.

Findings include the following:

1. On 9-20-11 at 11:30 a.m. unidentified liquid was pooling on the concrete floor beneath and adjacent to the Medical Waste Sterilizer in the Compactor Room (G282). Liquid waste was present on the floor covering approximately 50 square feet (10 by 5 feet). At this time the Sterilizer was in operation and was discharging liquid waste to the floor drain beneath the unit. Maintenance staff was present and stated that the source of the liquid was unknown.

2. On 9-20-11 at 11:40 a.m. accumulated paper items including medical supply wrappers, paper souffle cups, dust, and lint was present on the floor between and along the metal rails of the Rollable Storage System and floor/wall junctures adjacent to storage cabinets within the General Store Room (G303). Accumulations of debris was present beneath each of the Rollable Storage cabinets.

B. Based on observation and interview the facility failed to maintain food preparation equipment in a clean, sanitary condition between used so as to prevent conditions favorable for the growth of pathogens and potential subsequent foodborne illness. This has the potential to affect all 40 patients, visitors, and employees consuming food prepared by the kitchen.

Findings include the following:

1. On 9-20-11 at 2:00 p.m. the meat slicer, covered with plastic and designated as clean and ready to use, was soiled with greasy residues on the front and rear blade surfaces. Small fragments of food and congealed fat was present on the recessed hole of the slicing blade and other recesses and crevices of the meat slicing platform and slicing armature. Food fragments were present in other hard to reach food contact surfaces and areas of the slicer. The Food Service Supervisor stated at this time that the slicer is used regularly to process pre-cooked, ready to eat meats including roast beef, ham, and turkey.

2. On 9-20-11 at 2:10 p.m. one food processing blender designated as clean and ready to use, had clear liquid remaining in it from dishwashing. The blender pitcher was covered tightly with a lid. Upon disassembly of the pitcher and blade assembly remnants of food matter was present on the food contact surfaces of the blade, blade assembly, and threaded neck of the pitcher.

Similar conditions were present on food contact surfaces in one of the small covered food processor basins (liquid and moist food deposits present on blade assembly).

Dried food deposits were present on food contact surfaces inside of two small food processor basins and blade assemblies.

The Food Service Supervisor stated that these devices are used to prepare mechanically altered diets for 1 to 2 patients on a daily basis.

3. On 9-20-11 at 2:15 p.m. the large commercial table-mounted mixer, covered with plastic and designated as ready to use, had accumulations of dried food food present on its rotating spindle and upper splash area. Food deposits were also present on the upper armature and recessed areas of metal hardware. Dried food matter was also present inside of the attached metal mixing bowl. Food prepared in the mixer is subject to cross contamination from accumulated dried food that detaches from vibration of the mixer. The Food Service Supervisor stated that the mixer is seldom used and has not been used for approximately one year.









07113


A. Uncorrected deficiencies were transferred from the Complaint Survey of 06/22/11: The provider failed to provide and maintain a safe and sanitary environment for patients and staff.

4. The 1st Floor Kitchen and Cafeteria is not maintained in accordance with the Illinois Hospital Licensing Requirements and the State of Illinois Plumbing Code:

b. The only Janitor's Closet in Dietary
lacks a mop sink. The mop
sink in this space has been removed and
there is no dedicated mop sink for
Dietary.

c. The floor in Dietary is a wet location
that requires watertight joints and cove
bases. The cove bases are separated
from the walls in places and the cove
bases are cracked, chipped or missing
in multiple locations.

The above item was not investigate
on 9/21/11 to determine whether
corrections have been made

5. 06/21/11: Wall mounted toilets throughout the facility are not installed in accordance with the Plumbing Code and/or the manufacturer's requirements. The joint between the finish wall and the toilet is open and not sealed with a water resistant material. This allows moisture, cleaning fluids and debris to fall between the toilet and into the chase behind the toilet.

Modified 9/21/11: The surveyors observed that most bathrooms, dietary, and other areas identified in the compliant survey had been cleaned and visible evidence of housekeeping deficiencies, stains and possible surface mold was cleaned up. The condition of the joints between the toilets and the wall was not re-investigated. Based upon interviews of Hospital personnel and the onsite outside contractor's personnel, the surveyor finds that the Hospital believes that many of the hidden mold problems and some of the surface conditions were caused by the failure of the plumbing seal for the waste of the wall mounted toilets. These toilets are installed throughout the facility. Further, it is required, based on the information provided from thr facility, that corrective actions will be necessary.

C. New deficiencies based upon the 9/21/11 Survey:

Interim Life Safety Measures as an alternative to full compliance with NFPA 101 - 2000: Due to the severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

1. The provider failed to implement interim life safety measures for deficiencies cited under the survey dated 9/21/11.

E. (New deficiencies based upon 9/21/11 Survey): Based upon the conditions observed on 6/22/11 and observed on 9/21/11 and based upon personnel interview and document review, the surveyors find that mold has been found in the concealed spaces between bathrooms. Hospital personnel indicated that they expect to find this condition in most if not all bathrooms on all floors (see also Item "B 5" above).

1. On the morning of 9/19/20 and on the afternoon of 9/21/11, the Hospital provided access to two bathrooms on the 3rd Floor for rooms that were no longer used as patient rooms (Rooms 309A and 310A). The two back to back bathrooms have been partially demolished by an outside contractor (that was also present). The floor and ceiling finishes of the two bathrooms were removed. The sinks and toilets were removed. The wall finishes and wall (studs and drywall) between the two bathrooms were completely removed.. The Hospital's representative and the contractor were both interviewed on 9/19/11 and 9/21/11 with the following results:

a. The contractor indicated that the
demolition and removal was conducted
in accordance with the Hospital's rules
for projects, infection control and for
mold abatement. This included negative
ventilation of the project area and double
bagging of the demo materials being
removed.

b. The contractor indicated that no mold
was found under the floor finishes.

c. The contractor indicated that mold was
found on the inside portions of the
drywall as much as 12" above the floor.
The contractor also indicated that the
lower portion or drywall was soggy or
soft. No samples of this material were
save and no testing was conducted to
determine what type of mold was
present, whether it was active or inert,
and/or if the substances observed were
mold.

d. The contractor indicated that the stud
track at the floor was rusted away and
that the lower portion of the wall studs
were significantly deteriorated. Again,
none of this material was saved for
testing or later examination.

e. The Hospital's representative indicated
that the Hospital expects to find this
same condition in most of the bathrooms
in the facility.

From observation the surveyor also finds:

f. The plumbing wastes, including two
toilets were capped off with rags.

g. The sprinkler heads in each space were
not turned up to the deck when the
ceilings were removed; this condition
requires interim life safety measures.

The above findings support that findings from the complaint survey of 6/22/11, which concluded that there is mold in the bathrooms of the building on multiple patient floors. Based upon multiple interviews, the surveyors find that the Hospital expects to find mold and deteriorating wall conditions in bathrooms. The scope of this condition is expected throughout the building. The severity of this condition has not been determined; see below

2. The bathroom mirror in Room 416 was removed on the afternoon of 9/20/11, to allow viewing of the plumbing cavity behind the bathroom. This room is an example of a project that took place recently in which the 4th Floor bathrooms were renovated. In the bathroom of 416, the surveyors observed no mold. The surveyors observed that the drywall on both sides of the wall had been replaced from the floor to about four feet above the floor. The light gage steel wall studs were partially removed from the floor to about four feet above the floor and were replaced with new studs. However, the existing studs were cut off at roughly four feet above the floor and the new studs were not spliced into the existing studs and were not run from deck to deck. The drywall in the bathroom (5' x 8') on each side of the plumbing wall was is stiffened only by steel stud with a break in the middle of each wall.

The corridor wall has about 12" of drywall at the floor that is not supported by studs or a stud track. This portion of the corridor wall is also part of an unrated shaft that is also cited under K 020. This condition is typical of many of the 4th Floor bathrooms

3. The Hospital has indicated that some form of outside testing was conducted. The information about who did the testing, what testing was conducted, where the testing conducted, the results of the testing and the qualifications of the testing agency was not available. There is no evidence that indicates that the Hospital has engaged the services of an industrial hygienist, a mold or moisture abatement consultant and/or contractor that specializes in abatement.

4. The Hospital has adopted a management plan for investigation, containment and abatement of mold that is based upon OSHA and/or EPA references. This plan contains four levels of contamination with Level I being the lowest level and Level IV the highest. Level III and Level IV includes recommendations for consultation with an industrial hygienist, or environmental health and safe professionals.

a. The provider was not able to identify
which Level of contamination has been
found at their facility and how this was
determined. There is no evidence or
report that identifies that source(s) of
mold that may be found in the bathroom
plumbing walls.

b. A project architect was also present for
the survey on all three days. The project
architect has identified a project that is
proposed to repair bathrooms walls,
abate any mold or deteriorating
conditions, replace shaft enclosures and
replace bathroom toilets in every
bathroom in the facility.

The shaft correction in many bathrooms
(but not all) will necessitate demolition
and removal of bathroom walls. In
other bathrooms, demolition is proposed
to install new floor mounted toilets and
to abate deteriorated wall conditions.
There is no indication of what Level of
abatement is necessary for all portions of
this project, based upon the Hospital
policies.

The following conditions are cited on the Complaint Survey dated 6/22/11 under tag A 700 and are repeated herein. They support the findings above. No attempt was made to determine whether portions of the findings below have been corrected as of 9/21/11.

The informatoin below are based upon random observation, personnel interview and limited document review during the complaint survey of 6/22/11. The following citations are also based upon observations throughout the hospital by looking; at wall and floor finishes, above ceilings and using existing access panels to view concealed spaces. Rooms with patients were not inspected with the exception of one Room on the 4th Floor . The investigation was mostly confined to toilet and shower rooms on Floors 2, 3 and 4. Random inspections were conducted on the 1st Floor and Ground Floor. No destructive demolition was conducted and no special means (pin hole cameras, etc) were used to observe concealed spaces.

Findings include:

A. The presence of what appears to be molds in patient bathrooms was confirmed by the surveyor. Based upon the following, the surveyor expects to find mold and moisture problems throughout toilet rooms (and/or in the plumbing chases for toilet rooms) on every floor.

1. There is a plumbing chase between patient room 404 and 403 with wall mounted sinks and wall mounted toilets installed back to back. The wall finishes, cove base and floor finishes are ceramic tile. The ceramic tile on the wall is new and has white grout. The ceramic cove base and floor tiles are older and the grout in the joint work is stained, discolored and damaged.

Access into the plumbing chase is limited to a small access panel under the sink. This access panel allows very little access (not enough to view into the space and not enough room for a camera. The surveyor reached into the cavity near the floor to feel the wall surface that the toilet is mounted to. The wall surface in the chase was soft and mushy (as opposed to hard drywall) near the floor. The surveyor's fingers were coated with a gray/blue/black residue after touching the wall in the chase. The surveyor finds that the lower portions of the wall are damaged by moisture problems in the wall and the residue is most likely mold growing on the wall. The extent of this problem in this room could not be determined further without demolition to expose the chase.

However, the surveyor observed the joint work in the ceramic tile at the plumbing wall was broken and discolored with a yellow material. There is waste water brown stain under the wall mounted toilet that appears to be a leak from the toilet. Much of the grout work in the floor tile around the toilet is stained or discolored.

Further, the surveyor observed a slight hump in the corridor wall along the outside of this bathroom. The wall surface and base moves slighting when pressed upon. This indicates that the wall is not attached to the floor track or floor plate at the base of the wall or it indicates that the steel track or plate inside the wall has deteriorated from moisture.

2. Patient Room 415: The surveyor observed a plastic barrier in the corridor in front of this room and observed that the toilet room was being renovated. A contractor was in the bathroom working on new ceramic tile wall finishes and ceramic tile floor finishes. It was readily obvious that portions of the drywall had been replaced. The demolished materials were not found in the room. The surveyor interviewed the contractor working on the toilet room. The contractor indicated that the old ceramic tile finishes had been removed. He indicated that the drywall on three walls was removed and replace to about four feet above the floor. When asked, he indicated that the drywall that was removed had mold on it. When asked, the contractor indicated that the steel floor track had to be replaced because it had rusted away.

The Director of Plant Operations indicated that the ceramic floor tile had mold under the tile and that the substrate was removed.

Patient Room 416: The surveyor found that the adjacent patient room was occupied. Staff asked for and received the patient's permission to look in the bathroom. The bathroom is back to back with Patient Room 415 and shares a plumbing chase. The bathroom has no access panel to the plumbing chase. The room has similar conditions, visually, to most of the bathrooms on this floor. The surveyor observed no evidence of any repair to wall or floor finishes or substrates.

3. 3rd Floor Shower Room near Room 318. This shower room is typical for most shower rooms in the building. Most but not all patients rooms have no showers in the patient bathrooms. Instead patient showers are provided off the corridors on each floor. The shower room near Room 318 has no ventilation and was much more humid that other showers observed. The shower was not clean. The ceramic tile finishes were discolored and coated with grime.

4. Patient Room 318 has a toilet room with back to back fixtures and a shared plumbing chase with the adjacent patient room.

The corridor wall surface is loose near the floor along the bathroom wall.

The wall and floor finishes are heavily discolored and the wall and cove base are loose at the toilet. The joints are not watertight. The surveyor observed wood blocking in the plumbing chase.

5. Dietitian's Office 314 (formerly a patient room and typical of many): The toilet room is typical of most patient toilet rooms on this floor.

There is no water tight seal between the toilet and the wall. The ceramic tile wall finishes have failed and the joints between the water and the floor are buckled. There are heavy stains on the wall under the toilet

6. Office 2-211 (with a typical patient toilet room): The cove base is vinyl and it is ripped and buckled. The toilet is not sealed to the wall finish.

7. Room 2-253: The ceramic tile joints in this room were originally white but have turned brown and black. The discoloration does not come out with rubbing or scraping. This is typical of many patient toilet rooms.

8. Room 2-214: Sheet vinyl flooring and a vinyl cover based have been installed directly over the ceramic tile. Some of the joints have failed at the vinyl cove base. There is discoloration at the joints and along the top of the cover based.

9. From random observation via access panels in patient toilet rooms the surveyor finds that plumbing chases to be full of debris and rags.

10. Ground Floor patient toilet room near an X-ray Room: The wall mounted toiled in this bathroom is not sealed to the wall with a water resistant seal or caulking material. This allows dirt, soiled materials and moisture behind the toilet and possibly into the plumbing chase.

End

.

A.) Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and reference therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

1. The provider failed to implement interim life safety measures for deficiencies cited under the survey dated 9/21/11.

A) Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517.

Findings include:

1. The following Life Safety Panels are serving loads other than those allowed by NFPA-70, Section 517-32 and NFPA-99, Section 3-4.2.2.2(b) .

a. Life Safety panel 4LSP is feeding
receptacles.

b. Panel 2LSP circuit 5 is serving the nurse
call .

c. Panel 1LSP has several circuits serving
loads such as nurse call and room
receptacles.

d. The only generator loads allowed to be
served by the Life Safety Branch are
selected lighting and receptacles at the
generator set location. Several Life
Safety Panels had circuits serving battery
chargers, heaters, louvers and other
generator loads.

e. Life Safety Panel GEL1 had several
circuits serving non Life Safety loads,
including a welder.

2. Panel 1CRP circuit 20 is serving a fire alarm load that should be fed from a Life Safety panel in accordance with NFPA-70, Section 517-32 and NFPA-99, Section 3-4.2.2.2(b) .

3. The fire alarm circuit breakers in the Life Safety Panels are not marked red and do nothave a locking device on the breakers to comply with NFPA-72, Section 1-5.2.5.

These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised by the loss of a single transfer switch.

Evidence includes:

A) From random observation, the surveyors find that electrical installations and materials do not comply with NFPA 70 -1999.

1) The surveyor finds the electrical extension cords and plug strips plugged in in series are in permanent use throughout the facility. Locations include but are not limited to:

a) Nourishment Room 366 - refrigerator on
extension cord

b) 3-236 Staff Break Room with extension
cord at radio near window

c) 1st Floor Dining Room Vending Room

d) 1st Floor Cafeteria (light at salad table
is on an extension cord, the soup
kettles are connected to a large yellow
extension cord

e) 1st Floor Kitchen - dietatechs desk

f) 1st Floor Human Resources - back
office area has multiple extension
cords along with plug strips that are
plugged in in series.

g) Ground Floor Communication Room
(accessed through Electrical Room)

2) Electrical circuits in electrical panels are not installed and maintained

a) A 3rd Floor Electrical Closet has several
circuits that are "tagged out." The
provider does not know why or what
these are. There is also a junction box in
this closet that lacks a cover.

b) Electrical Closet 2-240; Panel 2L-2 has
ten circuits that are labeled as
"unknown" all ten circuits were "on".
The provider was not able to explain the
black electricians tape that was found
over some of the circuit breakers.

3) Business Office 1-197 (near former storage room that is now an office) multiple cables and data wires above the ceiling are supported by conduit and arm-a-flex and are not supported in accordance with NFPA 70.

4) G-250 Bio-Hazard Holding Room: access to switchgear or electrical panels in this area is blocked by carts. A 3'-0" clear space in front of the panels is not maintained in accordance with NFPA 70..

Failure to maintain and identify devices and equipment in accordance with NFPA 70 could result: in failure of devices and systems, delayed response by staff or fire personnel and/or fires in devices that are not installed in accordance with NFPA 70.

.


17659


Based on random observation during the survey walk-through not all portions of the building systems are installed in accordance with NFPA 70 (1999).

Findings include:

1. Rooftop mechanical equipment does not have a GFCI receptacle within 25' of equipment as required by NFPA-70, Section 210-63.

2. Duplex receptacles served by emergency power in patient rooms and several critical care areas are not color coded as required by NFPA-70, Section 517-33(c).

3. Two of the three operating rooms were not equipped with battery operated emergency lighting as required by NFPA-99, Section 3-3.2.1.2(a)5e.

4. Normal power receptacles were not provided in C-section rooms, operating rooms, emergency rooms G-184 and G-185, and ICU rooms as required by NFPA-70, Section 517-19, and NFPA-99, Section 3-3.2.1.2(a)1. In the event of a transfer switch failure upon return to normal power, the operating rooms could be left with no power.

Evidence includes:

A) The provider lacks documentation of monthly testing of fire fighter service on all elevators in accordance with 9.4.6. of NFPA 101 and ASME/ANSI A17.3.

B) Documentation for annual testing of automatic elevator recall functions, for all elevators in accordance with ASME/ANSI A17.3, that includes the designated primary floor of recall and alternate floor of recall) was not available on site.

Failure to test and maintain elevators could result in failure of elevator functions in an emergency.

.


17659


Based on random observation during the survey walk-through portions of the elevator control system are not installed in accordance with ASME A17.1.

Findings include:

1. The surveyor did not find that the hydraulic elevator machine rooms were equipped with shunt trip devices to meet the requirements of ASME A17.1-102.2.c.3

2. The surveyor did not find that the disconnect for the emergency lighting and controls for the hydraulic elevators were properly labeled in accordance with NFPA-70, Section 620-53.

Failure to install and maintain required devices and systems for elevators could result in failure.

.