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Based on observation, the facility failed to maintain the building construction as evidenced by unsealed penetrations. This affected Buildings 1 and 3 and had the potential to allow the spread of smoke during a fire and harm to the patients.

Findings:

During the facility tour with Staff 1, 2 and 3 on March 12 and 14, 2012, the facility walls and ceilings were observed.

At 11:50 a.m. on March 12, 2012, in the 2nd floor roof access room in Building 3, there was an approximately two inch unsealed penetration in the wall where the door knob met the wall. Staff 2 confirmed there was an unsealed penetration in the wall.

At 1:35 p.m. on March 14, 2012, in the Central Supply Sterilizer Room in Building 1, there was an approximately two inch unsealed penetration in the ceiling and an approximately three inch by eight inch unsealed penetration above the floor on the north wall. Staff 1 confirmed there were unsealed penetrations in the wall and ceiling.

Based on observation, the facility failed to maintain the corridor separation to resist the passage of smoke as evidenced by corridor doors that were impeded from closing and unsealed penetrations in corridor walls. This affected Building 3 and had the potential to allow the migration of smoke causing harm to the patients.

Findings:

During the facility tour with Staff 2 and 3 on March 12, 2012, the corridors were observed.

At 11:20 a.m. on March 12, 2012, there was an approximately three inch unsealed penetration in the 1st floor corridor wall of the Imaging Suite in Building 3. The unsealed penetration was around an air duct that penetrated the wall. Staff 2 confirmed there was an unsealed area around the air duct.

At 12:07 p.m. on March 12, 2012, there was an approximately three inch unsealed penetration in the 2nd floor east corridor wall of the Therapy Area in Building 3. The unsealed penetration was around an air duct that penetrated the wall. Staff 2 confirmed there was an unsealed area around the air duct.

At 4:25 p.m. on March 13, 2012, there were three pipes that penetrated the corridor wall above the drop ceiling adjacent to the fire alarm panel. There was an approximately two inch, unsealed area around each pipe where the pipe penetrated the wall. Staff a confirmed there was an unsealed area around each pipe. Blue prints provided by the facility indicated a one-hour rated corridor wall from the floor to the roof.

NFPA 80 Standard for Fire Doors and Fire Windows (1999 Edition), 15-2.4.3 All horizontal or vertical sliding and rolling fire doors shall be inspected and tested annually to check for proper operation and full closure. Resetting of the release mechanism shall be done in accordance with the manufacturer's instructions. A written record shall be maintained and shall be made available to the authority having jurisdiction.

NFPA 80 Standard for Fire Doors and Fire Windows (1999 Edition) 15-2.4.4 Fusible links or other heat-actuated devices and release devices shall not be painted.

NFPA 101 Life Safety Code (2000 Edition) 8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) *Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows.

Based on observation, the facility failed to maintain the rolling fire doors as evidenced by the failure to provide documentation for the maintenance of the roll down doors, a compromised rated door frame and corridor doors that failed to fully close and latch without assistance. This affected Buildings 1 and 2 and had the potential for the door to fail to function and the spread of smoke causing harm to the patients.

Findings:

During the facility tour with Staff 1 on March 13 and 14, 2012, the corridor doors were observed.

1. At 5 p.m. on March 13, 2012, the facility failed to provide documentation for the maintenance of the roll down door at the reception desk observed in Building 2. The roll down door was part of the corridor egress path. Blue prints provided by the facility indicated a one-hour rated corridor wall from the floor to the roof. Staff 1 stated the maintenance report was not available.

2. At 3:08 p.m. on March 14, 2012, the rated corridor door frame to the 4th Floor Maternal Child Health Director's Office in Building 1 had been penetrated for the latch for a dead bolt. The penetration negated the rating of the door frame and the ability of the door frame to protect against the passage of smoke. Staff 1 confirmed there was a penetration in the door frame.

Based on observation, the facility failed to maintain the smoke barriers as evidenced by unsealed penetrations in a smoke barrier. This affected Building 2 and had the potential to fail to contain smoke during a fire which could cause harm to the patients.

Findings:

During the facility tour with Staff 1 on March 12, 2012, the facility smoke barriers were observed.

At 5:29 p.m. on March 12, 2012, there were approximately five unsealed penetrations of different sizes in the smoke barrier adjacent to the roll down window in the lobby of Building 2. Staff 1 confirmed there were unsealed penetrations in the smoke barrier.

NFPA 101 Life Safety Code 2000 Edition, 8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with
the following.
(a) *Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows.

NFPA 101 Life Safety Code 2000 Edition, 8.3.3 Fire Barrier Used as Smoke Barrier. A fire barrier shall
be permitted to be used as a smoke barrier, provided that it meets the requirements of 8.3.4 through 8.3.6.

NFPA 80 Standard for Fire Doors and Fire Windows (1999 Edition) 1-5.1 Listed items shall be identified by a label. Labels shall be applied in locations that are readily visible and convenient for identification by the authority having jurisdiction after installation of the assembly.

NFPA 80, Standard for Fire Doors and Fire Windows 1999 Edition. 2-4.1.3 All components of closing devices used shall be attached securely to doors and frames by steel screws or through-bolts.

Based on observation, the facility failed to maintain the smoke barrier doors as evidenced by barrier doors that failed to latch and as evidenced by smoke barrier door rating labels that had been painted over. This affected Building 1 and had the potential to fail to contain smoke during a fire, the failure to install proper rated doors and causing injury to the patients.

Findings:

During the facility tour with Staff 1 on March 14 and 15, 2012, the facility smoke barriers were observed.

1. At 10:05 a.m. on March 14, 2012, the door rating labels in the smoke barrier at the entrance to the SNF corridor from Building 1 were painted over. The door ratings could not be identified. Staff 1 confirmed the rating labels were painted over.

2. At 2:55 p.m. on March 14, 2012, 1 of 2 door leaves in the smoke barrier door separating Units 3.1 and 3.2 in Building 1 failed to latch when tested. Staff 1 confirmed the door leaf failed to latch. The doors were equipped with surface vertical rod hardware for latching at the top and bottom of the door. The bottom bolt failed to latch.

3. At 2:57 p.m. on March 14, 2012, 1 of 2 door leaves in the smoke barrier door separating Units 3.1 and 3.3 in Building 1 failed to latch when tested. Staff 1 confirmed the door leaf failed to latch. The doors were equipped with surface vertical rod hardware for latching at the top and bottom of the door. The bottom bolt failed to latch.

4. At 8:35 a.m. on March 14, 2012, 2 of 2 door leaves in barrier door #2094 in the Operating Room in Building 1 failed to latch when tested. Staff 1 confirmed the door leaves failed to latch.

Based on observation and interview, the facility failed to protect the hazardous areas from other areas as evidenced by a self-closing corridor door that failed to latch. This affected Building 1 and had the potential to fail to contain smoke and fire causing harm to patients.

Findings:

During the facility tour with Staff 1 on March 14, 2012, the hazardous areas were observed.

At 9:28 a.m., the self-closing corridor door to the Lab Technical Area in Building 1 failed to fully close and latch without assistance. Staff 1 confirmed the door failed to fully close and latch without assistance.

NFPA 101 Life Safety Code (2000 Edition) 19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
Exception: As modified by 19.2.2 through 19.2.11
NFPA 101 Life Safety Code (2000 Edition) 7.2.1.5 - Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
NFPA 101 Life Safety Code (2000 Edition) 7.2.1.5.4 - A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm) above the finished floor. Doors shall be operable with not more than one releasing operation.
Based on observation, the facility failed to maintain exit access as evidenced by corridor doors that required more than one releasing operation. This affected Building 1 and had the potential for delaying egress in an emergency.
Findings:
During the facility tour with Staff 1 on March 13, 2012, the corridor doors were observed.
At 10:34 a.m., 2 of 2 corridor doors to the OB Operating Room in Building 1 were equipped with dead-bolt locks. When locked, two actions were required to open the door and exit the Operating Room. Staff 1 confirmed that two releasing actions were required to open each door when the door was locked.

NFPA 99 Standard for Health Care Facilities (1999 Edition) 3-3 Electrical System Requirements.
3-3.2.1.2 All Patient Care Areas. 5. Wiring in Anesthetizing Locations.
e. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

NFPA 101 Life Safety Code (2000 Edition) 7.9.3 Periodic testing of emergency lighting equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

NFPA 101 Life Safety Code (2000 Edition) 7.10.9.2 Testing. Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance
with 7.9.3.

Based on observation and interview, the facility failed to maintain the emergency lighting as evidenced by the failure to provide documentation for the monthly and annual testing of the lights and the failure to provide emergency lighting in an operating room. This affected Building 1 and had the potential for the lighting to fail.

Findings:

During the document review and facility tour with Staff 1, 2 and 3 on March 12, 13 and 14, 2012, the emergency lighting was observed.

At 10:35 a.m. on March 13, 2012, the OB Operating Room in Building 1 was observed. There were no emergency lights observed in the Operating Room. Staff 1 stated the Operating Room was connected to the emergency generator for emergency lighting.

NFPA 72 National Fire Alarm Code (1999 Edition) 2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

NFPA 72 National Fire Alarm Code (1999 Edition) 7-3 Inspection and Testing Frequency.

7-3.1* Visual Inspection. Visual inspection shall be performed in accordance with the schedules in Section 7-3 or more often if required by the authority having jurisdiction. The visual inspection shall be made to ensure that there are no changes that affect equipment performance.

Exception No. 1: Devices or equipment that is inaccessible for safety considerations (for example, continuous process operations, energized electrical equipment, radiation, and excessive height) shall be inspected during scheduled shutdowns if approved by the authority having jurisdiction.
Extended intervals shall not exceed 18 months.

Exception No. 2: If automatic inspection is performed at a frequency of not less than weekly by a remotely monitored fire alarm control unit specifically listed for such application, the visual inspection frequency shall be permitted to be annual. The requirements of Table 7-3.1 shall apply.

NFPA 72 National Fire Alarm Code (1999 Edition) 7-3.2 Testing. Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply.

Exception: Devices or equipment that are inaccessible for safety considerations (for example, continuous process operations, energized electrical equipment, radiation, and excessive height) shall be tested during scheduled shutdowns if approved by the authority having jurisdiction but shall not be tested more than every 18 months.

NFPA 72 National Fire Alarm Code (1999 Edition) Table 7-3.2 Testing Frequencies, Item 6(d)(1) Sealed lead acid batteries are to be replaced every 4 years.

NFPA 101 Life Safety Code (2000 Edition) 9.6.2.6 Each manual fire alarm box on a system shall be accessible, unobstructed, and visible.

Based on observation, interview and document review, the facility failed to maintain the fire alarm system as evidenced by an obstructed manual fire alarm box, undated batteries in fire alarm panels, the failure to test a fire alarm system monthly, and by the failure to provide documentation for the annual inspection and testing of the fire alarm system. This affected Buildings 2 and 3 and had the potential for the delay in alarm activation, fire alarms system failure and harm to the patients.

Findings:

During the document review and facility tour with Staff 1, 2 and 3 on March 12 and 13, 2012, the manual fire alarm boxes were observed and the fire alarms inspection and test records were reviewed.

1. At 11:10 a.m. on March 12, 2012, the sealed, lead acid battery (SLA) for the main fire alarm panel located in Building 3 was not dated as to when the battery was installed. Staff 2 confirmed the battery was not dated as to when it was installed.

2. At 11:15 a.m. on March 12, 2012, a duct detector was observed above the drop ceiling in the first floor corridor adjacent to the Imaging Center in Building 3. Staff 2 and 3 were unsure if the detector and the damper connected to the detector was active and did not know if the air duct was active. A vendor letter dated 3-13-12 indicated the detector was connected to a fire panel observed in the first floor waiting area for the Out-patient Laboratory and Out-patient Radiology. The vendor letter indicated the panel was no longer in service. Staff 2 and 3 stated the air conditioning system would need to be checked to see if the duct with the detector was still active.

3. At 5:11 p.m. on March 12, 2012, there was no manual fire alarm system in Building 3 to automatically warn the building occupants. Staff 2 and 3 confirmed there was no manual fire alarm in the building.

4. At 5:11 p.m. on March 12, 2012, the sprinkler system was tested in Building 3. The fire alarm panel communicated the fire alarm to the monitoring company. The fire alarm activation on the panel failed to automatically warn the building occupants. Staff 2 and 3 confirmed the alarm failed to activate an alarm to warn the building occupants.

5. At 5:30 p.m. on March 12, 2012, access to the manual fire alarm box in the Lobby of Building 2 was obstructed by a chair. Staff 2 and 3 confirmed the chair obstructed access to the manual fire alarm box and moved the chair.

NFPA 13 Standard for the Installation of Sprinkler Systems (1999 Edition), 5-6.5.1.2 Sprinklers shall be arranged to comply with 5-5.5.2, Table 5-6.5.1.2, and Figure 5-6.5.1.2(a).

NFPA 13 Standard for the Installation of Sprinkler Systems (1999 Edition), Table 5-6.5.1.2 Positioning of Sprinklers to Avoid Obstructions to Discharge (SSU/SSP) requires where the distance from the sprinkler to the side of the obstruction is less than 1 foot, the maximum allowable distance of the sprinkler deflector above the bottom of the obstruction is zero inches. An obstruction greater than 1 foot to less than 18 inches, the maximum allowable distance of the sprinkler deflector above the bottom of the obstruction is 2 1/2 inches.

NFPA 13 Standard for the Installation of Sprinkler Systems (1999 edition) 5-13.8 Sprinklers shall be installed under exterior roof or canopies exceeding 4 ft (1.2 m) in width.

Exception: Sprinkler are permitted to be omitted where the canopy or roof is noncombustible or limited combustible construction.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (1998 Edition), 2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendent, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, or in the improper orientation.

Exception No. 1: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.

Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems
(1998 Edition) 2-2.1.2 Unacceptable obstructions to spray patterns shall be corrected.

NFPA 101 Life Safety Code (2000 Edition), 19.3.4.2* Initiation. Initiation of the required fire alarm systems shall be by manual means in accordance with 9.6.2 and by means of any required sprinkler system waterflow alarms, detection devices, or detection systems.

NFPA 101 Life Safety Code (2000 Edition), 20.3.4.2 Initiation. Initiation of the required fire alarm systems
shall be by manual means in accordance with 9.6.2 and by means of any detection devices or detection systems required.

NFPA 101 Life Safety Code (2000 Edition), 9.6.2.1 Where required by other sections of this Code, actuation of the complete fire alarm system shall occur by any or all of the following means of initiation, but shall not be limited to such means:
(1) Manual fire alarm initiation
(2) Automatic detection
(3) Extinguishing system operation

Based on observation, the facility failed to maintain the facility sprinkler system as evidenced by sprinkler heads with foreign material on the sprinkler heads, unsprinklered canopies, obstructed sprinkler spray patterns and a waterflow alarm that failed to annunciation on the fire alarm panel. This affected Buildings 3 and had the potential for sprinkler failure leading to patient injury.

Findings:

During the facility tour with Staff 1, 2 and 3 March 12, 13 and 14, 2012, the facility sprinkler system was observed.


1. At 11:15 a.m. on March 12, 2012, there was an approximately 8 foot by 12 foot canopy attached to the roof at the main entrance and an approximately 8 foot by 12 foot canopy attached to the roof at the rear entrance of Building 3 that were not sprinklered. Staff 2 confirmed the canopies were not sprinklered and stated he did not know if the canopies were treated or made of flame resistive materials.

2. At 1:25 p.m. on March 14, 2012, the sprinkler head in Refrigerator 1 and Refrigerator 2 in the Kitchen in Building 1 were approximately three inches adjacent to a light fixture. The bottom of the light fixture was even with the bottom of the sprinkler deflector and would obstruct the sprinkler spray pattern. Staff 1 confirmed the light fixtures were within three inches of the sprinkler deflectors.

3. At 2:20 p.m. on March 14, 2012, the sprinkler head in the East Risk Management corridor in Building 1 was approximately three inches adjacent to an exit sign. The bottom of the exit sign extended approximately six inches below the bottom of the sprinkler deflector and would obstruct the sprinkler spray pattern. Staff 1 confirmed the exit sign was within three inches of the sprinkler deflector.

4. At 8:40 p.m. on March 15, 2012, the sprinkler head in the Operating Room Housekeeping Room #2092 in Building 1 was approximately six inches adjacent to a light fixture. The bottom of the light fixture extended approximately two inches below the bottom of the sprinkler deflector and would obstruct the sprinkler spray pattern. Staff 1 confirmed the light fixture was within six inches of the sprinkler deflector.

NFPA 10 Standard for Portable Fire Extinguishers (1998 Edition) 1-6.6 Fire extinguishers shall not be obstructed or obscured from view.

Exception: In large rooms, and in certain locations where visual obstruction cannot be completely avoided, means shall be provided to indicate the location.

NFPA 10 Standard for Portable Fire Extinguishers (1998 Edition) 1-6.7 Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or place in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer's instructions. Wheeled-type extinguishers shall be located in a designated location.

Based on observation and interview, the facility failed to maintain access to the fire extinguishers as evidenced by obstructed access to fire extinguishers and a fire extinguisher hung on a hanger not designed for the fire extinguisher. This affected Buildings 1 and 3 and had the potential for some persons not to be able to access the extinguisher, persons being injured due to having to reach for the extinguisher or dislodgement of the extinguisher. This could delay the extinguishment of a fire and cause injury to the patients.

Findings:

During the facility tour with Staff 1, 2 and 3 on March 12, 13 and 14, 2012, the fire extinguishers were observed.

1. At 12:10 p.m. on March 12, 2012, access to the fire extinguisher in the Lobby of Building 3 adjacent to Suite 108 was obstructed by a chair in front of the fire extinguisher cabinet. Staff 2 confirmed the access was blocked by the chair and moved the chair to allow access to the extinguisher.

2. At 11:08 a.m. on March 13, 2012, visual access to the fire extinguisher in the Medical Records area of Building 1 was obstructed. The facility failed to provide a means to indicate the location of the extinguisher in the room. Staff 1 confirmed the access to the extinguisher was visually obscured.

3. At 9:25 a.m. on March 14, 2012, access to the fire extinguisher Station #147 in the lab technical area was obstructed by a work deck. To access the extinguisher required reaching approximately twelve inches across the work deck. Staff 1 confirmed the access was obstructed by the work deck.

At 1:27 p.m. on March 14, 2012, the K-Class fire extinguisher in the Kitchen of Building 1 was not mounted on an extinguisher hanger designed for the fire extinguisher. The extinguisher was designed to be hung on the wall with a J hanger. The extinguisher was hung on a hanger with a hook. Staff 1 confirmed the extinguisher was not secured on a J hanger.

NFPA 101 Life Safety Code (2000 Edition) 19.7.4* Smoking. Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.

Exception: In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.

Based on observation and document review, the facility failed to enforce the facility smoking policy as evidenced by the failure to post "NO SMOKING" signs or the international sign for no smoking at entrances to the facility. This affected Buildings 2 and 3 and had the potential for smoking in the facility.

Findings:

During the document review and facility tour with Staff 1 on March 15, 2012, the facility smoking policy was reviewed and the facility entrances were observed.

1. At 7:47 a.m., the facility failed to post a "NO SMOKING" sign or a sign with the international symbol for no smoking at the main entrance of Building 3. Staff 1 stated he thought there was a sign posted at the entrance. On page 1 of the facility policy titled "Smoking," the policy indicates "No Smoking" signs shall be posted at building entrance points."

2. At 7:55 a.m., the facility failed to post a "NO SMOKING" sign or a sign with the international symbol for no smoking at the main entrance of Building 2. Staff 1 stated he thought there was a sign posted at the entrance. On page 1 of the facility policy titled "Smoking," the policy indicates "No Smoking" signs shall be posted at building entrance points."

NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems (1999 Edition), 2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.

NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems (1999 Edition), 2-3.4.2 Service openings shall be identified with letters having a minimum of 1/2 in. (1.27 cm) to indicate the location of the fire protection device(s) within.

NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems (1999 Edition), 3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they close fully; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Based on observation and interview, the facility failed to maintain the heating, ventilating and air-conditioning system as evidenced by the failure to provide lettering on duct service openings adjacent to dampers and the failure to provide documentation for the testing and maintenance of the dampers. This affected Buildings 1 and 2 and had the potential for staff to be unaware of the presence of the damper for maintenance and testing leading to damper failure and harm to the patients.

Findings:

During the facility tour with Staff 1 on March 13 and 14, 2012, the facility dampers were observed.

At 4:25 p.m. on March 13, 2012, the duct access panel adjacent to the damper above the corridor adjacent to the fire alarm panel closet in Building 2 was not identified indicating a damper within the duct. Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.

At 6:30 p.m. on March 13, 2012, the facility failed to provide records verifying the fire dampers in Building 2 had been maintained. Staff 1 stated the fire dampers maintenance records were not available.

At 9:53 a.m. on March 14, 2012, the duct access panel adjacent to the damper above the corridor entrance to the SNF from Building 1 was not identified indicating a damper within the duct. The barrier with the duct was adjacent to the Pink Ladies' Desk. Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.

NFPA 99 Standard for Health Care Facilities (1999 Edition) 4-3.5.3* Gas Systems Recordkeeping-Level 1. Prior to the use of any medical gas piping system for patient care, the responsible authority of the facility shall ensure that all tests required in 4-3.4.1 have been successfully conducted and permanent records of the test maintained in the facility files.

Based on observation and document review, the facility failed to maintain the oxygen system as evidenced by the failure to provide documentation for the repairs to the oxygen system. This affected Buildings 1 and had the potential for oxygen system failure leading to harm of the patients.

Findings:

During the document review on March 12, 2012, the oxygen system test results were reviewed.

At 3:55 p.m. on March 12, 2012, the facility provided test records for the oxygen supply and distribution system in Building 1 dated 2-3-12. The report indicated the repairs had not yet been made. Staff 2 stated the repairs had been scheduled but not yet completed.

NFPA 70 National Electrical Code (1999 edition) 370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

NFPA 70 National Electrical Code (1999 Edition) 384-13. General. All panelboards shall have a rating not less than the minimum feeder capacity required for the load computed in accordance with Article 220. Panelboards shall be durably marked by the manufacturer with the voltage and the current rating and the number of phases for which they are designed and with the manufacturer's name or trademark in such a manner so as to be visible after installation, without disturbing the interior parts or wiring. All panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors.

NFPA 70 National Electrical Code (1999 Edition), 400-7 Uses Permitted.
(a) Uses. Flexible cords and cables shall be used only for the following:

(1) Pendants
(2) Wiring of fixtures
(3) Connection of portable lamps, portable and mobile signs, or appliances
(4) Elevator cables
(5) Wiring of cranes and hoists
(6) Connection of stationary equipment to facilitate their frequent interchange
(7) Prevention of the transmission of noise or vibration
(8) Appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, and the appliance is intended or identified for flexible cord connection
(9) Data processing cables as permitted by Section 645-5
(10) Connection of moving parts
(11) Temporary wiring as permitted in Sections 305-4(b) and 305-4(c)

NFPA 70 National Electrical Code (1999 Edition) 400-8. Uses Not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure

NFPA 99 Standard for Health Care Facilities (1999 Edition) 3-3.2.1.1 Electrical Installation. Installation shall be in accordance with NFPA 70, National Electrical Code.

NFPA 99 Standard for Health Care Facilities (1999 Edition) 3-3.2.1.2 (f) Wet Locations. 1. Fixed receptacles, equipment connected by cord and plug, and fixed electrical equipment shall be tested:
(1) When first installed
(2) Where there is evidence of damage
(3) After any repairs, or
(4) At intervals not exceeding 6 months

NFPA 99 Standard for Health Care Faculties (1999 Edition), 3-3.3.3 Receptacle Testing in Patient Care Areas

(a) The physical integrity of each receptacle shall be confirmed by visual inspection.

(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.

(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.

(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

NFPA 99 Standard for Health Care Facilities (1999 Edition), 3-3.4.2.3 Maintenance and Testing of Electrical System.

(a) Testing Interval for Receptacles in Patient Care Areas.

1. Testing shall be performed after initial installation, replacement, or servicing of the device.

2. Additional testing shall be performed at intervals defined by documented performance data.

Exception: Receptacles not listed as hospital-grade shall be tested at intervals not exceeding 12 months.

Based on observation and interview, the facility failed to maintain the electrical wiring and equipment as evidenced by an electrical receptacle that was missing a cover plate, as evidenced by breakers in the on position and not labeled as to the purpose or use, the failure to provide documentation for the testing of the electrical receptacles, as evidenced by patient care equipment plugged into surge protectors instead of directly into an electrical receptacle, the use of surge protectors to provide additional outlets in place of providing fixed wired receptacles and the failure to provide documentation that the use of surge protectors in providing additional outlets on the circuits was in compliance with NFPA 70. This affected Buildings 1, 3, 4 and 5 and had the potential for electrical shock or fire and causing harm to the patients.

Findings:

During the document review and facility tour with Staff 1, 2 and 3 on March 12, 13 and 14, 2012, the electrical receptacles and panels were observed and receptacle testing documents were reviewed.

1. At 11:55 a.m. on March 12, 2012, the electrical receptacle on the south wall in the 2nd Floor Information Technology Room in Building 3 was missing the cover plate. Staff 2 confirmed the receptacle was missing the cover plate.

2. At 10:33 a.m. on March 13, 2012, in the OB Operating Room in Building 1, there was a patient warmer and the OR table plugged into a multi-plug adapter with surge protection instead of directly into a fixed wired electrical receptacle. The adapter was used as a substitute for additional fixed wired electrical receptacles. Staff 1 confirmed the use of the surge protector and stated he did not have documentation that adding the additional receptacles through the use of the surge protector was approved and installed in accordance with NFPA 70, National Electrical Code.

3. At 10:33 a.m. on March 13, 2012, in the OB Operating Room in Building 1, there was a Bovi and a pump plugged into a multi-plug adapter with surge protection instead of directly into a fixed wired electrical receptacle. The adapter was used as a substitute for additional fixed wired electrical receptacles. Staff 1 confirmed the use of the surge protector and stated he did not have documentation that adding the additional receptacles through the use of the surge protector was approved and installed in accordance with NFPA 70, National Electrical Code.

4. At 10:56 a.m. on March 13, 2012, on Emergency Electrical Panel ELB in the basement of Building 1, breakers 9, 11, and 12-18 were in the on position and not labeled as to the area served by the breakers. Staff 1 confirmed the breakers were not labeled. Staff 1 opened the panel and found the breakers not to be connected to power and switched the breakers to the off position.

5. At 8:40 a.m. on March 14, 2012, on Electrical Panel LSPC in Building 1, breakers 8-12 were marked "Spare" and were in the on position and not labeled as to the area served by the breakers. Staff 1 confirmed the breakers were not labeled and in the on position.

6. At 8:43 a.m. on March 14, 2012, on Electrical Panel EL1 in Building 1, breakers 1, 3, 5, 7, 9 and 11 were marked "Spare" and were in the on position and not labeled as to the area served by the breakers. Staff 1 confirmed the breakers were not labeled and in the on position.

7. At 3:39 p.m. on March 14, 2012, on Electrical Panel LSL3 in Building 1, breakers 7-12 were marked "Spare" and were in the on position and not labeled as to the area served by the breakers. Staff 1 confirmed the breakers were not labeled and in the on position.

8. At 8:25 a.m. on March 15, 2012, in the Operating Room 1 in Building 1, there was a patient bed and a pump plugged into a multi-plug adapter with surge protection instead of directly into a fixed wired electrical receptacle. The adapter was used as a substitute for additional fixed wired electrical receptacles. Staff 1 confirmed the use of the surge protector and stated he did not have documentation that adding the additional receptacles through the use of the surge protector was approved and installed in accordance with NFPA 70, National Electrical Code.

9. At 10:29 a.m. on March 15, 2012, on Electrical Panel EP2B in Building 1, breakers 14, 27, 35, 37 39 and 41 were marked "Spare" and were in the on position and not labeled as to the area served by the breakers. Staff 1 confirmed the breakers were not labeled and in the on position.

10. At 10:30 a.m. on March 15, 2012, on Electrical Panel EP2A in Building 1, breakers 28, 30, 32, 34, 36, 38, 40 and 42 were marked "Spare" and were in the on position and not labeled as to the area served by the breakers. Staff 1 confirmed the breakers were not labeled and in the on position.

11. At 10:30 a.m. on March 15, 2012, on Electrical Panel EL2 in Building 1, breakers 7 and 9-12 were marked "Spare" and were in the on position and not labeled as to the area served by the breakers. Staff 1 confirmed the breakers were not labeled and in the on position.

Based on observation, the facility failed to maintain the building construction as evidenced by unsealed penetrations. This affected Buildings 1 and 3 and had the potential to allow the spread of smoke during a fire and harm to the patients.

Findings:

During the facility tour with Staff 1, 2 and 3 on March 12 and 14, 2012, the facility walls and ceilings were observed.

At 11:50 a.m. on March 12, 2012, in the 2nd floor roof access room in Building 3, there was an approximately two inch unsealed penetration in the wall where the door knob met the wall. Staff 2 confirmed there was an unsealed penetration in the wall.

At 1:35 p.m. on March 14, 2012, in the Central Supply Sterilizer Room in Building 1, there was an approximately two inch unsealed penetration in the ceiling and an approximately three inch by eight inch unsealed penetration above the floor on the north wall. Staff 1 confirmed there were unsealed penetrations in the wall and ceiling.

Based on observation, the facility failed to maintain the corridor separation to resist the passage of smoke as evidenced by corridor doors that were impeded from closing and unsealed penetrations in corridor walls. This affected Building 3 and had the potential to allow the migration of smoke causing harm to the patients.

Findings:

During the facility tour with Staff 2 and 3 on March 12, 2012, the corridors were observed.

At 11:20 a.m. on March 12, 2012, there was an approximately three inch unsealed penetration in the 1st floor corridor wall of the Imaging Suite in Building 3. The unsealed penetration was around an air duct that penetrated the wall. Staff 2 confirmed there was an unsealed area around the air duct.

At 12:07 p.m. on March 12, 2012, there was an approximately three inch unsealed penetration in the 2nd floor east corridor wall of the Therapy Area in Building 3. The unsealed penetration was around an air duct that penetrated the wall. Staff 2 confirmed there was an unsealed area around the air duct.

At 4:25 p.m. on March 13, 2012, there were three pipes that penetrated the corridor wall above the drop ceiling adjacent to the fire alarm panel. There was an approximately two inch, unsealed area around each pipe where the pipe penetrated the wall. Staff a confirmed there was an unsealed area around each pipe. Blue prints provided by the facility indicated a one-hour rated corridor wall from the floor to the roof.

NFPA 80 Standard for Fire Doors and Fire Windows (1999 Edition), 15-2.4.3 All horizontal or vertical sliding and rolling fire doors shall be inspected and tested annually to check for proper operation and full closure. Resetting of the release mechanism shall be done in accordance with the manufacturer's instructions. A written record shall be maintained and shall be made available to the authority having jurisdiction.

NFPA 80 Standard for Fire Doors and Fire Windows (1999 Edition) 15-2.4.4 Fusible links or other heat-actuated devices and release devices shall not be painted.

NFPA 101 Life Safety Code (2000 Edition) 8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) *Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows.

Based on observation, the facility failed to maintain the rolling fire doors as evidenced by the failure to provide documentation for the maintenance of the roll down doors, a compromised rated door frame and corridor doors that failed to fully close and latch without assistance. This affected Buildings 1 and 2 and had the potential for the door to fail to function and the spread of smoke causing harm to the patients.

Findings:

During the facility tour with Staff 1 on March 13 and 14, 2012, the corridor doors were observed.

1. At 5 p.m. on March 13, 2012, the facility failed to provide documentation for the maintenance of the roll down door at the reception desk observed in Building 2. The roll down door was part of the corridor egress path. Blue prints provided by the facility indicated a one-hour rated corridor wall from the floor to the roof. Staff 1 stated the maintenance report was not available.

2. At 3:08 p.m. on March 14, 2012, the rated corridor door frame to the 4th Floor Maternal Child Health Director's Office in Building 1 had been penetrated for the latch for a dead bolt. The penetration negated the rating of the door frame and the ability of the door frame to protect against the passage of smoke. Staff 1 confirmed there was a penetration in the door frame.

Based on observation, the facility failed to maintain the smoke barriers as evidenced by unsealed penetrations in a smoke barrier. This affected Building 2 and had the potential to fail to contain smoke during a fire which could cause harm to the patients.

Findings:

During the facility tour with Staff 1 on March 12, 2012, the facility smoke barriers were observed.

At 5:29 p.m. on March 12, 2012, there were approximately five unsealed penetrations of different sizes in the smoke barrier adjacent to the roll down window in the lobby of Building 2. Staff 1 confirmed there were unsealed penetrations in the smoke barrier.

NFPA 101 Life Safety Code 2000 Edition, 8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with
the following.
(a) *Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows.

NFPA 101 Life Safety Code 2000 Edition, 8.3.3 Fire Barrier Used as Smoke Barrier. A fire barrier shall
be permitted to be used as a smoke barrier, provided that it meets the requirements of 8.3.4 through 8.3.6.

NFPA 80 Standard for Fire Doors and Fire Windows (1999 Edition) 1-5.1 Listed items shall be identified by a label. Labels shall be applied in locations that are readily visible and convenient for identification by the authority having jurisdiction after installation of the assembly.

NFPA 80, Standard for Fire Doors and Fire Windows 1999 Edition. 2-4.1.3 All components of closing devices used shall be attached securely to doors and frames by steel screws or through-bolts.

Based on observation, the facility failed to maintain the smoke barrier doors as evidenced by barrier doors that failed to latch and as evidenced by smoke barrier door rating labels that had been painted over. This affected Building 1 and had the potential to fail to contain smoke during a fire, the failure to install proper rated doors and causing injury to the patients.

Findings:

During the facility tour with Staff 1 on March 14 and 15, 2012, the facility smoke barriers were observed.

1. At 10:05 a.m. on March 14, 2012, the door rating labels in the smoke barrier at the entrance to the SNF corridor from Building 1 were painted over. The door ratings could not be identified. Staff 1 confirmed the rating labels were painted over.

2. At 2:55 p.m. on March 14, 2012, 1 of 2 door leaves in the smoke barrier door separating Units 3.1 and 3.2 in Building 1 failed to latch when tested. Staff 1 confirmed the door leaf failed to latch. The doors were equipped with surface vertical rod hardware for latching at the top and bottom of the door. The bottom bolt failed to latch.

3. At 2:57 p.m. on March 14, 2012, 1 of 2 door leaves in the smoke barrier door separating Units 3.1 and 3.3 in Building 1 failed to latch when tested. Staff 1 confirmed the door leaf failed to latch. The doors were equipped with surface vertical rod hardware for latching at the top and bottom of the door. The bottom bolt failed to latch.

4. At 8:35 a.m. on March 14, 2012, 2 of 2 door leaves in barrier door #2094 in the Operating Room in Building 1 failed to latch when tested. Staff 1 confirmed the door leaves failed to latch.

Based on observation and interview, the facility failed to protect the hazardous areas from other areas as evidenced by a self-closing corridor door that failed to latch. This affected Building 1 and had the potential to fail to contain smoke and fire causing harm to patients.

Findings:

During the facility tour with Staff 1 on March 14, 2012, the hazardous areas were observed.

At 9:28 a.m., the self-closing corridor door to the Lab Technical Area in Building 1 failed to fully close and latch without assistance. Staff 1 confirmed the door failed to fully close and latch without assistance.

NFPA 101 Life Safety Code (2000 Edition) 19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
Exception: As modified by 19.2.2 through 19.2.11
NFPA 101 Life Safety Code (2000 Edition) 7.2.1.5 - Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
NFPA 101 Life Safety Code (2000 Edition) 7.2.1.5.4 - A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm) above the finished floor. Doors shall be operable with not more than one releasing operation.
Based on observation, the facility failed to maintain exit access as evidenced by corridor doors that required more than one releasing operation. This affected Building 1 and had the potential for delaying egress in an emergency.
Findings:
During the facility tour with Staff 1 on March 13, 2012, the corridor doors were observed.
At 10:34 a.m., 2 of 2 corridor doors to the OB Operating Room in Building 1 were equipped with dead-bolt locks. When locked, two actions were required to open the door and exit the Operating Room. Staff 1 confirmed that two releasing actions were required to open each door when the door was locked.

NFPA 99 Standard for Health Care Facilities (1999 Edition) 3-3 Electrical System Requirements.
3-3.2.1.2 All Patient Care Areas. 5. Wiring in Anesthetizing Locations.
e. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

NFPA 101 Life Safety Code (2000 Edition) 7.9.3 Periodic testing of emergency lighting equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

NFPA 101 Life Safety Code (2000 Edition) 7.10.9.2 Testing. Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance
with 7.9.3.

Based on observation and interview, the facility failed to maintain the emergency lighting as evidenced by the failure to provide documentation for the monthly and annual testing of the lights and the failure to provide emergency lighting in an operating room. This affected Building 1 and had the potential for the lighting to fail.

Findings:

During the document review and facility tour with Staff 1, 2 and 3 on March 12, 13 and 14, 2012, the emergency lighting was observed.

At 10:35 a.m. on March 13, 2012, the OB Operating Room in Building 1 was observed. There were no emergency lights observed in the Operating Room. Staff 1 stated the Operating Room was connected to the emergency generator for emergency lighting.

NFPA 72 National Fire Alarm Code (1999 Edition) 2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

NFPA 72 National Fire Alarm Code (1999 Edition) 7-3 Inspection and Testing Frequency.

7-3.1* Visual Inspection. Visual inspection shall be performed in accordance with the schedules in Section 7-3 or more often if required by the authority having jurisdiction. The visual inspection shall be made to ensure that there are no changes that affect equipment performance.

Exception No. 1: Devices or equipment that is inaccessible for safety considerations (for example, continuous process operations, energized electrical equipment, radiation, and excessive height) shall be inspected during scheduled shutdowns if approved by the authority having jurisdiction.
Extended intervals shall not exceed 18 months.

Exception No. 2: If automatic inspection is performed at a frequency of not less than weekly by a remotely monitored fire alarm control unit specifically listed for such application, the visual inspection frequency shall be permitted to be annual. The requirements of Table 7-3.1 shall apply.

NFPA 72 National Fire Alarm Code (1999 Edition) 7-3.2 Testing. Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply.

Exception: Devices or equipment that are inaccessible for safety considerations (for example, continuous process operations, energized electrical equipment, radiation, and excessive height) shall be tested during scheduled shutdowns if approved by the authority having jurisdiction but shall not be tested more than every 18 months.

NFPA 72 National Fire Alarm Code (1999 Edition) Table 7-3.2 Testing Frequencies, Item 6(d)(1) Sealed lead acid batteries are to be replaced every 4 years.

NFPA 101 Life Safety Code (2000 Edition) 9.6.2.6 Each manual fire alarm box on a system shall be accessible, unobstructed, and visible.

Based on observation, interview and document review, the facility failed to maintain the fire alarm system as evidenced by an obstructed manual fire alarm box, undated batteries in fire alarm panels, the failure to test a fire alarm system monthly, and by the failure to provide documentation for the annual inspection and testing of the fire alarm system. This affected Buildings 2 and 3 and had the potential for the delay in alarm activation, fire alarms system failure and harm to the patients.

Findings:

During the document review and facility tour with Staff 1, 2 and 3 on March 12 and 13, 2012, the manual fire alarm boxes were observed and the fire alarms inspection and test records were reviewed.

1. At 11:10 a.m. on March 12, 2012, the sealed, lead acid battery (SLA) for the main fire alarm panel located in Building 3 was not dated as to when the battery was installed. Staff 2 confirmed the battery was not dated as to when it was installed.

2. At 11:15 a.m. on March 12, 2012, a duct detector was observed above the drop ceiling in the first floor corridor adjacent to the Imaging Center in Building 3. Staff 2 and 3 were unsure if the detector and the damper connected to the detector was active and did not know if the air duct was active. A vendor letter dated 3-13-12 indicated the detector was connected to a fire panel observed in the first floor waiting area for the Out-patient Laboratory and Out-patient Radiology. The vendor letter indicated the panel was no longer in service. Staff 2 and 3 stated the air conditioning system would need to be checked to see if the duct with the detector was still active.

3. At 5:11 p.m. on March 12, 2012, there was no manual fire alarm system in Building 3 to automatically warn the building occupants. Staff 2 and 3 confirmed there was no manual fire alarm in the building.

4. At 5:11 p.m. on March 12, 2012, the sprinkler system was tested in Building 3. The fire alarm panel communicated the fire alarm to the monitoring company. The fire alarm activation on the panel failed to automatically warn the building occupants. Staff 2 and 3 confirmed the alarm failed to activate an alarm to warn the building occupants.

5. At 5:30 p.m. on March 12, 2012, access to the manual fire alarm box in the Lobby of Building 2 was obstructed by a chair. Staff 2 and 3 confirmed the chair obstructed access to the manual fire alarm box and moved the chair.

NFPA 13 Standard for the Installation of Sprinkler Systems (1999 Edition), 5-6.5.1.2 Sprinklers shall be arranged to comply with 5-5.5.2, Table 5-6.5.1.2, and Figure 5-6.5.1.2(a).

NFPA 13 Standard for the Installation of Sprinkler Systems (1999 Edition), Table 5-6.5.1.2 Positioning of Sprinklers to Avoid Obstructions to Discharge (SSU/SSP) requires where the distance from the sprinkler to the side of the obstruction is less than 1 foot, the maximum allowable distance of the sprinkler deflector above the bottom of the obstruction is zero inches. An obstruction greater than 1 foot to less than 18 inches, the maximum allowable distance of the sprinkler deflector above the bottom of the obstruction is 2 1/2 inches.

NFPA 13 Standard for the Installation of Sprinkler Systems (1999 edition) 5-13.8 Sprinklers shall be installed under exterior roof or canopies exceeding 4 ft (1.2 m) in width.

Exception: Sprinkler are permitted to be omitted where the canopy or roof is noncombustible or limited combustible construction.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (1998 Edition), 2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendent, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, or in the improper orientation.

Exception No. 1: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.

Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems
(1998 Edition) 2-2.1.2 Unacceptable obstructions to spray patterns shall be corrected.

NFPA 101 Life Safety Code (2000 Edition), 19.3.4.2* Initiation. Initiation of the required fire alarm systems shall be by manual means in accordance with 9.6.2 and by means of any required sprinkler system waterflow alarms, detection devices, or detection systems.

NFPA 101 Life Safety Code (2000 Edition), 20.3.4.2 Initiation. Initiation of the required fire alarm systems
shall be by manual means in accordance with 9.6.2 and by means of any detection devices or detection systems required.

NFPA 101 Life Safety Code (2000 Edition), 9.6.2.1 Where required by other sections of this Code, actuation of the complete fire alarm system shall occur by any or all of the following means of initiation, but shall not be limited to such means:
(1) Manual fire alarm initiation
(2) Automatic detection
(3) Extinguishing system operation

Based on observation, the facility failed to maintain the facility sprinkler system as evidenced by sprinkler heads with foreign material on the sprinkler heads, unsprinklered canopies, obstructed sprinkler spray patterns and a waterflow alarm that failed to annunciation on the fire alarm panel. This affected Buildings 3 and had the potential for sprinkler failure leading to patient injury.

Findings:

During the facility tour with Staff 1, 2 and 3 March 12, 13 and 14, 2012, the facility sprinkler system was observed.


1. At 11:15 a.m. on March 12, 2012, there was an approximately 8 foot by 12 foot canopy attached to the roof at the main entrance and an approximately 8 foot by 12 foot canopy attached to the roof at the rear entrance of Building 3 that were not sprinklered. Staff 2 confirmed the canopies were not sprinklered and stated he did not know if the canopies were treated or made of flame resistive materials.

2. At 1:25 p.m. on March 14, 2012, the sprinkler head in Refrigerator 1 and Refrigerator 2 in the Kitchen in Building 1 were approximately three inches adjacent to a light fixture. The bottom of the light fixture was even with the bottom of the sprinkler deflector and would obstruct the sprinkler spray pattern. Staff 1 confirmed the light fixtures were within three inches of the sprinkler deflectors.

3. At 2:20 p.m. on March 14, 2012, the sprinkler head in the East Risk Management corridor in Building 1 was approximately three inches adjacent to an exit sign. The bottom of the exit sign extended approximately six inches below the bottom of the sprinkler deflector and would obstruct the sprinkler spray pattern. Staff 1 confirmed the exit sign was within three inches of the sprinkler deflector.

4. At 8:40 p.m. on March 15, 2012, the sprinkler head in the Operating Room Housekeeping Room #2092 in Building 1 was approximately six inches adjacent to a light fixture. The bottom of the light fixture extended approximately two inches below the bottom of the sprinkler deflector and would obstruct the sprinkler spray pattern. Staff 1 confirmed the light fixture was within six inches of the sprinkler deflector.

NFPA 10 Standard for Portable Fire Extinguishers (1998 Edition) 1-6.6 Fire extinguishers shall not be obstructed or obscured from view.

Exception: In large rooms, and in certain locations where visual obstruction cannot be completely avoided, means shall be provided to indicate the location.

NFPA 10 Standard for Portable Fire Extinguishers (1998 Edition) 1-6.7 Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or place in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer's instructions. Wheeled-type extinguishers shall be located in a designated location.

Based on observation and interview, the facility failed to maintain access to the fire extinguishers as evidenced by obstructed access to fire extinguishers and a fire extinguisher hung on a hanger not designed for the fire extinguisher. This affected Buildings 1 and 3 and had the potential for some persons not to be able to access the extinguisher, persons being injured due to having to reach for the extinguisher or dislodgement of the extinguisher. This could delay the extinguishment of a fire and cause injury to the patients.

Findings:

During the facility tour with Staff 1, 2 and 3 on March 12, 13 and 14, 2012, the fire extinguishers were observed.

1. At 12:10 p.m. on March 12, 2012, access to the fire extinguisher in the Lobby of Building 3 adjacent to Suite 108 was obstructed by a chair in front of the fire extinguisher cabinet. Staff 2 confirmed the access was blocked by the chair and moved the chair to allow access to the extinguisher.

2. At 11:08 a.m. on March 13, 2012, visual access to the fire extinguisher in the Medical Records area of Building 1 was obstructed. The facility failed to provide a means to indicate the location of the extinguisher in the room. Staff 1 confirmed the access to the extinguisher was visually obscured.

3. At 9:25 a.m. on March 14, 2012, access to the fire extinguisher Station #147 in the lab technical area was obstructed by a work deck. To access the extinguisher required reaching approximately twelve inches across the work deck. Staff 1 confirmed the access was obstructed by the work deck.

At 1:27 p.m. on March 14, 2012, the K-Class fire extinguisher in the Kitchen of Building 1 was not mounted on an extinguisher hanger designed for the fire extinguisher. The extinguisher was designed to be hung on the wall with a J hanger. The extinguisher was hung on a hanger with a hook. Staff 1 confirmed the extinguisher was not secured on a J hanger.

NFPA 101 Life Safety Code (2000 Edition) 19.7.4* Smoking. Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.

Exception: In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.

Based on observation and document review, the facility failed to enforce the facility smoking policy as evidenced by the failure to post "NO SMOKING" signs or the international sign for no smoking at entrances to the facility. This affected Buildings 2 and 3 and had the potential for smoking in the facility.

Findings:

During the document review and facility tour with Staff 1 on March 15, 2012, the facility smoking policy was reviewed and the facility entrances were observed.

1. At 7:47 a.m., the facility failed to post a "NO SMOKING" sign or a sign with the international symbol for no smoking at the main entrance of Building 3. Staff 1 stated he thought there was a sign posted at the entrance. On page 1 of the facility policy titled "Smoking," the policy indicates "No Smoking" signs shall be posted at building entrance points."

2. At 7:55 a.m., the facility failed to post a "NO SMOKING" sign or a sign with the international symbol for no smoking at the main entrance of Building 2. Staff 1 stated he thought there was a sign posted at the entrance. On page 1 of the facility policy titled "Smoking," the policy indicates "No Smoking" signs shall be posted at building entrance points."

NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems (1999 Edition), 2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.

NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems (1999 Edition), 2-3.4.2 Service openings shall be identified with letters having a minimum of 1/2 in. (1.27 cm) to indicate the location of the fire protection device(s) within.

NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems (1999 Edition), 3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they close fully; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Based on observation and interview, the facility failed to maintain the heating, ventilating and air-conditioning system as evidenced by the failure to provide lettering on duct service openings adjacent to dampers and the failure to provide documentation for the testing and maintenance of the dampers. This affected Buildings 1 and 2 and had the potential for staff to be unaware of the presence of the damper for maintenance and testing leading to damper failure and harm to the patients.

Findings:

During the facility tour with Staff 1 on March 13 and 14, 2012, the facility dampers were observed.

At 4:25 p.m. on March 13, 2012, the duct access panel adjacent to the damper above the corridor adjacent to the fire alarm panel closet in Building 2 was not identified indicating a damper within the duct. Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.

At 6:30 p.m. on March 13, 2012, the facility failed to provide records verifying the fire dampers in Building 2 had been maintained. Staff 1 stated the fire dampers maintenance records were not available.

At 9:53 a.m. on March 14, 2012, the duct access panel adjacent to the damper above the corridor entrance to the SNF from Building 1 was not identified indicating a damper within the duct. The barrier with the duct was adjacent to the Pink Ladies' Desk. Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.

NFPA 99 Standard for Health Care Facilities (1999 Edition) 4-3.5.3* Gas Systems Recordkeeping-Level 1. Prior to the use of any medical gas piping system for patient care, the responsible authority of the facility shall ensure that all tests required in 4-3.4.1 have been successfully conducted and permanent records of the test maintained in the facility files.

Based on observation and document review, the facility failed to maintain the oxygen system as evidenced by the failure to provide documentation for the repairs to the oxygen system. This affected Buildings 1 and had the potential for oxygen system failure leading to harm of the patients.

Findings:

During the document review on March 12, 2012, the oxygen system test results were reviewed.

At 3:55 p.m. on March 12, 2012, the facility provided test records for the oxygen supply and distribution system in Building 1 dated 2-3-12. The report indicated the repairs had not yet been made. Staff 2 stated the repairs had been scheduled but not yet completed.

NFPA 70 National Electrical Code (1999 edition) 370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

NFPA 70 National Electrical Code (1999 Edition) 384-13. General. All panelboards shall have a rating not less than the minimum feeder capacity required for the load computed in accordance with Article 220. Panelboards shall be durably marked by the manufacturer with the voltage and the current rating and the number of phases for which they are designed and with the manufacturer's name or trademark in such a manner so as to be visible after installation, without disturbing the interior parts or wiring. All panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors.

NFPA 70 National Electrical Code (1999 Edition), 400-7 Uses Permitted.
(a) Uses. Flexible cords and cables shall be used only for the following:

(1) Pendants
(2) Wiring of fixtures
(3) Connection of portable lamps, portable and mobile signs, or appliances
(4) Elevator cables
(5) Wiring of cranes and hoists
(6) Connection of stationary equipment to facilitate their frequent interchange
(7) Prevention of the transmission of noise or vibration
(8) Appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, and the appliance is intended or identified for flexible cord connection
(9) Data processing cables as permitted by Section 645-5
(10) Connection of moving parts
(11) Temporary wiring as permitted in Sections 305-4(b) and 305-4(c)

NFPA 70 National Electrical Code (1999 Edition) 400-8. Uses Not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure

NFPA 99 Standard for Health Care Facilities (1999 Edition) 3-3.2.1.1 Electrical Installation. Installation shall be in accordance with NFPA 70, National Electrical Code.

NFPA 99 Standard for Health Care Facilities (1999 Edition) 3-3.2.1.2 (f) Wet Locations. 1. Fixed receptacles, equipment connected by cord and plug, and fixed electrical equipment shall be tested:
(1) When first installed
(2) Where there is evidence of damage
(3) After any repairs, or
(4) At intervals not exceeding 6 months

NFPA 99 Standard for Health Care Faculties (1999 Edition), 3-3.3.3 Receptacle Testing in Patient Care Areas

(a) The physical integrity of each receptacle shall be confirmed by visual inspection.

(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.

(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.

(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

NFPA 99 Standard for Health Care Facilities (1999 Edition), 3-3.4.2.3 Maintenance and Testing of Electrical System.

(a) Testing Interval for Receptacles in Patient Care Areas.

1. Testing shall be performed after initial installation, replacement, or servicing of the device.

2. Additional testing shall be performed at intervals defined by documented performance data.

Exception: Receptacles not listed as hospital-grade shall be tested at intervals not exceeding 12 months.

Based on observation and interview, the facility failed to maintain the electrical wiring and equipment as evidenced by an electrical receptacle that was missing a cover plate, as evidenced by breakers in the on position and not labeled as to the purpose or use, the failure to provide documentation for the testing of the electrical receptacles, as evidenced by patient care equipment plugged into surge protectors instead of directly into an electrical receptacle, the use of surge protectors to provide additional outlets in place of providing fixed wired receptacles and the failure to provide documentation that the use of surge protectors in providing additional outlets on the circuits was in compliance with NFPA 70. This affected Buildings 1, 3, 4 and 5 and had the potential for electrical shock or fire and causing harm to the patients.

Findings:

During the document review and facility tour with Staff 1, 2 and 3 on March 12, 13 and 14, 2012, the electrical receptacles and panels were observed and receptacle testing documents were reviewed.

1. At 11:55 a.m. on March 12, 2012, the electrical receptacle on the south wall in the 2nd Floor Information Technology Room in Building 3 was missing the cover plate. Staff 2 confirmed the receptacle was missing the cover plate.

2. At 10:33 a.m. on March 13, 2012, in the OB Operating Room in Building 1, there was a patient warmer and the OR table plugged into a multi-plug adapter with surge protection instead of directly into a fixed wired electrical receptacle. The adapter was used as a substitute for additional fixed wired electrical receptacles. Staff 1 confirmed the use of the surge protector and stated he did not have documentation that adding the additional receptacles through the use of the surge protector was approved and installed in accordance with NFPA 70, National Electrical Code.

3. At 10:33 a.m. on March 13, 2012, in the OB Operating Room in Building 1, there was a Bovi and a pump plugged into a multi-plug adapter with surge protection instead of directly into a fixed wired electrical receptacle. The adapter was used as a substitute for additional fixed wired electrical receptacles. Staff 1 confirmed the use of the surge protector and stated he did not have documentation that adding the additional receptacles through the use of the surge protector was approved and installed in accordance with NFPA 70, National Electrical Code.

4. At 10:56 a.m. on March 13, 2012, on Emergency Electrical Panel ELB in the basement of Building 1, breakers 9, 11, and 12-18 were in the on position and not labeled as to the area served by the breakers. Staff 1 confirmed the breakers were not labeled. Staff 1 opened the panel and found the breakers not to be connected to power and switched the breakers to the off position.

5. At 8:40 a.m. on March 14, 2012, on Electrical Panel LSPC in Building 1, breakers 8-12 were marked "Spare" and were in the on position and not labeled as to the area served by the breakers. Staff 1 confirmed the breakers were not labeled and in the on position.

6. At 8:43 a.m. on March 14, 2012, on Electrical Panel EL1 in Building 1, breakers 1, 3, 5, 7, 9 and 11 were marked "Spare" and were in the on position and not labeled as to the area served by the breakers. Staff 1 confirmed the breakers were not labeled and in the on position.

7. At 3:39 p.m. on March 14, 2012, on Electrical Panel LSL3 in Building 1, breakers 7-12 were marked "Spare" and were in the on position and not labeled as to the area served by the breakers. Staff 1 confirmed the breakers were not labeled and in the on position.

8. At 8:25 a.m. on March 15, 2012, in the Operating Room 1 in Building 1, there was a patient bed and a pump plugged into a multi-plug adapter with surge protection instead of directly into a fixed wired electrical receptacle. The adapter was used as a substitute for additional fixed wired electrical receptacles. Staff 1 confirmed the use of the surge protector and stated he did not have documentation that adding the additional receptacles through the use of the surge protector was approved and installed in accordance with NFPA 70, National Electrical Code.

9. At 10:29 a.m. on March 15, 2012, on Electrical Panel EP2B in Building 1, breakers 14, 27, 35, 37 39 and 41 were marked "Spare" and were in the on position and not labeled as to the area served by the breakers. Staff 1 confirmed the breakers were not labeled and in the on position.

10. At 10:30 a.m. on March 15, 2012, on Electrical Panel EP2A in Building 1, breakers 28, 30, 32, 34, 36, 38, 40 and 42 were marked "Spare" and were in the on position and not labeled as to the area served by the breakers. Staff 1 confirmed the breakers were not labeled and in the on position.

11. At 10:30 a.m. on March 15, 2012, on Electrical Panel EL2 in Building 1, breakers 7 and 9-12 were marked "Spare" and were in the on position and not labeled as to the area served by the breakers. Staff 1 confirmed the breakers were not labeled and in the on position.