HospitalInspections.org

Evidence includes:

A) Corrected 03/08/12

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.

03/08/12: The above item was not corrected. The provider lacks documentation that indicates how a single smoke detector installed behind the registration area, installed 21' from one wall complies with NFPA 72.

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.

The above item was not corrected in accordance with the PoC submitted.

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



A). Corrected 03/09/12


B). Corrected 03/09/12

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) Deleted 03/09/12

4) Corrected 03/08/12

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.

03/09/12: A two hour barrier has been installed in the above room to terminate the shaft above. Two ceiling dampers were installed at the duct penetrations of this barrier instaed of fire dampers.

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

03/09/12: The above mechanical room is open to two vertical shafts. In accordance with NFPA 90A, the room is part of the shaft enclosures and the storage uses and termporary constractor's constructoin and staging uses in this space conflict with the requirements of NFPA 90A

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. Corrected 03/08/12

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

The correction date for the above item is confusing and does not match other project dates.

3. Corrected 03/08/12

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. Modified 03/08/12): 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 minimum 1
hour fire rating as a required component
for a means of egress.

Also, the above stair is identified at the
Lower Level as an exit (with an
illuminated exit sign). The stair
discharge into the corridor at the Upper
Level does not comply with 7.7.1 or
7.7.2 (the surveyor notes that the Level
of Exit Discharge is not fully
sprinklered).

2. Corrected 03/08/12

3. Corrected 03/08/12

4. The required Exit stair (near Pharmacy
Storage) located within the original part
of the building (not sprinkler protected)
does not comply with Chapter 7 and 8 of
NFPA 101.

a. The penetrations cited in the
previous survey were not corrected
in accordance with the last
submitted PoC.

b. The stair on both levels is used for
storage (deficiency includes waste
containers, supplies, coat racks, etc.)

c. Four of four stair doors on two
levels are not a minimum of one
hour fire doors. The doors on the
Lower Level lack positive latching
hardware (latchsets were removed).

d. The wall construction at both levels
is not one hour fire rated
construction. Wall construction on
one or both sides of the walls (above
the ceiling are incomplete). There
are multiple voids and holes that are
not sealed, drywall is not fire taped
and multiple penetrations are not
sealed for one hour construction.

e. Duct penetrations at the Lower
Level lack fire dampers. The Upper
Level has a plenum return air
opening in the stair enclosure
wall above the ceiling. A fire
damper is installed in this opening.
The opening is not smoke tight
and a combination fire/smoke
damper with a smoke detector in
the plenum is not provided







.

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.

03/08/12: The above item was not corrected in accordance with the last submitted PoC. The door does not close to latch and local smoke detectors were not installed.

2) (Modified 03/08/12): The 1st Floor Medical Records area is a hazardous area. One dutch door has a magnetic hold open device but lacks local smoke detection in accordance with 7.2.1.8.

3) Corrected 03/09/12

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) Corrected 03/08/12

2) Corrected 03/08/12

3) Corrected 03/08/12

4) Corrected 03/09/12

5) Corrected 03/09/12

6) Corrected 03/09/12

7) Corrected 03/09/12


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. Corrected 03/09/12

3. Corrected 03/08/12

4. Corrected 03/09/12

B). Corrected 03/09/12


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.

03/08/12: The above room is still used for storage and the door lacks self closing hardware.

2. Revised 03/08/12: 3rd floor room # 334 (actual room number) has been converted to a storage room and lacks 60 minute fire rated walls to the deck above in accordance with 18.3.2.1. The walls above the ceiling are not even smoke tight.

.

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


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. Corrected 03/09/12

2. Deleted 03/08/12

3. Corrected 03/08/12

B). Corrected 03/08/12

C). Corrected 03/08/12

D). Corrected 03/08/12





.

Evidence includes:

A) Corrected 03/08/12

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) Corrected 03/08/12

2) Corrected 03/08/12

3) 1st Floor

a) Corrected 03/08/12

b) Corrected 03/08/12

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) Corrected 03/09/12


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.

No PoC was provided for the above item

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) Corrected 03/08/12

2) Corrected 03/09/12

3) Corrected 03/09/12


.

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.

Modified 03/09/12: 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 :

1st Floor Dining Room


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20224


A). Corrected 03/09/12

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 Radiology Unit and the building, however, the surveyor was informed that there was no documentation available.

03/08/12: The provider lacks documentation that demonstrates that the fire alarm system has been tested, serviced and maintained annually for the past 12 months in accordance with NFPA 72-1999.

The above item was not corrected in accordance with the last submitted PoC.


B). Deleted 03/08/12
.

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) Corrected 03/09/12

D) Corrected 03/09/12

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 Radiology Unit and the building, however, the surveyor was informed that there was no documentation available.

03/08/12: The provider lacks documentation that demonstrates that the sprinkler system on both floors of this building has been tested, serviced and maintained in accordance with NFPA 25-1999.

1) Documentation of quarterly testing of flow switches using a complying inspector's test valve was not available for the past four quarters.

2) Documentation for annual testing, inspection and maintenance was not available for the past 12 months.

The above item was not corrected in accordance with the last submitted PoC.

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 lacks documentation that clearly indicates that all fire dampers 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).

03/09/12: The preliminary documentation for November of 2011still shows dampers that are disabled, dampers where access is blocked, etc.

The above item was not corrected in accordance with the last submitted PoC.

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) Corrected 03/08/12


.

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. Corrected 03/09/12

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 .

03/09/12: The provider was unable to demonstrate how the above item was corrected.

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.

.
A) Corrected 03/09/12

B. Corrected 03/08/12









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. Corrected 03/08/12

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.

03/08/12: Ventilatoin was not provided for the above shower room in accordance with the last submitted PoC.

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

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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. Corrected 03/08/12

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. Corrected 03/09/12

2. Corrected 03/09/12

3. Corrected 03/09/12

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) Corrected 03/08/12

b) Corrected 03/09/12

c) Corrected 03/09/12

d) Corrected 03/09/12

e) Corrected 03/09/12

f) Corrected 03/09/12

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. (Panel 3L-2

03/08/12: The above item was not
corrected in accordance with the last
submitted PoC

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) Corrected 03/09/12

4) Corrected 03/09/12

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. Upper Rooftop: mechanical equipment does not have a GFCI receptacle within 25' of all pieces of equipment on the roof (including all exhuast fans) 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.

.