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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. They do not comply with
NFPA 90A and the
installations do not comply with
current CMS policies.

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).

A detailed phasing schedule (updated with each PoC) is not provided that identifies the scope of work for each phase and a completion date (mm/dd/yy) for each phase.

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 environments with no access on some floors.

04/10/13 - A PoC was not provided for the above item. No correction date was provided. Both the plan of correction lack specifics for the above locations. The PoC does not clearly identify what is proposed for each floor and the project plans for Project 9561 do not accurately identify the shaft enclosures at duct penetrations at each floor. Based on observation on 4/10/13, the surveyor observed that two fire dampers are missing above the 4th Floor ceiling at each end of the building (at the locations cited).

3) Deleted 03/09/12

4) Corrected 03/08/12
.



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:

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. What phase is this item part of?


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:

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

The above item was not corrected in accordance with the last submitted PoC; what phase is this item part of?

3. Corrected 03/08/12

Evidence includes:

A) Corrected 12/10/12

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.

The above item will remain open until the end of all corrections.

.
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.

A detailed phasing schedule (updated with each PoC) is not provided that identifies the scope of work for each phase and a completion date (mm/dd/yy) for each phase.

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 the facility, that corrective actions will be necessary.

A detailed phasing schedule (updated with each PoC) is not provided that identifies the scope of work for each phase and a completion date (mm/dd/yy) for each phase.

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. Corrected 4/10/13 - the above item will remain cited until all deficiencies have been corrected.

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).

A detailed phasing schedule (updated with each PoC) is not provided that identifies the scope of work for each phase and a completion date (mm/dd/yy) for each phase.

1. Deleted 04/10/13

2. Deleted 04/10/13

3. Corrected 04/10/13

4. Corrected 04/10/13

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 information 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: Ventilation 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. Corrected 04/10/13

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. Corrected 04/10/13

A detailed phasing schedule for all of the above (updated with each PoC) is not provided that identifies the scope of work for each phase and a completion date (mm/dd/yy) for each phase.


End

.

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) .

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.

4/10/13: NFPA 70 does not specifically
allow the engine block heater and the
battery chargers for the genset to be
powered from the Life Safety Branch
of emergency power.
Revise and re-submit.

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)
electrical extension cords and plug
strips plugged-in in series.

h) Corrected 04/10/13

i) Corrected 04/10/13

2) Corrected 12/10/12
3) Corrected 03/09/12
4) Corrected 03/09/12

5) (04/10/13) Chiller Room next to the Boiler Room: access to switchgear was blocked by multiple stored items adn equpment.

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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. Corrected 12/10/12

2. Corrected 12/10/12

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. Corrected 12/10/12