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Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by unsealed penetrations and open ceiling tiles. This affected Building 2 and Building 3 and had the potential to allow the spread of smoke during a fire.

Findings:

During the facility tour with Staff 1 on January 10 and 11, 2012, the facility walls and ceilings were observed.

1. At 3:35 p.m. on January 10, 2012, in the elevator room 1-95 of Building 3, there was an unsealed one half inch gap around a two inch conduit that penetrated the left wall. Staff 1 confirmed the conduit was not sealed where the conduit penetrated the wall.

2. At 2:47 p.m. on January 11, 2012, the sprinkler escutcheon in the Transfusion Storage Room of Building 2 was missing, exposing an unsealed three quarter inch gap around the sprinkler pipe where the pipe penetrated the ceiling. Staff 56 confirmed the escutcheon was missing and there was a three quarter inch gap around the sprinkler pipe where the pipe penetrated the ceiling.



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3. At 10:54 a.m. on January 11, 2012, there were three ceiling tiles missing in the ceiling of the Building 3, Second Floor server equipment room.

4. At 10:56 a.m. on January 11, 2012, there was an unsealed 4 inch sleeve with a bundle of blue cables passing through the wall between the second floor server equipment room and Room 2-16 of Building 3.

5. At 10:58 a.m. on January 11, 2012, there was 3 foot by 8 foot area above the ceiling tiles where the sheetrock was removed in the wall common to the bathroom in the second floor server equipment room of Building 3.

6. At 10:59 a.m. on January 11, 2012, there was a ? inch unsealed pipe sleeve that passed up the wall above the ceiling tile in the Building 3 second floor server equipment room to the ceiling area above the third floor server equipment.

7. At 11:45 a.m. on January 11, 2012, there was an unsealed two inch pipe sleeve with a one inch penetration around a bundle of blue cables which passed through the wall above the ceiling in ICU Equipment Room 2-184 in Building 3.

8. At 1:40 p.m. on January 12, 2012, there was an approximately ? inch ceiling penetration on one side of the sprinkler pipe in Building 5, Emergency Department Cast Room. The escutcheon was missing.

9. At 3:27 p.m. on January 12, 2012, there was an approximately ? inch ceiling penetration around the sprinkler pipe in Building 5, CT Procedure Room. The escutcheon was missing.

Based on observation, the facility failed to maintain the integrity of the corridor walls. This was evidenced by an unsealed corridor wall penetration. This affected Building 3 and had the potential to allow the passage of smoke causing harm to the patients.

Findings:

During the facility tour with Staff 1on August 10, 2010, the facility corridor walls and ceilings were observed.

At 3:08 p.m. on January 10, 2012, above the door on the corridor side to the Board Room in Building 3, there was an unsealed one inch gap around a conduit that penetrated the wall. Staff 1 confirmed there was an unsealed penetration in the corridor wall.

NFPA 80 Standard for Fire Doors and Fire Windows (1999 Edition)15-2.1.1* Hardware shall be examined frequently and any parts found to be inoperative shall be replaced immediately.

NFPA 80 Standard for Fire Doors and Fire Windows (1999 Edition)15-2.1.3 Chains or cables employed on suspended doors shall be inspected frequently for excessive wear and stretching.

NFPA 80 Standard for Fire Doors and Fire Windows (1999 Edition)15-2.2.1 Guides and bearings shall be kept well lubricated to facilitate operation.

NFPA 80 Standard for Fire Doors and Fire Windows (1999 Edition)15-2.2.2 Chains or cables on biparting, counterbalanced doors shall be checked frequently and adjustments shall be made to ensure proper latching and to keep the doors in proper relation to the opening.

NFPA 80 Standard for Fire Doors and Fire Windows (1999 Edition)15-2.4.1 Self-closing devices shall be kept in proper working condition at all times.

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 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 corridor doors. This was evidenced by the failure to provide documentation for the inspection and maintenance of the rolling fire windows, by doors that failed to latch and self-closing doors that were impeded from closing. This affected Buildings 3, 4 and 5 and had the potential to fail to contain smoke during a fire leading to injury to the patients.

Findings:

During the facility tour with Staff 1 on January 10, 11 and 12, 2012, the corridor doors were observed.


1. At 1:28 p.m. on January 10, 2012, the corridor door to the Mammography Dexa Room in suite 203 of Building 4 failed to fully close and latch. Staff 56 confirmed the door failed to fully close and latch. 26388

2.. At 3:42 p.m. on January 10, 2012, the door between the Pharmacy and the Pharmacy IV room in Building 3 failed to latch. Staff 1 confirmed the door failed to latch. 26388

3.. At 5:08 p.m. on January 10, 2012, the Medical Staff Office was observed. The rated, self-closing doors to the CMO Office, the Medical Staff Director ' s Office, the assistant Director ' s Office and the Quality Manager ' s Officer in Building 3 were each obstructed from closing by a door wedge. Staff 1 confirmed the doors were obstructed from closing by the door wedges. 26388

4.. At 9:25 a.m. on January 12, 2012, the inspection, maintenance and test records for the roll down fire windows were requested. The fire alarm vendor stated the windows were only tested with the fire alarm system. The maintenance director stated the facility only tested the windows with the fire alarm system. The maintenance director stated there was no inspection and maintenance program to examine the hardware, inspect the chains or cables for excessive wear and stretching, or lubrication of the guides and bearings.

5. At 2:20 p.m. on January 12, 2012, the corridor door to the OB Dictation Room was equipped with a dead-bolt. The dead-bolt was not self-latching. When closed, the door failed to latch unless the dead-bolt was manually engaged. Staff 1 confirmed the door was not self-latching.



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6. At 9:39 a.m. on January 10, 2012, a patient room door at room 225 in Building 3 failed to latch in three of three attempts. The door latch was jammed.

7. At 9:41 a.m. on January 10, 2012, a patient room door at room 211 in Building 3 failed to latch in three of three attempts. The door latch was binding.

8. At 10:40 a.m. on January 10, 2012, a patient room door at room 228 in Building 3 failed to latch in three of three attempts. The door latch was binding.

9. At 5:17 p.m., on January 10, 2012 a laboratory entrance door labeled 1-222A in Building 3 failed to latch in six of eight attempts. Staff 64 confirmed the door failed to latch.

NFPA 101 Life Safety Code, 2000 Edition
7.10.8.1* No Exit. Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows: NO EXIT

Such sign shall have the word NO in letters 2 in. (5 cm) high with a stroke width of 3/8 in. (1 cm) and the word EXIT in letters 1 in. (2.5 cm) high, with the word EXIT below the word NO.
Exception: This requirement shall not apply to approved existing signs.

Based on observation, the facility failed to mark access to exits. This was evidenced by no signs posted for two exits, one hallway exit directional change, and a corridor that was not an exit and not identified as not an exit. This affected Buildings 2, 5 and 7 and could delay evacuation in the event of a fire.

Findings:

During the facility tour and interview with Staff 59 on January 11, 2012, the facility corridors and exit signs were observed.

1. At 3:02 p.m. on January 11, 2012, when looking towards the end of the corridor adjacent to room 155 in Building 2, there was no exit directional sign visible. Staff 56 confirmed there was no visible exit sign when looking in the corridor towards room 155.

2. At 1:50 p.m. on January 12, 2012, when looking east in the corridor at the smoke barrier adjacent to the Staffing Office in Building 5, there was no visible exit sign when looking towards the smoke barrier if the smoke barrier doors were closed. Staff 61 confirmed there were no exit signs visible when looking at the smoke barrier if the smoke barrier doors were closed.



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3. At 3:25 p.m. on January 11, 2012, there were no exit signs visible anywhere inside Building 7. Staff 59 confirmed that there were no exit signs visible.

4. At 3:30 p.m. on January 11, 2012, there was no exit sign for the exit door from the back hallway of Building 7.

5. At 3:32 p.m. on January 11, 2012, there was no directional exit sign where the exit access corridor turned to the left in the back hallway of Building 7.

6. At 3:38 p.m. on January 11, 2012, there was a dead-end front hallway that was next to the office in Building 7. The door had been locked and blocked. The hallway was greater than ten feet long and had no sign indicating that this was not an exit.

7. At 3:45 p.m. on January 11, 2012, there was no exit sign visible for the main entrance at the lobby area of Building 7 when viewed from inside the therapy area.

Based on observation, the facility failed to maintain their smoke barrier wall to resist the passage of smoke. This was evidenced by unsealed penetrations in the smoke barrier walls. This affected Buildings 2, 3 and 5 and had the potential to fail to contain smoke during a fire which could cause harm to the residents.

Findings:

During the facility tour with Facility Staff on January 10 and 11, 2012, the facility smoke barriers were observed.

1. At 3:15 p.m. on January 10, 2012, there were two, approximately one and one/quarter inch unsealed penetrations on the west side of the smoke barrier adjacent to the Board Room in Building 3. Staff 1 confirmed there were unsealed penetrations in the smoke barrier.

2. At 2:25 p.m. on January 11, 2012, there was an approximately one-quarter inch unsealed penetration around the sprinkler pipe that penetrated the barrier above the corridor door from the waiting room to the Out-patient Surgery Center in Building 2. Staff 56 confirmed there was an unsealed penetration in the separation barrier.

3. At 10:25 a.m. on January 12, 2012, there was an approximately three inch unsealed penetration in the smoke barrier adjacent to the attic access in the Selma Campus Respiratory Therapy Office in Building 5. There were wires running through the penetration. Staff 61 confirmed there was an unsealed penetration in the smoke barrier and stated the wires were for the IT system.

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.

Based on observation, the facility failed to maintain smoke barrier doors and failed ensure that the fire rating of the smoke barrier doors were readable. This was evidenced the door frame rating labels that were painted over and doors that failed to latch. This affected Buildings 3 and 5 and had the potential for non-rated doors to be installed and the failure of the doors to contain smoke during a fire.

Findings:

During the facility tour with Staff on January 12, 2012, the facility smoke and fire barriers were observed.

1. At 8:51 a.m. on January 12, 2012, the double set of doors at the Patient Only elevator foyer at the third floor of Building 3 failed to latch in three of three attempts. Staff 64 observed that the doors did not latch.




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2. At 10:25 a.m. on January 12, 2012, 8 of 8 barrier door frame labels on the south side of the Radiology Corridor in Building 5 were painted over. The floor plan provided by the facility noted the south side of the Radiology Corridor to be some type of barrier. Building blue-prints were unavailable to determine the rating and type of barrier. Staff 61 confirmed the frame rating labels were painted over.

Based on observation, the facility failed to ensure that doors protecting gift shops were not prevented from closing. This was evidenced by the door to the gift shop that was held in the open position by a rubber door wedge. This could result in the spread of fire or smoke, in the event of a fire affecting two of twenty smoke compartments.

During the facility tour on 1/9/12 and 1/10/12 the gift shop door was observed.

At 4:02 p.m. on January 9, 2012, there was a rubber wedge holding the Gift Shop door to the lobby in Building 3 in a fully opened position.

Based on observation and interview, the facility failed to maintain readily available exits. This was evidenced by equipment obstructing egress. This could result in a delay of evacuation during a fire and affected Building 3.

Findings:

During the facility tour with Staff 59 on 1/11/12, the facility exits and exit access were observed on the first floor of Building 3.

1. At 11:35 a.m. on January 11, 2012, in the Emergency Department of Building 3, there was a gurney stored along the wall next to a set of smoke barrier doors at location placard " HW4. " These doors provided egress access in both directions. When the double set of opposite swing doors closed, the gurney obstructed egress down to a clearance of approximately 18 inches.

2. At 11:39 a.m. on January 11, 2012, in the Emergency Department of Building 3, there were two chairs stored along the wall next to a set of smoke barrier doors at location placard " HW5. " These doors provided egress access in both directions. When the double set of opposite swing doors closed, the chairs obstructed egress down to a clearance of approximately 16 inches.

3. At 11:42 a.m. on January 11, 2012, in the Emergency Department of Building 3, there was a gurney stored along the wall next to a set of smoke barrier doors at location placard " HW6. " These doors provided egress access in both directions. When the double set of opposite swing doors closed, the gurney obstructed egress down to a clearance of approximately 22 inches.

During an interview on 1/11/12 at 11:37 p.m., staff 59 was asked to explain the reason for the gurneys and chairs with location placards. He described that these were provided for patient locations while being seen in the Emergency Department.

NFPA 101 Life Safety Code (2000 Edition) 3.3.107* Illuminated, Internally. Refers to an illumination source that is contained inside the device or legend that is illuminated.

NFPA 101 Life Safety Code (2000 Edition) 7.10.1.2* Exits. Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

NFPA 101 Life Safety Code (2000 Edition) 7.10.7.1 Listing. Internally illuminated signs, other than approved existing signs, or existing signs having the required wording in legible letters not less than 4 in. (10.2 cm) high, shall be listed in accordance with UL 924, Standard for Safety Emergency Lighting and Power Equipment.
Exception: This requirement shall not apply to signs that are in accordance with 7.10.1.3 and 7.10.1.5.

NFPA 101 Life Safety Code (2000 Edition) 39.2.10 Marking of Means of Egress. Means of egress shall have signs in accordance with Section 7.10.

Based on observation, the facility failed to maintain the exit signs. This was evidenced by expired self-illuminated exit signs and a corridor where an exit sign was not visible. This affected Buildings 2, 5 and 6 and had the potential for the delaying egress from the building.

Findings:

During the facility tour with Staff on January 11 and 12, 2012, the facility exit signs were observed.

1. At 11:31 a.m. on January 11, 2012, the self-illuminated exit sign adjacent to the Occupational Therapy reception desk in Building 6 had printed on the sign "Replace before April 2010." Staff 56 confirmed the sign stated it should be replaced before April 2010.

2. At 2:10 p.m. on January 11, 2012, the self-illuminated exit sign adjacent to room 161 in Building 2 had printed on the sign "Replace before 6/2008." Staff 56 confirmed the sign stated it should be replaced before 6/2008.

3. At 3:06 p.m. on January 11, 2012, the self-illuminated exit sign adjacent to room 142 in Building 2 had printed on the sign "Replace before 6/2008." Staff 56 confirmed the sign stated it should be replaced before 6/2008.

4. At 11:25 a.m. on January 12, 2012, the self-illuminated exit sign adjacent to room 48 in Building 5 had printed on the sign "Replace before 4-2011." Staff 61 confirmed the sign stated it should be replaced before April 2011.

5. At 11:35 a.m. on January 12, 2012, the self-illuminated exit sign adjacent to room 20 in Building 5 had printed on the sign "Replace before 4-2011." Staff 61 confirmed the sign stated it should be replaced before April 2011.

6. At 1:45 p.m. on January 12, 2012, the self-illuminated exit sign adjacent to the Chapel in Building 5 had printed on the sign "Replace before 4-2011." Staff 61 confirmed the sign stated it should be replaced before April 2011.

7. At 1:52 p.m. on January 12, 2012, the self-illuminated exit sign adjacent to the OB Nurse Station in Building 5 had printed on the sign "Replace before 4-2011." Staff 61 confirmed the sign stated it should be replaced before April 2011.

Based on interview and document review, the facility failed to ensure that fire drills were conducted to prepare staff to protect patients from fire. This was evidenced by the failure to provide documentation that required fire drills were conducted, the failure to use a coded announcement during a NOC shift drill and the failure to provide documentation for staff response to the drill outside of the immediate drill area. This had the potential for staff to be unable to react under different circumstances and different times during the shift and affected the Buildings 2, 3 and 5.

Findings:

During the document review on January 9, 12 and 13, 2012, the facility fire drill report logs were reviewed.

1. At 1:15 p.m. on January 9, 2012, the facility was requested to provide documentation for fire drills. At 3:45 p.m. the drill records were incomplete. Staff 56 stated the drills were incomplete and that the facility was attempting to provide a complete drill record. At 8:15 a.m. on January 13, 2012, the complete fire drill records were requested. The facility failed to provide 4 of 4 required drill records for the Ambulatory Surgery Center located in Building 2. Staff 56 confirmed the four drill reports were not available.

2. At 1:30 p.m. on January 9, 2012, the facility was requested to provide documentation for fire drills. At 3:45 p.m., the facility failed to provide 6 of 12 required drill records for Building 3. The facility failed to provide documentation for the AM, PM and NOC shifts for the 1st quarter (January-March) of 2011, the AM and PM shifts for the 2nd quarter (April-June) of 2011 and the NOC shift for the 3rd quarter (July-September) of 2011. Staff 1 confirmed the reports were not available.

3. At 3:45 p.m. on January 9, 2012, 6 of 12 required drill records for Building 3 failed to document staff reaction during the drill in areas away from the drill location. 5 of 6 drill indicated alarm activation or an overhead page to alert other areas. The 4th quarter drill of 2011 on the NOC shift documented that the alarm was not activated and that no overhead page was announced which failed to alert other areas for participation in the drill. Staff 1 confirmed the drill reports failed to document staff response in other areas of the facility.

4. At 8:45 a.m. on January 12, 2012, the facility was requested to provide documentation for fire drills. The facility failed to provide 7 of 12 required drill records for Building 5. The facility failed to provide documentation for the AM, PM and NOC shifts for the 2nd quarter of 2011, the PM shift for the 3rd quarter of 2011 and the PM and NOC shifts for the 4th quarter of 2011. Staff 56 confirmed the reports were not available.

NFPA 72 National Fire Alarm Code? 1999 Edition. 1-6.2 Completion Documents.
1-6.2.1* A record of completion (Figure 1-6.2.1) shall be prepared for each system. Parts 1, 2, and 4 through 10 shall be completed after the system is installed and the installation wiring has been checked. Part 3 shall be completed after the operational acceptance tests have been completed. A preliminary copy of the record of completion shall be given to the system owner and, if requested, to other authorities having jurisdiction after completion of the installation wiring tests. A final copy shall be provided after completion of the operational
acceptance tests.

NFPA 72 National Fire Alarm Code? 1999 Edition. 1-6.2.2 Every system shall include the following documentation, which shall be delivered to the owner or the owner ' s representative upon final acceptance of the system:
(1) *An owner ' s manual and installation instructions covering all system equipment
(2) Record drawings

NFPA 72 National Fire Alarm Code? 1999 Edition. 7-1.6 System Testing.
7-1.6.1 Initial Acceptance Testing. All new systems shall be inspected and tested in accordance with the requirements of Chapter 7.

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 72 National Fire Alarm Code? 1999 Edition. 7-5.1* Permanent Records. After successful completion of acceptance tests approved by the authority having jurisdiction, a set of reproducible as-built installation drawings, operation and maintenance manuals, and a written sequence of operation shall be provided to the building owner or the owner ' s designated representative. The owner shall be responsible for maintaining these records for the life of the system for examination by any authority having jurisdiction. Paper or electronic media shall be permitted.

NFPA 72 National Fire Alarm Code? 1999 Edition. 7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be provided that includes the following
information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business
address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, " Tests performed in accordance with Section __________. "
(8) Functional test of detectors
(9) *Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15)Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place)

NFPA 101 Life Safety Code (2000 Edition) 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 101 Life Safety Code 2000 Edition. 9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.

NFPA 101 Life Safety Code (2000 Edition) 9.7.2.1* Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

NFPA 101 Life Safety Code 2000 Edition. 19.3.4.3 Occupant Notification. Occupant notification shall be accomplished automatically, without delay, upon operation of any fire alarm activating device by means of an internal audible alarm in accordance with 9.6.3.

Based on observation, the facility failed to maintain their fire alarm system. This was evidenced by batteries that were not dated as to when the batteries were installed in the panel or when the batteries were manufactured, by the failure to provide fire alarm completion documents, tamper supervisory alarms that were not monitored, by four audible devices that failed to annunciate, by the failure to provide current documentation for the annual inspection and testing of the fire alarm control panel, the annual charger and discharge test of the sealed lead acid batteries and the annual testing of the Initiating Devices including alarm notification devices. This affected Buildings 2, 3, 4, 5 and 7 and had the potential for fire alarm system failure.

Findings:

During the document review and facility tour with Facility Staff between January 9 to 13, 2012, the fire alarm systems were observed and maintenance documents were reviewed.

1. At 5:00 p.m. on January 9, 2012, the facility failed to provide documentation for the annual fire alarm inspection and testing for Building 7.

2.. At 10:58 a.m. on January 11, 2012, the combination audible/visible annunciator 1-013 on the first floor of Building 3 near door 1-19 in Administration was observed. The chime failed to alarm after activation of a smoke detector.

3. At 10:59 a.m. on January 11, 2012, the combination audible/visible annunciator 1-015 on the first floor of Building 3 in Administration was observed. The chime failed to alarm after activation of a smoke detector.

4. At 11:01 a.m. on January 11, 2012, the combination audible/visible annunciator 1-012 on the first floor of Building 3 in Administration was observed. The chime failed to alarm after activation of a smoke detector.

5. At 11:05 a.m. on January 11, 2012, the combination audible/visible annunciator 1-09 on the first floor of Building 3 was observed. The chime failed to alarm after activation of a smoke detector.

6. At 3:48 p.m. on January 11, 2012, the facility failed to provide a current inspection and test record from the owner of Building 7 for the fire alarm panel and system. Staff 59 confirmed that the only record provided by the building owner was for an incomplete annual fire alarm inspection with a repair proposal dated from 2010.

7. At 4:00 p.m. on January 11, 2012, the fire alarm bell failed to sound during testing of the inspector test valve for Building 7. An accumulation of stucco was observed inside the electrically operated alarm bell.




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8. At 10:05 a.m. on January 10, 2012, the two batteries for the fire alarm panel identified as NAC Panel 8 in Building 3 were not labeled as to when the batteries were installed in the panel or labeled with the date of manufacture. Staff 1 confirmed the batteries were not labeled.

9. At 2:00 p.m. on January 10, 2012, the facility was requested to provide fire alarm final completion documents for Building 4. The documents were again requested at 8:00 a.m. on January 13, 2012. The facility failed to provide fire alarm completion documentation including the initial acceptance test and a record of completion. Staff 58 stated the documents were not available.


10. At 2:20 p.m. on January 11, 2012, 2 of 2 batteries for the main fire alarm panel in Building 2 were not dated as to when the batteries were installed in the fire alarm panel. Staff 56 confirmed there was no date on the batteries and stated he did not know if the facility had documentation as to when the batteries were installed.

11. At 11:05 a.m. on January 12, 2012, the facility provided documentation for the testing and maintenance of the fire alarm system for Building 5. The report failed to provide documentation specific to the fire alarm inspection of the system in the MRI Building. The MRI Building was a standalone building on the Selma Campus. Staff 61 stated the information specific to the MRI Building was not available.

12. At 4:30 p.m. on January 12, 2012, the tamper switch was activated on the Post Indicator Valve for Building 2. The alarm sounded at the main panel and the sub panel near the main entrance in the waiting room. Both areas were not constantly attended. The tamper alarm was not received at the monitoring station. Staff 59 stated the tamper was monitored at the switchboard at the old hospital and apparently had not been redirected to the monitoring company when the switchboard was moved to the new hospital.

NFPA 101 Life Safety Code (2000 Edition) 9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72 National Fire Alarm Code (1999 Edition) 7-7.1 Scope. Chapter 7 shall cover the minimum requirements for the inspection, testing, and maintenance of the fire alarm systems described in Chapter 1, 3 and 5 and for their initiation and notification components described in Chapter 2 and 4. The testing and maintenance requirements for one- and two-family dwelling units shall be located in Chapter 8. Single station detectors used for other than one- and two-family dwelling units shall be tested and maintained in accordance with Chapter 7. More stringent inspection, testing, or maintenance procedures that are required by other parties shall be permitted.

NFPA 72 National Fire Alarm Code (1999 Edition), 7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.

To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:

(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction

Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or replaced.

Exception No.1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.

Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.

The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

NFPA 72 National Fire Alarm Code (1999 Edition), 8-3.5 Unless otherwise recommended by the manufacturer, smoke alarms installed in accordance with Chapters 18, 19, or 21 of NFPA 101, Life Safety Code, shall be replaced when they fail to respond to tests conducted in accordance with 8-3.4 but shall not remain in service longer than 10 years from the date of installation.

Based on observation, interview and document review, the facility failed to maintain the smoke alarms as evidenced by the failure to provide current documentation for the sensitivity testing of the smoke alarms and single station, battery operated smoke alarms that were in service longer than 10 years. This affected Building 5 and had the potential for detector failure.

Findings:

During the document review and facility tour with Facility Staff on January 12, 2012, the fire alarm system test records were reviewed and the smoke alarms were observed.

1. At 8:45 a.m. on January 12, 2012, the facility provided documentation for the fire alarm system tests dated 3/3/11, 6/23/11, 9/13/11 and 12/2/11. The reports failed to document the sensitivity testing of the system based smoke alarms in Building 5. Staff 61 stated there were no other documents available for review.

2. At 10:00 a.m. on January 12, 2012, three single station, battery operated smoke alarms were observed in the standalone building housing the Pharmacy adjacent to Building 5. The smoke alarms were dated 12-97-4 (April 4, 1987). The smoke alarms were over 14 years past due for replacement. Staff 61 confirmed the smoke alarms were dated April 4, 1987.

NFPA 13 Standard for the Installation of Sprinkler Systems (1999 Edition), 3-2.9.2 A special sprinkler wrench shall also be provided and kept in the cabinet to be used in the removal and installation of sprinklers.

NFPA 13 Standard for the Installation of Sprinkler Systems (1999 Edition), 3-8.3 Identification of Valves. All control, drain, and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs. The sign shall be secured with corrosion-resistant wire, chain or other approved means.

NFPA 13 Standard for the Installation of Sprinkler Systems (1999 Edition) 5-3.1.5.2 When existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartmented space shall be changed.
NFPA 13 Standard for the Installation of Sprinkler Systems (1999 Edition), 5-6.6* Clearance to Storage (Standard Pendent and Upright Spray Sprinklers). The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

Exception: Where other standards specify greater minimums, they shall be followed.

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.

NFPA 13 Standard for the Installation of Sprinkler Systems (1999 Edition) 10-1 Approval of Sprinkler Systems and Private Fire Service Mains. The installing contractor shall do the following:
(1) Notify the authority having jurisdiction and the property owner or the property owner's authorized representative of the time and date testing will be performed
(2) Perform all required acceptance tests (see Section 10.2).
(3) Complete and sign the appropriate contractor's material and test certificate(s) [see Figures 10-1(a) and 10-1(b)]
NFPA 13 Standard for the Installation of Sprinkler Systems (1999 Edition) 10-2.4.4 The main drain valve shall be opened and remain open until the system pressure stabilizes. The static and residual pressures shall be recorded on the contractor's test certificate.
NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (1998 Edition) 1-8 Records. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (1998 Edition) 1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (1998 Edition) 2-1 General. This chapter provides the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems. Table 2-1 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.
Exception: Valves and fire department connections shall be inspected, tested, and maintained in accordance with Chapter 9.
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, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, 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 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (1998 Edition) 2-2.1.3 The supply of spare sprinklers shall be inspected annually for the following:
(a) The proper number and type of sprinklers
(b) A sprinkler wrench for each type of sprinkler
2-2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the
pipe or hung from the pipe.
Exception No. 1:* Pipe and fittings installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Pipe installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.
2-2.3* Hangers and Seismic Braces. Sprinkler pipe hangers and seismic braces shall be inspected annually from the floor level. Hangers and seismic braces shall not be damaged or loose. Hangers and seismic braces that are damaged or loose shall be replaced or refastened.
Exception No. 1: *Hangers and seismic braces installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Hangers 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) 2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.
NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (1998 Edition) 2-2.7* Hydraulic Nameplate. The hydraulic nameplate, if provided, shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible.
NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (1998 Edition) 2-3.3* Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.
NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (1998 Edition) 2-4.1.6* A special sprinkler wrench shall be provided and kept in the cabinet to be used in the removal and installation of sprinklers. One sprinkler wrench shall be provided for each type of sprinkler installed.
NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (1998 Edition) 9-3.5 Maintenance. The operating stems of outside screw and yoke valves shall be lubricated annually. The valve then shall be completely closed and reopened to test its operation and distribute the lubricant.
NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (1998 Edition) 9-5.1.1 All valves shall be inspected quarterly. The inspection shall verify that the valves are in the following condition:
(a) In the open position
(b) Not leaking
(c) Maintaining downstream pressures in accordance with the design criteria
(d) In good condition, with handwheels installed and unbroken
NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (1998 Edition) 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

Based on observation and document review, the facility failed to maintain the fire sprinkler system as evidenced by quick response sprinkler heads in a smoke compartment which also contained standard sprinkler heads, by missing fire department connection (FDC) caps, by sprinkler heads with foreign debris on the heads, by missing identification signs, by the failure to provide a wrench for changing the sprinkler heads, by the failure to provide documentation for the acceptance test of the fire sprinkler system, the failure to provide documentation for the 5-year certification, the annual fire sprinkler inspection and maintenance and the failure to provide documentation for the quarterly sprinkler tests and inspections. This affected Buildings 3, 4, 5 and 6 and had the potential for sprinkler system failure leading to harm of the patients.

Findings:

During the document review and facility tour with Staff 1 on January 10, 11 and 12, 2012, the facility sprinkler system inspection reports were reviewed and the sprinkler system was observed.

1. At 5 p.m. on January 9, 2012, the facility failed to provide documentation for the fire alarm and sprinkler system inspection and testing records for Building 7. There were no documents for quarterly, annual and five year testing of the sprinkler system.

2 . At 2:58 p.m. on January 11, 2012, there was rust visible on the body of the sprinkler under the exterior soffit at the north east corner of building 7. The rust stains came down onto the sprinkler from above the soffit.

3. At 3:09 p.m. on January 11, 2012 the sprinkler riser for Building 7 was accessible to the public and the main control valve was not securely chained and locked.

4. At 3:10 p.m. on January 11, 2012, there was no identification sign attached to the fire sprinkler control valve of Building 7.

5. At 3:11 p.m. on January 11, 2012, the pressure gauge on the fire sprinkler riser for Building 7 was faulty and visually obscured. Staff 59 removed the discolored bezel and the needle was observed at the zero pressure reading.

6. At 3:15 p.m. on January 11, 2012, there was no identification sign at the fire department connection for Building 7.

7. At 3:16 p.m. on January 11, 2012, the fire department connections for Building 7 did not spin freely.

8. At 3:48 p.m. on January 11, 2012, there was no current record from the owner of Building 7 for the fire alarm panel and system and there was no sprinkler system quarterly, annual, or five-year certification.

9. At 9:04 a.m. on January 12, 2012, maintenance staff failed to readily identify where the inspector test valves were located in the stairwells. There were no identification signs for the inspector test valve and drain valves on the risers at both the second and third floor levels of Building 3.

10. At 12:05 p.m. on January 12, 2012, there was storage stacked within approximately ten inches of a sprinkler in Building 5 Emergency Department oxygen cylinder storage room.






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11. At 9:27 a.m. on January 10, 2012, 2 of 2 FDC caps were missing on the FDC on the 3rd floor roof area of Building 3. Staff 1 confirmed the caps were missing and stated the caps had been removed so the local fire department could install lockable FDC caps.
12. At 11:37 a.m. on January 10, 2012, the spare sprinkler head box for Building 4 was observed. The facility failed to provide a special sprinkler wrench to be used for the removal and installation of sprinkler heads. Staff 56 confirmed there was no wrench in the spare sprinkler head box.
13. At 2:00 p.m. on January 10, 2012, the facility was requested to provide documentation for the acceptance test records for Building 4 fire sprinkler system. Staff 59 stated the facility did not have the documentation as required in NFPA 13 10-1. Staff 59 stated the building was occupied in 2010.
14. At 2:00 p.m. on January 10, 2012, the facility was requested to provide documentation for the quarterly inspection and test records for the Building 4 fire sprinkler system. The facility failed to provide documentation for the quarterly inspections to assure they were free of physical damage, there was no evidence that the valves were inspected, there was no documentation for the inspection of the hydraulic nameplate and there was no evidence that the fire department connections were inspected. Staff 58 confirmed there was no additional documentation of the quarterly sprinkler tests and inspection beyond testing the inspector test valve and recording pressure in the system before, during and after testing of the inspector test valve.
15. At 2:00 p.m. on January 10, 2012, the facility was requested to provide documentation for the annual inspection, test and maintenance records for the Building 4 fire sprinkler system. The facility failed to provide documentation for the annual inspection of the fire sprinkler system that included inspection of the sprinkler pipes and fittings, the inspection of the spare sprinkler heads, inspection of the sprinkler pipe hangers and seismic braces and maintenance and lubrication of the valves. Staff 58 confirmed there was no additional documentation of the annual sprinkler tests, maintenance and inspection beyond testing the inspector test valve and recording pressure in the system before, during and after testing of the inspector test valve.
16. At 2:25 p.m. on January 10, 2 of 2 sprinkler heads in the kitchen walk-in refrigerator in Building 3 had the protective caps on the sprinkler heads. Staff 1 confirmed the protective caps were on the sprinkler heads.

17. At 2:25 p.m. on January 10, 2 of 2 sprinkler heads in the kitchen walk-in freezer in Building 3 had the protective caps on the sprinkler heads. Staff 1 confirmed the protective caps were on the sprinkler heads.

18. At 11:30 a.m. on January 11, 2012, the facility failed to provide documentation for the 5 year certification, documentation for an annual inspection and maintenance within the last twelve months and 4 of 4 quarterly inspections for the last twelve months as required by NFPA 25. Staff 58 confirmed there was no documentation. Staff 56 stated Building 6 was leased but did not know if the owner had the documents.

19. At 11:48 a.m. on January 11, 2012, quick response sprinkler heads were observed in Occupational Therapy office area and office corridor of Building 6. The smoke compartment also contained standard response sprinkler heads. Staff 1 confirmed there were quick response sprinkler heads and standard response sprinkler heads in the smoke compartment.


20. At 9:45 a.m. on January 12, 2012, the facility failed to provide documentation for the 5 year certification of the sprinkler system for Building 5 that included internal inspection of the alarm valves and their associated strainers, filters, and restriction orifices, internal inspection of the valves, internal inspection of the strainers, filters, and restricted orifices, and internal examination for obstructions. Staff 61 confirmed there was no documentation for the 5-year certification. The facility sprinkler riser tag was dated 2006. Staff 61 confirmed the tag on the riser was dated 2006.


21. At 2:27 p.m. on January 12, 2012, the sprinkler head in the Nursery of Building 5 adjacent to the sink had paint on the deflector. Staff 61 confirmed there was paint on the deflector.

22. At 2:28 p.m. on January 12, 2012, the sprinkler head in the Central Supply Sterilizer Room in Building 5 had dust build-up on the sprinkler head. Staff 61 confirmed there was dust build-up on the sprinkler head.

23. At 8:15 a.m. on January 13, 2012, the facility failed to provide documentation of the final acceptance test of the fire sprinkler system for Building 3 including the recording of the static and residual pressures. Staff 1 confirmed the record failed to document the static and residual pressures. Acceptance test records were requested during the entrance conference on January 9, 2012.

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.

Based on observation, the facility failed to maintain their fire extinguishers. This was evidenced by the failure to maintain access to a fire extinguisher and the failure to provide a means to indicate extinguisher locations where extinguishers were obstructed from view. This affected Building 5 and had the potential for the delay in accessing the fire extinguishers for extinguishing a fire and had the potential for some persons not to be able to access the extinguisher or being injured due to having to reach for the extinguisher.

Findings:

During the facility tour with Staff on January 12, 2011, the fire extinguishers were observed.

1. At 11:00 a.m. on January 12, 2012, 2 of 2 fire extinguishers in the Laboratory adjacent to Building 5 were visually obstructed. There was an extinguisher in the northwest room. When in the lab, there was no means to indicate there was an extinguisher in the northwest room. The second extinguisher was located adjacent to a machine in the southwest corner of the laboratory. There was a sign above the extinguisher pointing to the extinguisher. From most of the laboratory work area, the sign and extinguisher were visually obstructed by the machine adjacent to the extinguisher. Staff 61 confirmed both extinguishers were visually obstructed.

2. At 2:28 p.m. on January 12, 2012, access to the fire extinguisher in the GI Lab of Building 5 was obstructed by a hamper in front of the extinguisher cabinet, forcing occupants to reach over the hamper if the extinguisher was needed. Staff 61 confirmed the access was blocked by the hamper and moved the hamper.

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.

NFPA 99 Standard for Health Care Facilities (1999 Edition) 5-4.1.1 The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Based on observation and document review, the facility failed to maintain the heating, ventilation and air conditioning (HVAC) system. This was evidenced by the failure to provide records for the testing and maintenance of the dampers, the failure to provide documentation for the action taken by the facility when the relative humidity in the operating room was less the 35 percent and the failure to identify damper access openings adjacent to dampers. This affected Buildings 2, 3 and 5. This 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 residents.

Findings:

During the document review and facility tour with Staff 1 between January 9 and January 13, 2012, the facility dampers were observed and policies and humidity logs were reviewed.
1. At 4:00 p.m. on January 9, 2012, the Building 3 humidity log indicated that the relative humidity on 12-28-11 was 33% for OR1, 34% for OR2, 31% for OR3, 34% for OR4 and 27% for OR6. OR6 was 29% on 12-29-11. The facility was requested to provide the policy and/or procedure taken by the OR when the relative humidity in the OR fell below 35%. At 8:15 a.m. on January 13, 2011, the facility failed to provide the policy and/or procedure taken by the OR when the relative humidity in the OR fell below 35%.
2. At 9:20 a.m. on January 10, 2012, the duct access panels in the Roof Mechanical Room on Building 3 were not identified indicating a damper within the ducts. Staff 1 confirmed there was no lettering on the access panels to note the presence of the dampers.

3. At 2:30 p.m. on January 11, 2012, the test and maintenance records for Building 2 were requested. The facility housed the Ambulatory Surgery Center. The facility failed to provide records for the testing and maintenance of the dampers. Staff 58 stated the dampers had not been tested and maintained and that there were no records available.

4. At 9:00 a.m. on January 12, 2012, the facility failed to provide records verifying the maintenance and testing of the fire dampers in Building 5. The vendor representative stated the company only maintained the mechanical smoke dampers, as documented in the fire alarm reports. Staff 61 stated the fire dampers were not maintained and that there were no records for review. Fire dampers were observed in 9 of 9 smoke compartments in Building 5 during the facility tour between the hours of 9:30 a.m. and 2:30 p.m.
5. At 9:15 a.m. on January 12, 2012, the Building 5 humidity log indicated that the relative humidity on 1-4-11 was 28% for OR1, 34% for OR2 and 27% for OR3. OR1 was 31%, OR2 was 34% and OR3 was 29% on 1-5-11. The facility was requested to provide the policy and/or procedure taken by the OR when the relative humidity in the OR fell below 35%. At 8:15 a.m. on January 13, 2011, the facility failed to provide the policy and/or procedure taken by the OR when the relative humidity in the OR fell below 35%.

NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations (1998 Edition) 7-2.1.1 A placard identifying the use of the extinguisher as secondary backup means to the automatic fire suppression system shall be conspicuously placed near each portable fire extinguisher in the cooking area.

NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations (1998 Edition) 8-3.1.2 When a vent cleaning service is used, a certificate showing date of inspection or cleaning be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company. It shall also indicate areas not cleaned.

Based on observation, the facility failed to maintain the kitchen cooking exhaust and fire suppression systems as evidenced by the facility's failure to display a label indicating the date cleaned and the name of the servicing company and by the failure to post a warning sign by the Class ABC extinguisher in the kitchen. This affected Building 5 and had the potential for the failure to maintain the exhaust system leading to a fire and improper use of the fire extinguisher leading to harm to the patients.

Findings:

During the facility tour with Staff on January 12, 2012, the facility kitchen exhaust system and fire extinguishers were observed.

1. At 9:35 a.m. on January 12, 2012, there was no sign adjacent to the Class ABC extinguisher in the kitchen in Building 5 warning staff to activate the fire extinguishing system prior to using the Class ABC fire extinguisher. Staff 61 confirmed there was no warning sign.

2. At 9:45 a.m. on January 12, 2012, the kitchen in Building 5 failed to display the label from the servicing company within the kitchen indicating the date the exhaust system was cleaned by the vendor. Staff 61 confirmed the vendor label was not displayed in the kitchen.

NFPA 99 Standard for Health Care Facilities (1999 Edition)
8-3.1.11 Storage Requirements.
8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3 85 m3).

(a) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
(b) Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor.
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:

1. A minimum distance of 20 ft (6.1 m), or
2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.

NFPA 99 Standard for Health Care Facilities (1999 Edition) 21-1 Referenced Publications. The following documents or portions thereof are referenced within this standard and shall be considered part of the requirements of this document. The edition indicated for each reference is the current edition as of the date of the NFPA issuance of this document.

NFPA 99 Standard for Health Care Facilities (1999 Edition) 21-1.2.6 CGA Publications. Compressed Gas Association, Inc., 1725 Jefferson Davis Highway, Arlington, VA 22202.

Pamphlet G-4-1987, Oxygen. III. STORAGE OF COMPRESSED AND LIQUEFIED GAS, Storage Requirements. All gas cylinders: Shall be stored so that full cylinders remain separate from empty cylinders.

Based on observation and interview, the facility failed to safely maintain the oxygen cylinder storage area. This was evidenced by the failure to separate empty and full cylinders, by combustible supplies and soiled linens stored with oxidizing gasses. This affected Buildings 2, 3 and 5 and had the potential for use of an empty cylinder in an emergency leading to harm to the patient and could cause fire.

Findings:

During the facility tour with Staff on January 10 and 11, 2012, the facility oxygen storage area was observed.

1. At 2:25 p.m. on January 10, 2012, there were five oxygen and one nitrous oxide E-sized cylinders stored in the Soiled Utility Room in the Surgery Area of Building 3. These were stored within two feet of shelving rack of miscellaneous combustible storage and a 16 cubic foot rolling cart that was filled with soiled bed pads and drapes.

2. At 2:53 p.m. on January 10, 2012, there were 13 full and partially full E-sized Oxygen cylinders stored in the Hazardous Storage, Room 1-270, on the first floor in Building 3. The oxygen cylinders were stored within two feet of a 16 cubic foot rolling cart that was full of soiled bed pads and drapes.


3. At 12:05 p.m. on January 12, 2012, there were 14 empty and full oxygen cylinders stored with combustible storage in the Building 5 oxygen storage area. The oxygen cylinders were stored together and were not labeled or separated as empty and full.




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4. At 3:04 p.m. on January 11, 2012, in the oxygen storage room 143 of Building 2, the oxygen cylinders were stored together and were not separated as empty and full. Staff 56 confirmed the oxygen cylinders were stored together and were not segregated as empty and full.

NFPA 418 Standard for Heliports 1995 Edition 3-6 Fire Protection. A foam fire extinguishing system shall be designed and installed to protect the rooftop landing pad.

Exception No. 1: A foam fire extinguishing system shall not be required for heliports located on parking garages, unoccupied buildings, or other similar unoccupied structures.
Exception No. 2: For H-1 heliports, two portable foam extinguishers, each having a rating of 20-A:160-B, shall be permitted to be used to satisfy this requirement.

Based on observation, the facility failed to ensure that the correct extinguishing type was provided in their heliport. This was evidenced by the failure to provide fire extinguishers of the type and rating required to protect the heliport. This affected Building 3 and had the potential to fail to extinguish a fuel fire leading to harm to the patients.

Findings:

During the facility tour with Staff 1 on January 10, 2012, the heliport was observed.

At 9:25 a.m. on January 10, 2012, the fire extinguisher at the heliport was a dry chemical extinguisher with a 10-A: 60-B:C rating. This was confirmed with Staff 56 on 1-23-12 at 1:00 p.m.

Based on observation and interview the facility failed to ensure the eyewash and shower in the Lab were maintained according to NFPA 99. This was evidenced by obstructed access to the eye wash and shower. This could result in a delay in the use of the emergency eye wash station and a potential increase in the severity of injury from a hazardous chemical exposure.

Findings:

During the facility tour on with Staff 59 on January 10, 2012, the emergency shower and eyewash station were observed in the Laboratory on the first floor of Building 3.

At 4:50 p.m., the eye wash station and shower were obstructed from access by card board boxes and plastic containers. There were nine open boxes, three folded boxes and two buckets that covered the shower area and eye wash access.

NFPA 99 Standard for Health Care Facilities (1999 Edition) 3-4.1.1.15 Alarm Annunciator. A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12).
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source in operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel-when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangment signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. (110: 3-5.5.2)

NFPA 110 Standard for Emergency and Standby Power Systems (1999 Edition) 3-5.4.5* Type of Battery. The battery shall be of the nickelcadmium or lead-acid type. Lead-acid batteries shall be furnished as charged when wet. Drain-dry batteries or drycharged lead-acid batteries shall be permitted. Vented nickelcadmium batteries shall be filled and charged when furnished and shall have listed flip-top, flame arrestor vent caps. The manufacturer shall provide installation, operation, and maintenance instructions, and, when shipped dry, electrolyte mixing instructions. Batteries shall not be installed until the battery charger is in service.
All batteries used in this service shall have been designed for this duty and shall have demonstrable characteristics of performance and reliability acceptable to the authority having jurisdiction. Batteries shall be prepared for use according to the battery manufacturer ' s instructions.
Starting batteries for Level 1 installations shall not be of the maintenance-free variety.

NFPA 110 Standard for Emergency and Standby Power Systems (1999 Edition) 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

NFPA 110 Standard for Emergency and Standby Power Systems (1999 Edition) 6-3.6* Storage batteries, including electrolyte levels, used in connection with Level 1 and Level 2 systems shall be inspected at intervals of not more than 7 days and shall be maintained in full compliance with manufacturer ' s specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects.

Based on interview and document review, the facility failed to maintain the generator as evidenced by the failure to provide documentation for the weekly inspection of the generator, by the failure to provide documentation for the weekly inspection and test of the generator batteries, by the failure to provide a remote panel for the emergency generator, as evidenced by the failure to provide the correct starting batteries and the failure to provide emergency lighting in the generator room. This affected Buildings 2, 3 and 5 and had the potential for generator failure leading to harm of the patients.

Findings:

During the document review and facility tour with Staff between January 9 and January 13, 2012, the facility generator test and inspection logs were reviewed and the generator was observed.

1. At 3:21 p.m. on January 9, 2012, the facility failed to provide weekly generator inspection records for 40 of 52 previous weeks for Building 3.

2. At 3:22 p.m. on January 9, 2012, Staff 57 explained that they checked the remote indicator panel located in the Maintenance shop but that they did not physically inspect the generators or batteries on a weekly basis for Building 3.

3. At 3:23 p.m. on January 9, 2012, Staff 58 stated that the starting batteries were sealed and that there was no access to inspect the electrolyte condition for each cell in the generator batteries for Building 3.





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5. At 3:25 p.m. on January 9, 2012, the monthly testing documentation " Emergency Generator Test Log, " indicated that the generators did not meet the minimum 30% of generator nameplate rating during the monthly load tests for Building 3. The records showed that the generators ran for 30 minutes each month and that once a year they ran for two hours. A once per year two-hour load test that was documented on the " Emergency Generator Operating Log " did not meet the annual load test requirement for 75% loading during the second hour of the load bank test.

During interviews with Staff 57 and 58 on 1/9/12, inspection and testing methods for the emergency power generators were described.

6. At 9:45 a.m. on January 12, 2012, the emergency generator for Building 5 was observed. The facility failed to provide battery-powered, emergency lighting in the generator room. Staff 61 confirmed there was no emergency lighting in the generator room.

7. At 9:45 a.m. on January 12, 2012, the emergency generator for Building 5 was observed. The batteries for the generator were maintenance free batteries and were not in compliance with NFPA 110 3-5.4.5. Staff 61 confirmed the batteries were maintenance free.

8. At 2:30 p.m. on January 12, 2012, Staff 62 was asked if Building 5 had remote panel for the emergency generator. Staff 62 stated the facility did not have a remote panel. The facility failed to provide a remote alarm annunciator panel for the emergency generator within the facility at a location readily observed by personnel at a regular work station to indicate when the emergency or auxiliary power source was operating or when the battery charger was malfunctioning.

9. At 4:00 p.m. on January 12, 2012, the facility failed to provide documentation for the weekly inspection of the generator and documentation of the specific gravity test of the generator batteries for the Building 2 that housed the Out-patient Surgery Center. Staff 58 confirmed the weekly inspections and specific gravity testing were not done. Staff 58 stated the inspection was only done on a monthly basis when the generator was tested. This was confirmed by document review of the generator test logs.

NFPA 99 Standard for Health Care Facilities (1999 Edition) 3-4.2.2.2 Emergency System.
(c)* Critical Branch. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and selected power circuits serving the following areas and functions related to patient care. It shall be permitted to subdivide the critical branch into two or more branches.
8. Task illumination, selected receptacles, and selected power circuits for the following:
a. General care beds (at least one duplex receptacle per patient bedroom)

NFPA 99 Standard for Health Care Facilities (1999 Edition) 3-4.2.2.4 Wiring Requirements. (b) Receptacles.
2.* The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable.

Based on observation and interview, the facility failed to maintain the electrical wiring and equipment as evidenced by the failure to provide emergency power in general care rooms. This affected Building 5 which had the potential for the delay in providing emergency power to equipment.

Findings:

During the facility tour with Staff 61 on January 12, 2012, the facility electrical wiring and equipment were observed.

At 2:10 p.m. on January 12, 2012, the facility failed to provide emergency power in the OB rooms in the south wing of Building 5. Red Receptacles were used in the facility to identify receptacles on emergency power. There were no red receptacles observed in the OB Rooms. Staff 59 stated the OB rooms were in the area that was formerly the Distinct Part Skilled Nursing Facility. Staff 59 stated the emergency receptacles in the corridor would be used in an emergency.

NFPA 70 (1999 Edition), article 110-12(C) Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasive, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating.

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), article 373-4. Unused Openings. Unused openings in enclosures within the scope of this article shall be effectively closed to afford protection substantially equivalent to that of the enclosures within the scope of this article. Where metal plugs or plates are used with nonmetallic cabinets or cutout boxes, they shall be recessed at least ? in. (6.35 mm) from the outer surface.

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 (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 (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 (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 Facilties (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, the facility failed to maintain the electrical system as evidenced by damaged electrical receptacle cover plates, damaged electrical receptacle, by breakers in the on position and not labeled as to the purpose or use, by the failure to provide a cover for an unused opening on an electrical panel and the use of a surge protector to extend power and provide additional receptacles for equipment instead of providing fixed wired electrical receptacles, medical devices that were plugged into unapproved multi-outlet extension cords, and daisy chained multi-outlet extension cord connections. This affected Buildings 1, 3, 4 and 5 and had the potential for electrical shock.

Findings:

During the facility tour with Facility Staff on January 10 and 11, 2012, the facility electrical system was observed.

1. At 9:43 a.m. on January 10, 2012, the electrical receptacle cover plate in the 3rd floor waiting room of Building 3 was damaged. Staff 1 confirmed the cover plate was damaged.


2. At 1:37 p.m. on January 10, 2012, there was a microwave oven and a coffee maker plugged into a surge protector in the Phlebotomy area 6 in the lab located in Building 4. The surge protector was used to extend power and as a substitute for providing additional fixed wired electrical receptacles. Staff 56 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 1:47 p.m. on January 10, 2012, the electrical receptacle in the corridor adjacent to the biohazard waste storage room 1222 in Building 4 had items broken off in the both receptacles. Staff 56 confirmed there were items broken off in the receptacle.



4. At 2:55 p.m. on January 10, 2012, the red electrical receptacle cover plate on the east wall of the Clean Linen Storage Room on the first floor of Building 3 was damaged. Staff 1 confirmed the cover plate was damaged.


5. At 1:54 p.m. on January 11, 2012, on Electrical Panel PP-A in Nuclear Medicine in Building 1, breaker 19 was in the on position and not labeled as to the area served by the breaker. Staff 56 confirmed the breaker was not labeled.

6. At 1:54 p.m. on January 11, 2012, on Electrical Panel PP-A in Nuclear Medicine in Building 1, the area on the panel for breaker 2 was open. There was no cover on the open area. Staff 56 confirmed the breaker area was open and not covered.


7. At 2:10 p.m. on January 12, 2012, the facility failed to provide documentation for the polarity testing of the electrical receptacles in the critical care and wet areas of Building 5 due at 6-month intervals. Staff 61 stated testing was only done annually.









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8. At 10:31 a.m. on January 10, 2012, there was a broken electrical cover plate on the electrical outlet behind the microwave in the pantry room 2-54 of Building 3.

9. At 1:37 p.m. on January 10, 2012, there was a Beaer Hugger heating blanket plugged into a non-approved multi-outlet extension cord, Tripp Lite model U24 RA-15.

10. At 1:46 p.m. on January 10, 2012, in OR #6 of Building 3, there was a surgery table plugged into an unapproved surge protected extension cord, Wiremold Power Tapp model 2MV36 UL 977 E which was sitting on the floor under the anesthesia equipment within 30 inches of the operating table. This was plugged into a second multi-outlet extension cord sitting inside the anesthesia equipment, TrippLite P415HG UL Power Tap 58M7,which was plugged into a third multi-outlet extension cord, mounted onto the same equipment, which was then plugged into an electrical outlet at the ceiling column.

11. At 2:15 p.m. on January 10, 2012, in OR #4 in Building 3, an operating table was plugged into an unapproved multi-outlet extension cord. This was a TrippLite PS-615-HGULTRA UL1365.

12. At 2:18 p.m. on January 10, 2012, refrigerator in the Anesthesia Workroom in Building 3 was plugged into a multi-outlet extension cord which had a frayed insulation cover at the plug into the wall outlet.

13. At 2:36 p.m. on January 10, 2012, a refrigerator was plugged into a multi-outlet extension cord in the OR staff lounge in Building 3.

14. At 2:40 p.m. on January 10, 2012, in the Endoscopy procedure room of Building 3, the surgery table was plugged into a multi-outlet extension cord, TrippLite LR6-2645 which was laying on the floor. This was plugged into a multi-outlet extension cord, TrippLite LR6-2645 in the anesthesia equipment which was plugged into an electrical outlet at the ceiling column.

15. At 3:15 p.m. on January 10, 2012, in OR #2 in Building 3, there was a surgery table, a pressure cuff monitor, plugged into a multi-outlet extension cord, SL Wabu Model #SLHC6-21/UL HC6, which was plugged into an electrical outlet in the ceiling column.

16. At 4:30 p.m. on January 10, 2012, there was a laboratory refrigerator for pathology specimen storage in the Building 3 Lab that was plugged into a 15 foot extension cord which was plugged into a counter top power strip electrical outlet in Room 1-214.

17. At 4:38 p.m. on January 10, 2012, there was a laboratory refrigerator with reagent storage plugged into a yellow colored 25 foot long three-way extension cord in Building 3.

18. At 11:55 a.m. on January 12, 2012, there was a microwave and a refrigerator plugged into a multi-outlet extension cord which was plugged into a wall outlet in Building 5 Emergency Department doctor ' s sleeping room.

19. At 1:50 p.m. on January 12, 2012, there was a multi-outlet extension cord which that was attached to the wall in Building 5 Emergency Department ' s admitting area. The wall outlet was pushed back into the outlet box.

20. At 4:01 p.m. on January 12, 2012, there was an extension cord in Building 5 that was run from behind a desk to a wall outlet in the Radiology Reading Room.

21. At 5:30 p.m. on January 12, 2012, at 5:30 p.m., five of six product data sheets provided by Staff 58 failed to indicate that the wiring devices in the Operating Rooms in Building 3 were UL approved for use on patient care equipment.

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by unsealed penetrations and open ceiling tiles. This affected Building 2 and Building 3 and had the potential to allow the spread of smoke during a fire.

Findings:

During the facility tour with Staff 1 on January 10 and 11, 2012, the facility walls and ceilings were observed.

1. At 3:35 p.m. on January 10, 2012, in the elevator room 1-95 of Building 3, there was an unsealed one half inch gap around a two inch conduit that penetrated the left wall. Staff 1 confirmed the conduit was not sealed where the conduit penetrated the wall.

2. At 2:47 p.m. on January 11, 2012, the sprinkler escutcheon in the Transfusion Storage Room of Building 2 was missing, exposing an unsealed three quarter inch gap around the sprinkler pipe where the pipe penetrated the ceiling. Staff 56 confirmed the escutcheon was missing and there was a three quarter inch gap around the sprinkler pipe where the pipe penetrated the ceiling.



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3. At 10:54 a.m. on January 11, 2012, there were three ceiling tiles missing in the ceiling of the Building 3, Second Floor server equipment room.

4. At 10:56 a.m. on January 11, 2012, there was an unsealed 4 inch sleeve with a bundle of blue cables passing through the wall between the second floor server equipment room and Room 2-16 of Building 3.

5. At 10:58 a.m. on January 11, 2012, there was 3 foot by 8 foot area above the ceiling tiles where the sheetrock was removed in the wall common to the bathroom in the second floor server equipment room of Building 3.

6. At 10:59 a.m. on January 11, 2012, there was a ? inch unsealed pipe sleeve that passed up the wall above the ceiling tile in the Building 3 second floor server equipment room to the ceiling area above the third floor server equipment.

7. At 11:45 a.m. on January 11, 2012, there was an unsealed two inch pipe sleeve with a one inch penetration around a bundle of blue cables which passed through the wall above the ceiling in ICU Equipment Room 2-184 in Building 3.

8. At 1:40 p.m. on January 12, 2012, there was an approximately ? inch ceiling penetration on one side of the sprinkler pipe in Building 5, Emergency Department Cast Room. The escutcheon was missing.

9. At 3:27 p.m. on January 12, 2012, there was an approximately ? inch ceiling penetration around the sprinkler pipe in Building 5, CT Procedure Room. The escutcheon was missing.

Based on observation, the facility failed to maintain the integrity of the corridor walls. This was evidenced by an unsealed corridor wall penetration. This affected Building 3 and had the potential to allow the passage of smoke causing harm to the patients.

Findings:

During the facility tour with Staff 1on August 10, 2010, the facility corridor walls and ceilings were observed.

At 3:08 p.m. on January 10, 2012, above the door on the corridor side to the Board Room in Building 3, there was an unsealed one inch gap around a conduit that penetrated the wall. Staff 1 confirmed there was an unsealed penetration in the corridor wall.

NFPA 80 Standard for Fire Doors and Fire Windows (1999 Edition)15-2.1.1* Hardware shall be examined frequently and any parts found to be inoperative shall be replaced immediately.

NFPA 80 Standard for Fire Doors and Fire Windows (1999 Edition)15-2.1.3 Chains or cables employed on suspended doors shall be inspected frequently for excessive wear and stretching.

NFPA 80 Standard for Fire Doors and Fire Windows (1999 Edition)15-2.2.1 Guides and bearings shall be kept well lubricated to facilitate operation.

NFPA 80 Standard for Fire Doors and Fire Windows (1999 Edition)15-2.2.2 Chains or cables on biparting, counterbalanced doors shall be checked frequently and adjustments shall be made to ensure proper latching and to keep the doors in proper relation to the opening.

NFPA 80 Standard for Fire Doors and Fire Windows (1999 Edition)15-2.4.1 Self-closing devices shall be kept in proper working condition at all times.

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 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 corridor doors. This was evidenced by the failure to provide documentation for the inspection and maintenance of the rolling fire windows, by doors that failed to latch and self-closing doors that were impeded from closing. This affected Buildings 3, 4 and 5 and had the potential to fail to contain smoke during a fire leading to injury to the patients.

Findings:

During the facility tour with Staff 1 on January 10, 11 and 12, 2012, the corridor doors were observed.


1. At 1:28 p.m. on January 10, 2012, the corridor door to the Mammography Dexa Room in suite 203 of Building 4 failed to fully close and latch. Staff 56 confirmed the door failed to fully close and latch. 26388

2.. At 3:42 p.m. on January 10, 2012, the door between the Pharmacy and the Pharmacy IV room in Building 3 failed to latch. Staff 1 confirmed the door failed to latch. 26388

3.. At 5:08 p.m. on January 10, 2012, the Medical Staff Office was observed. The rated, self-closing doors to the CMO Office, the Medical Staff Director ' s Office, the assistant Director ' s Office and the Quality Manager ' s Officer in Building 3 were each obstructed from closing by a door wedge. Staff 1 confirmed the doors were obstructed from closing by the door wedges. 26388

4.. At 9:25 a.m. on January 12, 2012, the inspection, maintenance and test records for the roll down fire windows were requested. The fire alarm vendor stated the windows were only tested with the fire alarm system. The maintenance director stated the facility only tested the windows with the fire alarm system. The maintenance director stated there was no inspection and maintenance program to examine the hardware, inspect the chains or cables for excessive wear and stretching, or lubrication of the guides and bearings.

5. At 2:20 p.m. on January 12, 2012, the corridor door to the OB Dictation Room was equipped with a dead-bolt. The dead-bolt was not self-latching. When closed, the door failed to latch unless the dead-bolt was manually engaged. Staff 1 confirmed the door was not self-latching.



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6. At 9:39 a.m. on January 10, 2012, a patient room door at room 225 in Building 3 failed to latch in three of three attempts. The door latch was jammed.

7. At 9:41 a.m. on January 10, 2012, a patient room door at room 211 in Building 3 failed to latch in three of three attempts. The door latch was binding.

8. At 10:40 a.m. on January 10, 2012, a patient room door at room 228 in Building 3 failed to latch in three of three attempts. The door latch was binding.

9. At 5:17 p.m., on January 10, 2012 a laboratory entrance door labeled 1-222A in Building 3 failed to latch in six of eight attempts. Staff 64 confirmed the door failed to latch.

NFPA 101 Life Safety Code, 2000 Edition
7.10.8.1* No Exit. Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows: NO EXIT

Such sign shall have the word NO in letters 2 in. (5 cm) high with a stroke width of 3/8 in. (1 cm) and the word EXIT in letters 1 in. (2.5 cm) high, with the word EXIT below the word NO.
Exception: This requirement shall not apply to approved existing signs.

Based on observation, the facility failed to mark access to exits. This was evidenced by no signs posted for two exits, one hallway exit directional change, and a corridor that was not an exit and not identified as not an exit. This affected Buildings 2, 5 and 7 and could delay evacuation in the event of a fire.

Findings:

During the facility tour and interview with Staff 59 on January 11, 2012, the facility corridors and exit signs were observed.

1. At 3:02 p.m. on January 11, 2012, when looking towards the end of the corridor adjacent to room 155 in Building 2, there was no exit directional sign visible. Staff 56 confirmed there was no visible exit sign when looking in the corridor towards room 155.

2. At 1:50 p.m. on January 12, 2012, when looking east in the corridor at the smoke barrier adjacent to the Staffing Office in Building 5, there was no visible exit sign when looking towards the smoke barrier if the smoke barrier doors were closed. Staff 61 confirmed there were no exit signs visible when looking at the smoke barrier if the smoke barrier doors were closed.



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3. At 3:25 p.m. on January 11, 2012, there were no exit signs visible anywhere inside Building 7. Staff 59 confirmed that there were no exit signs visible.

4. At 3:30 p.m. on January 11, 2012, there was no exit sign for the exit door from the back hallway of Building 7.

5. At 3:32 p.m. on January 11, 2012, there was no directional exit sign where the exit access corridor turned to the left in the back hallway of Building 7.

6. At 3:38 p.m. on January 11, 2012, there was a dead-end front hallway that was next to the office in Building 7. The door had been locked and blocked. The hallway was greater than ten feet long and had no sign indicating that this was not an exit.

7. At 3:45 p.m. on January 11, 2012, there was no exit sign visible for the main entrance at the lobby area of Building 7 when viewed from inside the therapy area.

Based on observation, the facility failed to maintain their smoke barrier wall to resist the passage of smoke. This was evidenced by unsealed penetrations in the smoke barrier walls. This affected Buildings 2, 3 and 5 and had the potential to fail to contain smoke during a fire which could cause harm to the residents.

Findings:

During the facility tour with Facility Staff on January 10 and 11, 2012, the facility smoke barriers were observed.

1. At 3:15 p.m. on January 10, 2012, there were two, approximately one and one/quarter inch unsealed penetrations on the west side of the smoke barrier adjacent to the Board Room in Building 3. Staff 1 confirmed there were unsealed penetrations in the smoke barrier.

2. At 2:25 p.m. on January 11, 2012, there was an approximately one-quarter inch unsealed penetration around the sprinkler pipe that penetrated the barrier above the corridor door from the waiting room to the Out-patient Surgery Center in Building 2. Staff 56 confirmed there was an unsealed penetration in the separation barrier.

3. At 10:25 a.m. on January 12, 2012, there was an approximately three inch unsealed penetration in the smoke barrier adjacent to the attic access in the Selma Campus Respiratory Therapy Office in Building 5. There were wires running through the penetration. Staff 61 confirmed there was an unsealed penetration in the smoke barrier and stated the wires were for the IT system.

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.

Based on observation, the facility failed to maintain smoke barrier doors and failed ensure that the fire rating of the smoke barrier doors were readable. This was evidenced the door frame rating labels that were painted over and doors that failed to latch. This affected Buildings 3 and 5 and had the potential for non-rated doors to be installed and the failure of the doors to contain smoke during a fire.

Findings:

During the facility tour with Staff on January 12, 2012, the facility smoke and fire barriers were observed.

1. At 8:51 a.m. on January 12, 2012, the double set of doors at the Patient Only elevator foyer at the third floor of Building 3 failed to latch in three of three attempts. Staff 64 observed that the doors did not latch.




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2. At 10:25 a.m. on January 12, 2012, 8 of 8 barrier door frame labels on the south side of the Radiology Corridor in Building 5 were painted over. The floor plan provided by the facility noted the south side of the Radiology Corridor to be some type of barrier. Building blue-prints were unavailable to determine the rating and type of barrier. Staff 61 confirmed the frame rating labels were painted over.

Based on observation, the facility failed to ensure that doors protecting gift shops were not prevented from closing. This was evidenced by the door to the gift shop that was held in the open position by a rubber door wedge. This could result in the spread of fire or smoke, in the event of a fire affecting two of twenty smoke compartments.

During the facility tour on 1/9/12 and 1/10/12 the gift shop door was observed.

At 4:02 p.m. on January 9, 2012, there was a rubber wedge holding the Gift Shop door to the lobby in Building 3 in a fully opened position.

Based on observation and interview, the facility failed to maintain readily available exits. This was evidenced by equipment obstructing egress. This could result in a delay of evacuation during a fire and affected Building 3.

Findings:

During the facility tour with Staff 59 on 1/11/12, the facility exits and exit access were observed on the first floor of Building 3.

1. At 11:35 a.m. on January 11, 2012, in the Emergency Department of Building 3, there was a gurney stored along the wall next to a set of smoke barrier doors at location placard " HW4. " These doors provided egress access in both directions. When the double set of opposite swing doors closed, the gurney obstructed egress down to a clearance of approximately 18 inches.

2. At 11:39 a.m. on January 11, 2012, in the Emergency Department of Building 3, there were two chairs stored along the wall next to a set of smoke barrier doors at location placard " HW5. " These doors provided egress access in both directions. When the double set of opposite swing doors closed, the chairs obstructed egress down to a clearance of approximately 16 inches.

3. At 11:42 a.m. on January 11, 2012, in the Emergency Department of Building 3, there was a gurney stored along the wall next to a set of smoke barrier doors at location placard " HW6. " These doors provided egress access in both directions. When the double set of opposite swing doors closed, the gurney obstructed egress down to a clearance of approximately 22 inches.

During an interview on 1/11/12 at 11:37 p.m., staff 59 was asked to explain the reason for the gurneys and chairs with location placards. He described that these were provided for patient locations while being seen in the Emergency Department.

NFPA 101 Life Safety Code (2000 Edition) 3.3.107* Illuminated, Internally. Refers to an illumination source that is contained inside the device or legend that is illuminated.

NFPA 101 Life Safety Code (2000 Edition) 7.10.1.2* Exits. Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

NFPA 101 Life Safety Code (2000 Edition) 7.10.7.1 Listing. Internally illuminated signs, other than approved existing signs, or existing signs having the required wording in legible letters not less than 4 in. (10.2 cm) high, shall be listed in accordance with UL 924, Standard for Safety Emergency Lighting and Power Equipment.
Exception: This requirement shall not apply to signs that are in accordance with 7.10.1.3 and 7.10.1.5.

NFPA 101 Life Safety Code (2000 Edition) 39.2.10 Marking of Means of Egress. Means of egress shall have signs in accordance with Section 7.10.

Based on observation, the facility failed to maintain the exit signs. This was evidenced by expired self-illuminated exit signs and a corridor where an exit sign was not visible. This affected Buildings 2, 5 and 6 and had the potential for the delaying egress from the building.

Findings:

During the facility tour with Staff on January 11 and 12, 2012, the facility exit signs were observed.

1. At 11:31 a.m. on January 11, 2012, the self-illuminated exit sign adjacent to the Occupational Therapy reception desk in Building 6 had printed on the sign "Replace before April 2010." Staff 56 confirmed the sign stated it should be replaced before April 2010.

2. At 2:10 p.m. on January 11, 2012, the self-illuminated exit sign adjacent to room 161 in Building 2 had printed on the sign "Replace before 6/2008." Staff 56 confirmed the sign stated it should be replaced before 6/2008.

3. At 3:06 p.m. on January 11, 2012, the self-illuminated exit sign adjacent to room 142 in Building 2 had printed on the sign "Replace before 6/2008." Staff 56 confirmed the sign stated it should be replaced before 6/2008.

4. At 11:25 a.m. on January 12, 2012, the self-illuminated exit sign adjacent to room 48 in Building 5 had printed on the sign "Replace before 4-2011." Staff 61 confirmed the sign stated it should be replaced before April 2011.

5. At 11:35 a.m. on January 12, 2012, the self-illuminated exit sign adjacent to room 20 in Building 5 had printed on the sign "Replace before 4-2011." Staff 61 confirmed the sign stated it should be replaced before April 2011.

6. At 1:45 p.m. on January 12, 2012, the self-illuminated exit sign adjacent to the Chapel in Building 5 had printed on the sign "Replace before 4-2011." Staff 61 confirmed the sign stated it should be replaced before April 2011.

7. At 1:52 p.m. on January 12, 2012, the self-illuminated exit sign adjacent to the OB Nurse Station in Building 5 had printed on the sign "Replace before 4-2011." Staff 61 confirmed the sign stated it should be replaced before April 2011.

Based on interview and document review, the facility failed to ensure that fire drills were conducted to prepare staff to protect patients from fire. This was evidenced by the failure to provide documentation that required fire drills were conducted, the failure to use a coded announcement during a NOC shift drill and the failure to provide documentation for staff response to the drill outside of the immediate drill area. This had the potential for staff to be unable to react under different circumstances and different times during the shift and affected the Buildings 2, 3 and 5.

Findings:

During the document review on January 9, 12 and 13, 2012, the facility fire drill report logs were reviewed.

1. At 1:15 p.m. on January 9, 2012, the facility was requested to provide documentation for fire drills. At 3:45 p.m. the drill records were incomplete. Staff 56 stated the drills were incomplete and that the facility was attempting to provide a complete drill record. At 8:15 a.m. on January 13, 2012, the complete fire drill records were requested. The facility failed to provide 4 of 4 required drill records for the Ambulatory Surgery Center located in Building 2. Staff 56 confirmed the four drill reports were not available.

2. At 1:30 p.m. on January 9, 2012, the facility was requested to provide documentation for fire drills. At 3:45 p.m., the facility failed to provide 6 of 12 required drill records for Building 3. The facility failed to provide documentation for the AM, PM and NOC shifts for the 1st quarter (January-March) of 2011, the AM and PM shifts for the 2nd quarter (April-June) of 2011 and the NOC shift for the 3rd quarter (July-September) of 2011. Staff 1 confirmed the reports were not available.

3. At 3:45 p.m. on January 9, 2012, 6 of 12 required drill records for Building 3 failed to document staff reaction during the drill in areas away from the drill location. 5 of 6 drill indicated alarm activation or an overhead page to alert other areas. The 4th quarter drill of 2011 on the NOC shift documented that the alarm was not activated and that no overhead page was announced which failed to alert other areas for participation in the drill. Staff 1 confirmed the drill reports failed to document staff response in other areas of the facility.

4. At 8:45 a.m. on January 12, 2012, the facility was requested to provide documentation for fire drills. The facility failed to provide 7 of 12 required drill records for Building 5. The facility failed to provide documentation for the AM, PM and NOC shifts for the 2nd quarter of 2011, the PM shift for the 3rd quarter of 2011 and the PM and NOC shifts for the 4th quarter of 2011. Staff 56 confirmed the reports were not available.

NFPA 72 National Fire Alarm Code? 1999 Edition. 1-6.2 Completion Documents.
1-6.2.1* A record of completion (Figure 1-6.2.1) shall be prepared for each system. Parts 1, 2, and 4 through 10 shall be completed after the system is installed and the installation wiring has been checked. Part 3 shall be completed after the operational acceptance tests have been completed. A preliminary copy of the record of completion shall be given to the system owner and, if requested, to other authorities having jurisdiction after completion of the installation wiring tests. A final copy shall be provided after completion of the operational
acceptance tests.

NFPA 72 National Fire Alarm Code? 1999 Edition. 1-6.2.2 Every system shall include the following documentation, which shall be delivered to the owner or the owner ' s representative upon final acceptance of the system:
(1) *An owner ' s manual and installation instructions covering all system equipment
(2) Record drawings

NFPA 72 National Fire Alarm Code? 1999 Edition. 7-1.6 System Testing.
7-1.6.1 Initial Acceptance Testing. All new systems shall be inspected and tested in accordance with the requirements of Chapter 7.

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 72 National Fire Alarm Code? 1999 Edition. 7-5.1* Permanent Records. After successful completion of acceptance tests approved by the authority having jurisdiction, a set of reproducible as-built installation drawings, operation and maintenance manuals, and a written sequence of operation shall be provided to the building owner or the owner ' s designated representative. The owner shall be responsible for maintaining these records for the life of the system for examination by any authority having jurisdiction. Paper or electronic media shall be permitted.

NFPA 72 National Fire Alarm Code? 1999 Edition. 7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be provided that includes the following
information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business
address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, " Tests performed in accordance with Section __________. "
(8) Functional test of detectors
(9) *Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15)Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place)

NFPA 101 Life Safety Code (2000 Edition) 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 101 Life Safety Code 2000 Edition. 9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.

NFPA 101 Life Safety Code (2000 Edition) 9.7.2.1* Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

NFPA 101 Life Safety Code 2000 Edition. 19.3.4.3 Occupant Notification. Occupant notification shall be accomplished automatically, without delay, upon operation of any fire alarm activating device by means of an internal audible alarm in accordance with 9.6.3.

Based on observation, the facility failed to maintain their fire alarm system. This was evidenced by batteries that were not dated as to when the batteries were installed in the panel or when the batteries were manufactured, by the failure to provide fire alarm completion documents, tamper supervisory alarms that were not monitored, by four audible devices that failed to annunciate, by the failure to provide current documentation for the annual inspection and testing of the fire alarm control panel, the annual charger and discharge test of the sealed lead acid batteries and the annual testing of the Initiating Devices including alarm notification devices. This affected Buildings 2, 3, 4, 5 and 7 and had the potential for fire alarm system failure.

Findings:

During the document review and facility tour with Facility Staff between January 9 to 13, 2012, the fire alarm systems were observed and maintenance documents were reviewed.

1. At 5:00 p.m. on January 9, 2012, the facility failed to provide documentation for the annual fire alarm inspection and testing for Building 7.

2.. At 10:58 a.m. on January 11, 2012, the combination audible/visible annunciator 1-013 on the first floor of Building 3 near door 1-19 in Administration was observed. The chime failed to alarm after activation of a smoke detector.

3. At 10:59 a.m. on January 11, 2012, the combination audible/visible annunciator 1-015 on the first floor of Building 3 in Administration was observed. The chime failed to alarm after activation of a smoke detector.

4. At 11:01 a.m. on January 11, 2012, the combination audible/visible annunciator 1-012 on the first floor of Building 3 in Administration was observed. The chime failed to alarm after activation of a smoke detector.

5. At 11:05 a.m. on January 11, 2012, the combination audible/visible annunciator 1-09 on the first floor of Building 3 was observed. The chime failed to alarm after activation of a smoke detector.

6. At 3:48 p.m. on January 11, 2012, the facility failed to provide a current inspection and test record from the owner of Building 7 for the fire alarm panel and system. Staff 59 confirmed that the only record provided by the building owner was for an incomplete annual fire alarm inspection with a repair proposal dated from 2010.

7. At 4:00 p.m. on January 11, 2012, the fire alarm bell failed to sound during testing of the inspector test valve for Building 7. An accumulation of stucco was observed inside the electrically operated alarm bell.




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8. At 10:05 a.m. on January 10, 2012, the two batteries for the fire alarm panel identified as NAC Panel 8 in Building 3 were not labeled as to when the batteries were installed in the panel or labeled with the date of manufacture. Staff 1 confirmed the batteries were not labeled.

9. At 2:00 p.m. on January 10, 2012, the facility was requested to provide fire alarm final completion documents for Building 4. The documents were again requested at 8:00 a.m. on January 13, 2012. The facility failed to provide fire alarm completion documentation including the initial acceptance test and a record of completion. Staff 58 stated the documents were not available.


10. At 2:20 p.m. on January 11, 2012, 2 of 2 batteries for the main fire alarm panel in Building 2 were not dated as to when the batteries were installed in the fire alarm panel. Staff 56 confirmed there was no date on the batteries and stated he did not know if the facility had documentation as to when the batteries were installed.

11. At 11:05 a.m. on January 12, 2012, the facility provided documentation for the testing and maintenance of the fire alarm system for Building 5. The report failed to provide documentation specific to the fire alarm inspection of the system in the MRI Building. The MRI Building was a standalone building on the Selma Campus. Staff 61 stated the information specific to the MRI Building was not available.

12. At 4:30 p.m. on January 12, 2012, the tamper switch was activated on the Post Indicator Valve for Building 2. The alarm sounded at the main panel and the sub panel near the main entrance in the waiting room. Both areas were not constantly attended. The tamper alarm was not received at the monitoring station. Staff 59 stated the tamper was monitored at the switchboard at the old hospital and apparently had not been redirected to the monitoring company when the switchboard was moved to the new hospital.

NFPA 101 Life Safety Code (2000 Edition) 9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72 National Fire Alarm Code (1999 Edition) 7-7.1 Scope. Chapter 7 shall cover the minimum requirements for the inspection, testing, and maintenance of the fire alarm systems described in Chapter 1, 3 and 5 and for their initiation and notification components described in Chapter 2 and 4. The testing and maintenance requirements for one- and two-family dwelling units shall be located in Chapter 8. Single station detectors used for other than one- and two-family dwelling units shall be tested and maintained in accordance with Chapter 7. More stringent inspection, testing, or maintenance procedures that are required by other parties shall be permitted.

NFPA 72 National Fire Alarm Code (1999 Edition), 7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.

To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:

(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction

Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or replaced.

Exception No.1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.

Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.

The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

NFPA 72 National Fire Alarm Code (1999 Edition), 8-3.5 Unless otherwise recommended by the manufacturer, smoke alarms installed in accordance with Chapters 18, 19, or 21 of NFPA 101, Life Safety Code, shall be replaced when they fail to respond to tests conducted in accordance with 8-3.4 but shall not remain in service longer than 10 years from the date of installation.

Based on observation, interview and document review, the facility failed to maintain the smoke alarms as evidenced by the failure to provide current documentation for the sensitivity testing of the smoke alarms and single station, battery operated smoke alarms that were in service longer than 10 years. This affected Building 5 and had the potential for detector failure.

Findings:

During the document review and facility tour with Facility Staff on January 12, 2012, the fire alarm system test records were reviewed and the smoke alarms were observed.

1. At 8:45 a.m. on January 12, 2012, the facility provided documentation for the fire alarm system tests dated 3/3/11, 6/23/11, 9/13/11 and 12/2/11. The reports failed to document the sensitivity testing of the system based smoke alarms in Building 5. Staff 61 stated there were no other documents available for review.

2. At 10:00 a.m. on January 12, 2012, three single station, battery operated smoke alarms were observed in the standalone building housing the Pharmacy adjacent to Building 5. The smoke alarms were dated 12-97-4 (April 4, 1987). The smoke alarms were over 14 years past due for replacement. Staff 61 confirmed the smoke alarms were dated April 4, 1987.

NFPA 13 Standard for the Installation of Sprinkler Systems (1999 Edition), 3-2.9.2 A special sprinkler wrench shall also be provided and kept in the cabinet to be used in the removal and installation of sprinklers.

NFPA 13 Standard for the Installation of Sprinkler Systems (1999 Edition), 3-8.3 Identification of Valves. All control, drain, and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs. The sign shall be secured with corrosion-resistant wire, chain or other approved means.

NFPA 13 Standard for the Installation of Sprinkler Systems (1999 Edition) 5-3.1.5.2 When existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartmented space shall be changed.
NFPA 13 Standard for the Installation of Sprinkler Systems (1999 Edition), 5-6.6* Clearance to Storage (Standard Pendent and Upright Spray Sprinklers). The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

Exception: Where other standards specify greater minimums, they shall be followed.

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.

NFPA 13 Standard for the Installation of Sprinkler Systems (1999 Edition) 10-1 Approval of Sprinkler Systems and Private Fire Service Mains. The installing contractor shall do the following:
(1) Notify the authority having jurisdiction and the property owner or the property owner's authorized representative of the time and date testing will be performed
(2) Perform all required acceptance tests (see Section 10.2).
(3) Complete and sign the appropriate contractor's material and test certificate(s) [see Figures 10-1(a) and 10-1(b)]
NFPA 13 Standard for the Installation of Sprinkler Systems (1999 Edition) 10-2.4.4 The main drain valve shall be opened and remain open until the system pressure stabilizes. The static and residual pressures shall be recorded on the contractor's test certificate.
NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (1998 Edition) 1-8 Records. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (1998 Edition) 1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (1998 Edition) 2-1 General. This chapter provides the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems. Table 2-1 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.
Exception: Valves and fire department connections shall be inspected, tested, and maintained in accordance with Chapter 9.
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, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, 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 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (1998 Edition) 2-2.1.3 The supply of spare sprinklers shall be inspected annually for the following:
(a) The proper number and type of sprinklers
(b) A sprinkler wrench for each type of sprinkler
2-2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the
pipe or hung from the pipe.
Exception No. 1:* Pipe and fittings installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Pipe installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.
2-2.3* Hangers and Seismic Braces. Sprinkler pipe hangers and seismic braces shall be inspected annually from the floor level. Hangers and seismic braces shall not be damaged or loose. Hangers and seismic braces that are damaged or loose shall be replaced or refastened.
Exception No. 1: *Hangers and seismic braces installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Hangers 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) 2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.
NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (1998 Edition) 2-2.7* Hydraulic Nameplate. The hydraulic nameplate, if provided, shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible.
NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (1998 Edition) 2-3.3* Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.
NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (1998 Edition) 2-4.1.6* A special sprinkler wrench shall be provided and kept in the cabinet to be used in the removal and installation of sprinklers. One sprinkler wrench shall be provided for each type of sprinkler installed.
NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (1998 Edition) 9-3.5 Maintenance. The operating stems of outside screw and yoke valves shall be lubricated annually. The valve then shall be completely closed and reopened to test its operation and distribute the lubricant.
NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (1998 Edition) 9-5.1.1 All valves shall be inspected quarterly. The inspection shall verify that the valves are in the following condition:
(a) In the open position
(b) Not leaking
(c) Maintaining downstream pressures in accordance with the design criteria
(d) In good condition, with handwheels installed and unbroken
NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (1998 Edition) 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

Based on observation and document review, the facility failed to maintain the fire sprinkler system as evidenced by quick response sprinkler heads in a smoke compartment which also contained standard sprinkler heads, by missing fire department connection (FDC) caps, by sprinkler heads with foreign debris on the heads, by missing identification signs, by the failure to provide a wrench for changing the sprinkler heads, by the failure to provide documentation for the acceptance test of the fire sprinkler system, the failure to provide documentation for the 5-year certification, the annual fire sprinkler inspection and maintenance and the failure to provide documentation for the quarterly sprinkler tests and inspections. This affected Buildings 3, 4, 5 and 6 and had the potential for sprinkler system failure leading to harm of the patients.

Findings:

During the document review and facility tour with Staff 1 on January 10, 11 and 12, 2012, the facility sprinkler system inspection reports were reviewed and the sprinkler system was observed.

1. At 5 p.m. on January 9, 2012, the facility failed to provide documentation for the fire alarm and sprinkler system inspection and testing records for Building 7. There were no documents for quarterly, annual and five year testing of the sprinkler system.

2 . At 2:58 p.m. on January 11, 2012, there was rust visible on the body of the sprinkler under the exterior soffit at the north east corner of building 7. The rust stains came down onto the sprinkler from above the soffit.

3. At 3:09 p.m. on January 11, 2012 the sprinkler riser for Building 7 was accessible to the public and the main control valve was not securely chained and locked.

4. At 3:10 p.m. on January 11, 2012, there was no identification sign attached to the fire sprinkler control valve of Building 7.

5. At 3:11 p.m. on January 11, 2012, the pressure gauge on the fire sprinkler riser for Building 7 was faulty and visually obscured. Staff 59 removed the discolored bezel and the needle was observed at the zero pressure reading.

6. At 3:15 p.m. on January 11, 2012, there was no identification sign at the fire department connection for Building 7.

7. At 3:16 p.m. on January 11, 2012, the fire department connections for Building 7 did not spin freely.

8. At 3:48 p.m. on January 11, 2012, there was no current record from the owner of Building 7 for the fire alarm panel and system and there was no sprinkler system quarterly, annual, or five-year certification.

9. At 9:04 a.m. on January 12, 2012, maintenance staff failed to readily identify where the inspector test valves were located in the stairwells. There were no identification signs for the inspector test valve and drain valves on the risers at both the second and third floor levels of Building 3.

10. At 12:05 p.m. on January 12, 2012, there was storage stacked within approximately ten inches of a sprinkler in Building 5 Emergency Department oxygen cylinder storage room.






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11. At 9:27 a.m. on January 10, 2012, 2 of 2 FDC caps were missing on the FDC on the 3rd floor roof area of Building 3. Staff 1 confirmed the caps were missing and stated the caps had been removed so the local fire department could install lockable FDC caps.
12. At 11:37 a.m. on January 10, 2012, the spare sprinkler head box for Building 4 was observed. The facility failed to provide a special sprinkler wrench to be used for the removal and installation of sprinkler heads. Staff 56 confirmed there was no wrench in the spare sprinkler head box.
13. At 2:00 p.m. on January 10, 2012, the facility was requested to provide documentation for the acceptance test records for Building 4 fire sprinkler system. Staff 59 stated the facility did not have the documentation as required in NFPA 13 10-1. Staff 59 stated the building was occupied in 2010.
14. At 2:00 p.m. on January 10, 2012, the facility was requested to provide documentation for the quarterly inspection and test records for the Building 4 fire sprinkler system. The facility failed to provide documentation for the quarterly inspections to assure they were free of physical damage, there was no evidence that the valves were inspected, there was no documentation for the inspection of the hydraulic nameplate and there was no evidence that the fire department connections were inspected. Staff 58 confirmed there was no additional documentation of the quarterly sprinkler tests and inspection beyond testing the inspector test valve and recording pressure in the system before, during and after testing of the inspector test valve.
15. At 2:00 p.m. on January 10, 2012, the facility was requested to provide documentation for the annual inspection, test and maintenance records for the Building 4 fire sprinkler system. The facility failed to provide documentation for the annual inspection of the fire sprinkler system that included inspection of the sprinkler pipes and fittings, the inspection of the spare sprinkler heads, inspection of the sprinkler pipe hangers and seismic braces and maintenance and lubrication of the valves. Staff 58 confirmed there was no additional documentation of the annual sprinkler tests, maintenance and inspection beyond testing the inspector test valve and recording pressure in the system before, during and after testing of the inspector test valve.
16. At 2:25 p.m. on January 10, 2 of 2 sprinkler heads in the kitchen walk-in refrigerator in Building 3 had the protective caps on the sprinkler heads. Staff 1 confirmed the protective caps were on the sprinkler heads.

17. At 2:25 p.m. on January 10, 2 of 2 sprinkler heads in the kitchen walk-in freezer in Building 3 had the protective caps on the sprinkler heads. Staff 1 confirmed the protective caps were on the sprinkler heads.

18. At 11:30 a.m. on January 11, 2012, the facility failed to provide documentation for the 5 year certification, documentation for an annual inspection and maintenance within the last twelve months and 4 of 4 quarterly inspections for the last twelve months as required by NFPA 25. Staff 58 confirmed there was no documentation. Staff 56 stated Building 6 was leased but did not know if the owner had the documents.

19. At 11:48 a.m. on January 11, 2012, quick response sprinkler heads were observed in Occupational Therapy office area and office corridor of Building 6. The smoke compartment also contained standard response sprinkler heads. Staff 1 confirmed there were quick response sprinkler heads and standard response sprinkler heads in the smoke compartment.


20. At 9:45 a.m. on January 12, 2012, the facility failed to provide documentation for the 5 year certification of the sprinkler system for Building 5 that included internal inspection of the alarm valves and their associated strainers, filters, and restriction orifices, internal inspection of the valves, internal inspection of the strainers, filters, and restricted orifices, and internal examination for obstructions. Staff 61 confirmed there was no documentation for the 5-year certification. The facility sprinkler riser tag was dated 2006. Staff 61 confirmed the tag on the riser was dated 2006.


21. At 2:27 p.m. on January 12, 2012, the sprinkler head in the Nursery of Building 5 adjacent to the sink had paint on the deflector. Staff 61 confirmed there was paint on the deflector.

22. At 2:28 p.m. on January 12, 2012, the sprinkler head in the Central Supply Sterilizer Room in Building 5 had dust build-up on the sprinkler head. Staff 61 confirmed there was dust build-up on the sprinkler head.

23. At 8:15 a.m. on January 13, 2012, the facility failed to provide documentation of the final acceptance test of the fire sprinkler system for Building 3 including the recording of the static and residual pressures. Staff 1 confirmed the record failed to document the static and residual pressures. Acceptance test records were requested during the entrance conference on January 9, 2012.

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.

Based on observation, the facility failed to maintain their fire extinguishers. This was evidenced by the failure to maintain access to a fire extinguisher and the failure to provide a means to indicate extinguisher locations where extinguishers were obstructed from view. This affected Building 5 and had the potential for the delay in accessing the fire extinguishers for extinguishing a fire and had the potential for some persons not to be able to access the extinguisher or being injured due to having to reach for the extinguisher.

Findings:

During the facility tour with Staff on January 12, 2011, the fire extinguishers were observed.

1. At 11:00 a.m. on January 12, 2012, 2 of 2 fire extinguishers in the Laboratory adjacent to Building 5 were visually obstructed. There was an extinguisher in the northwest room. When in the lab, there was no means to indicate there was an extinguisher in the northwest room. The second extinguisher was located adjacent to a machine in the southwest corner of the laboratory. There was a sign above the extinguisher pointing to the extinguisher. From most of the laboratory work area, the sign and extinguisher were visually obstructed by the machine adjacent to the extinguisher. Staff 61 confirmed both extinguishers were visually obstructed.

2. At 2:28 p.m. on January 12, 2012, access to the fire extinguisher in the GI Lab of Building 5 was obstructed by a hamper in front of the extinguisher cabinet, forcing occupants to reach over the hamper if the extinguisher was needed. Staff 61 confirmed the access was blocked by the hamper and moved the hamper.

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.

NFPA 99 Standard for Health Care Facilities (1999 Edition) 5-4.1.1 The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Based on observation and document review, the facility failed to maintain the heating, ventilation and air conditioning (HVAC) system. This was evidenced by the failure to provide records for the testing and maintenance of the dampers, the failure to provide documentation for the action taken by the facility when the relative humidity in the operating room was less the 35 percent and the failure to identify damper access openings adjacent to dampers. This affected Buildings 2, 3 and 5. This 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 residents.

Findings:

During the document review and facility tour with Staff 1 between January 9 and January 13, 2012, the facility dampers were observed and policies and humidity logs were reviewed.
1. At 4:00 p.m. on January 9, 2012, the Building 3 humidity log indicated that the relative humidity on 12-28-11 was 33% for OR1, 34% for OR2, 31% for OR3, 34% for OR4 and 27% for OR6. OR6 was 29% on 12-29-11. The facility was requested to provide the policy and/or procedure taken by the OR when the relative humidity in the OR fell below 35%. At 8:15 a.m. on January 13, 2011, the facility failed to provide the policy and/or procedure taken by the OR when the relative humidity in the OR fell below 35%.
2. At 9:20 a.m. on January 10, 2012, the duct access panels in the Roof Mechanical Room on Building 3 were not identified indicating a damper within the ducts. Staff 1 confirmed there was no lettering on the access panels to note the presence of the dampers.

3. At 2:30 p.m. on January 11, 2012, the test and maintenance records for Building 2 were requested. The facility housed the Ambulatory Surgery Center. The facility failed to provide records for the testing and maintenance of the dampers. Staff 58 stated the dampers had not been tested and maintained and that there were no records available.

4. At 9:00 a.m. on January 12, 2012, the facility failed to provide records verifying the maintenance and testing of the fire dampers in Building 5. The vendor representative stated the company only maintained the mechanical smoke dampers, as documented in the fire alarm reports. Staff 61 stated the fire dampers were not maintained and that there were no records for review. Fire dampers were observed in 9 of 9 smoke compartments in Building 5 during the facility tour between the hours of 9:30 a.m. and 2:30 p.m.
5. At 9:15 a.m. on January 12, 2012, the Building 5 humidity log indicated that the relative humidity on 1-4-11 was 28% for OR1, 34% for OR2 and 27% for OR3. OR1 was 31%, OR2 was 34% and OR3 was 29% on 1-5-11. The facility was requested to provide the policy and/or procedure taken by the OR when the relative humidity in the OR fell below 35%. At 8:15 a.m. on January 13, 2011, the facility failed to provide the policy and/or procedure taken by the OR when the relative humidity in the OR fell below 35%.

NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations (1998 Edition) 7-2.1.1 A placard identifying the use of the extinguisher as secondary backup means to the automatic fire suppression system shall be conspicuously placed near each portable fire extinguisher in the cooking area.

NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations (1998 Edition) 8-3.1.2 When a vent cleaning service is used, a certificate showing date of inspection or cleaning be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company. It shall also indicate areas not cleaned.

Based on observation, the facility failed to maintain the kitchen cooking exhaust and fire suppression systems as evidenced by the facility's failure to display a label indicating the date cleaned and the name of the servicing company and by the failure to post a warning sign by the Class ABC extinguisher in the kitchen. This affected Building 5 and had the potential for the failure to maintain the exhaust system leading to a fire and improper use of the fire extinguisher leading to harm to the patients.

Findings:

During the facility tour with Staff on January 12, 2012, the facility kitchen exhaust system and fire extinguishers were observed.

1. At 9:35 a.m. on January 12, 2012, there was no sign adjacent to the Class ABC extinguisher in the kitchen in Building 5 warning staff to activate the fire extinguishing system prior to using the Class ABC fire extinguisher. Staff 61 confirmed there was no warning sign.

2. At 9:45 a.m. on January 12, 2012, the kitchen in Building 5 failed to display the label from the servicing company within the kitchen indicating the date the exhaust system was cleaned by the vendor. Staff 61 confirmed the vendor label was not displayed in the kitchen.

NFPA 99 Standard for Health Care Facilities (1999 Edition)
8-3.1.11 Storage Requirements.
8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3 85 m3).

(a) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
(b) Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor.
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:

1. A minimum distance of 20 ft (6.1 m), or
2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.

NFPA 99 Standard for Health Care Facilities (1999 Edition) 21-1 Referenced Publications. The following documents or portions thereof are referenced within this standard and shall be considered part of the requirements of this document. The edition indicated for each reference is the current edition as of the date of the NFPA issuance of this document.

NFPA 99 Standard for Health Care Facilities (1999 Edition) 21-1.2.6 CGA Publications. Compressed Gas Association, Inc., 1725 Jefferson Davis Highway, Arlington, VA 22202.

Pamphlet G-4-1987, Oxygen. III. STORAGE OF COMPRESSED AND LIQUEFIED GAS, Storage Requirements. All gas cylinders: Shall be stored so that full cylinders remain separate from empty cylinders.

Based on observation and interview, the facility failed to safely maintain the oxygen cylinder storage area. This was evidenced by the failure to separate empty and full cylinders, by combustible supplies and soiled linens stored with oxidizing gasses. This affected Buildings 2, 3 and 5 and had the potential for use of an empty cylinder in an emergency leading to harm to the patient and could cause fire.

Findings:

During the facility tour with Staff on January 10 and 11, 2012, the facility oxygen storage area was observed.

1. At 2:25 p.m. on January 10, 2012, there were five oxygen and one nitrous oxide E-sized cylinders stored in the Soiled Utility Room in the Surgery Area of Building 3. These were stored within two feet of shelving rack of miscellaneous combustible storage and a 16 cubic foot rolling cart that was filled with soiled bed pads and drapes.

2. At 2:53 p.m. on January 10, 2012, there were 13 full and partially full E-sized Oxygen cylinders stored in the Hazardous Storage, Room 1-270, on the first floor in Building 3. The oxygen cylinders were stored within two feet of a 16 cubic foot rolling cart that was full of soiled bed pads and drapes.


3. At 12:05 p.m. on January 12, 2012, there were 14 empty and full oxygen cylinders stored with combustible storage in the Building 5 oxygen storage area. The oxygen cylinders were stored together and were not labeled or separated as empty and full.




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4. At 3:04 p.m. on January 11, 2012, in the oxygen storage room 143 of Building 2, the oxygen cylinders were stored together and were not separated as empty and full. Staff 56 confirmed the oxygen cylinders were stored together and were not segregated as empty and full.

NFPA 418 Standard for Heliports 1995 Edition 3-6 Fire Protection. A foam fire extinguishing system shall be designed and installed to protect the rooftop landing pad.

Exception No. 1: A foam fire extinguishing system shall not be required for heliports located on parking garages, unoccupied buildings, or other similar unoccupied structures.
Exception No. 2: For H-1 heliports, two portable foam extinguishers, each having a rating of 20-A:160-B, shall be permitted to be used to satisfy this requirement.

Based on observation, the facility failed to ensure that the correct extinguishing type was provided in their heliport. This was evidenced by the failure to provide fire extinguishers of the type and rating required to protect the heliport. This affected Building 3 and had the potential to fail to extinguish a fuel fire leading to harm to the patients.

Findings:

During the facility tour with Staff 1 on January 10, 2012, the heliport was observed.

At 9:25 a.m. on January 10, 2012, the fire extinguisher at the heliport was a dry chemical extinguisher with a 10-A: 60-B:C rating. This was confirmed with Staff 56 on 1-23-12 at 1:00 p.m.

Based on observation and interview the facility failed to ensure the eyewash and shower in the Lab were maintained according to NFPA 99. This was evidenced by obstructed access to the eye wash and shower. This could result in a delay in the use of the emergency eye wash station and a potential increase in the severity of injury from a hazardous chemical exposure.

Findings:

During the facility tour on with Staff 59 on January 10, 2012, the emergency shower and eyewash station were observed in the Laboratory on the first floor of Building 3.

At 4:50 p.m., the eye wash station and shower were obstructed from access by card board boxes and plastic containers. There were nine open boxes, three folded boxes and two buckets that covered the shower area and eye wash access.

NFPA 99 Standard for Health Care Facilities (1999 Edition) 3-4.1.1.15 Alarm Annunciator. A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12).
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source in operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel-when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangment signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. (110: 3-5.5.2)

NFPA 110 Standard for Emergency and Standby Power Systems (1999 Edition) 3-5.4.5* Type of Battery. The battery shall be of the nickelcadmium or lead-acid type. Lead-acid batteries shall be furnished as charged when wet. Drain-dry batteries or drycharged lead-acid batteries shall be permitted. Vented nickelcadmium batteries shall be filled and charged when furnished and shall have listed flip-top, flame arrestor vent caps. The manufacturer shall provide installation, operation, and maintenance instructions, and, when shipped dry, electrolyte mixing instructions. Batteries shall not be installed until the battery charger is in service.
All batteries used in this service shall have been designed for this duty and shall have demonstrable characteristics of performance and reliability acceptable to the authority having jurisdiction. Batteries shall be prepared for use according to the battery manufacturer ' s instructions.
Starting batteries for Level 1 installations shall not be of the maintenance-free variety.

NFPA 110 Standard for Emergency and Standby Power Systems (1999 Edition) 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

NFPA 110 Standard for Emergency and Standby Power Systems (1999 Edition) 6-3.6* Storage batteries, including electrolyte levels, used in connection with Level 1 and Level 2 systems shall be inspected at intervals of not more than 7 days and shall be maintained in full compliance with manufacturer ' s specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects.

Based on interview and document review, the facility failed to maintain the generator as evidenced by the failure to provide documentation for the weekly inspection of the generator, by the failure to provide documentation for the weekly inspection and test of the generator batteries, by the failure to provide a remote panel for the emergency generator, as evidenced by the failure to provide the correct starting batteries and the failure to provide emergency lighting in the generator room. This affected Buildings 2, 3 and 5 and had the potential for generator failure leading to harm of the patients.

Findings:

During the document review and facility tour with Staff between January 9 and January 13, 2012, the facility generator test and inspection logs were reviewed and the generator was observed.

1. At 3:21 p.m. on January 9, 2012, the facility failed to provide weekly generator inspection records for 40 of 52 previous weeks for Building 3.

2. At 3:22 p.m. on January 9, 2012, Staff 57 explained that they checked the remote indicator panel located in the Maintenance shop but that they did not physically inspect the generators or batteries on a weekly basis for Building 3.

3. At 3:23 p.m. on January 9, 2012, Staff 58 stated that the starting batteries were sealed and that there was no access to inspect the electrolyte condition for each cell in the generator batteries for Building 3.





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5. At 3:25 p.m. on January 9, 2012, the monthly testing documentation " Emergency Generator Test Log, " indicated that the generators did not meet the minimum 30% of generator nameplate rating during the monthly load tests for Building 3. The records showed that the generators ran for 30 minutes each month and that once a year they ran for two hours. A once per year two-hour load test that was documented on the " Emergency Generator Operating Log " did not meet the annual load test requirement for 75% loading during the second hour of the load bank test.

During interviews with Staff 57 and 58 on 1/9/12, inspection and testing methods for the emergency power generators were described.

6. At 9:45 a.m. on January 12, 2012, the emergency generator for Building 5 was observed. The facility failed to provide battery-powered, emergency lighting in the generator room. Staff 61 confirmed there was no emergency lighting in the generator room.

7. At 9:45 a.m. on January 12, 2012, the emergency generator for Building 5 was observed. The batteries for the generator were maintenance free batteries and were not in compliance with NFPA 110 3-5.4.5. Staff 61 confirmed the batteries were maintenance free.

8. At 2:30 p.m. on January 12, 2012, Staff 62 was asked if Building 5 had remote panel for the emergency generator. Staff 62 stated the facility did not have a remote panel. The facility failed to provide a remote alarm annunciator panel for the emergency generator within the facility at a location readily observed by personnel at a regular work station to indicate when the emergency or auxiliary power source was operating or when the battery charger was malfunctioning.

9. At 4:00 p.m. on January 12, 2012, the facility failed to provide documentation for the weekly inspection of the generator and documentation of the specific gravity test of the generator batteries for the Building 2 that housed the Out-patient Surgery Center. Staff 58 confirmed the weekly inspections and specific gravity testing were not done. Staff 58 stated the inspection was only done on a monthly basis when the generator was tested. This was confirmed by document review of the generator test logs.

NFPA 99 Standard for Health Care Facilities (1999 Edition) 3-4.2.2.2 Emergency System.
(c)* Critical Branch. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and selected power circuits serving the following areas and functions related to patient care. It shall be permitted to subdivide the critical branch into two or more branches.
8. Task illumination, selected receptacles, and selected power circuits for the following:
a. General care beds (at least one duplex receptacle per patient bedroom)

NFPA 99 Standard for Health Care Facilities (1999 Edition) 3-4.2.2.4 Wiring Requirements. (b) Receptacles.
2.* The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable.

Based on observation and interview, the facility failed to maintain the electrical wiring and equipment as evidenced by the failure to provide emergency power in general care rooms. This affected Building 5 which had the potential for the delay in providing emergency power to equipment.

Findings:

During the facility tour with Staff 61 on January 12, 2012, the facility electrical wiring and equipment were observed.

At 2:10 p.m. on January 12, 2012, the facility failed to provide emergency power in the OB rooms in the south wing of Building 5. Red Receptacles were used in the facility to identify receptacles on emergency power. There were no red receptacles observed in the OB Rooms. Staff 59 stated the OB rooms were in the area that was formerly the Distinct Part Skilled Nursing Facility. Staff 59 stated the emergency receptacles in the corridor would be used in an emergency.

NFPA 70 (1999 Edition), article 110-12(C) Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasive, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating.

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), article 373-4. Unused Openings. Unused openings in enclosures within the scope of this article shall be effectively closed to afford protection substantially equivalent to that of the enclosures within the scope of this article. Where metal plugs or plates are used with nonmetallic cabinets or cutout boxes, they shall be recessed at least ? in. (6.35 mm) from the outer surface.

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 (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 (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 (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 Facilties (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, the facility failed to maintain the electrical system as evidenced by damaged electrical receptacle cover plates, damaged electrical receptacle, by breakers in the on position and not labeled as to the purpose or use, by the failure to provide a cover for an unused opening on an electrical panel and the use of a surge protector to extend power and provide additional receptacles for equipment instead of providing fixed wired electrical receptacles, medical devices that were plugged into unapproved multi-outlet extension cords, and daisy chained multi-outlet extension cord connections. This affected Buildings 1, 3, 4 and 5 and had the potential for electrical shock.

Findings:

During the facility tour with Facility Staff on January 10 and 11, 2012, the facility electrical system was observed.

1. At 9:43 a.m. on January 10, 2012, the electrical receptacle cover plate in the 3rd floor waiting room of Building 3 was damaged. Staff 1 confirmed the cover plate was damaged.


2. At 1:37 p.m. on January 10, 2012, there was a microwave oven and a coffee maker plugged into a surge protector in the Phlebotomy area 6 in the lab located in Building 4. The surge protector was used to extend power and as a substitute for providing additional fixed wired electrical receptacles. Staff 56 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 1:47 p.m. on January 10, 2012, the electrical receptacle in the corridor adjacent to the biohazard waste storage room 1222 in Building 4 had items broken off in the both receptacles. Staff 56 confirmed there were items broken off in the receptacle.



4. At 2:55 p.m. on January 10, 2012, the red electrical receptacle cover plate on the east wall of the Clean Linen Storage Room on the first floor of Building 3 was damaged. Staff 1 confirmed the cover plate was damaged.


5. At 1:54 p.m. on January 11, 2012, on Electrical Panel PP-A in Nuclear Medicine in Building 1, breaker 19 was in the on position and not labeled as to the area served by the breaker. Staff 56 confirmed the breaker was not labeled.

6. At 1:54 p.m. on January 11, 2012, on Electrical Panel PP-A in Nuclear Medicine in Building 1, the area on the panel for breaker 2 was open. There was no cover on the open area. Staff 56 confirmed the breaker area was open and not covered.


7. At 2:10 p.m. on January 12, 2012, the facility failed to provide documentation for the polarity testing of the electrical receptacles in the critical care and wet areas of Building 5 due at 6-month intervals. Staff 61 stated testing was only done annually.









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8. At 10:31 a.m. on January 10, 2012, there was a broken electrical cover plate on the electrical outlet behind the microwave in the pantry room 2-54 of Building 3.

9. At 1:37 p.m. on January 10, 2012, there was a Beaer Hugger heating blanket plugged into a non-approved multi-outlet extension cord, Tripp Lite model U24 RA-15.

10. At 1:46 p.m. on January 10, 2012, in OR #6 of Building 3, there was a surgery table plugged into an unapproved surge protected extension cord, Wiremold Power Tapp model 2MV36 UL 977 E which was sitting on the floor under the anesthesia equipment within 30 inches of the operating table. This was plugged into a second multi-outlet extension cord sitting inside the anesthesia equipment, TrippLite P415HG UL Power Tap 58M7,which was plugged into a third multi-outlet extension cord, mounted onto the same equipment, which was then plugged into an electrical outlet at the ceiling column.

11. At 2:15 p.m. on January 10, 2012, in OR #4 in Building 3, an operating table was plugged into an unapproved multi-outlet extension cord. This was a TrippLite PS-615-HGULTRA UL1365.

12. At 2:18 p.m. on January 10, 2012, refrigerator in the Anesthesia Workroom in Building 3 was plugged into a multi-outlet extension cord which had a frayed insulation cover at the plug into the wall outlet.

13. At 2:36 p.m. on January 10, 2012, a refrigerator was plugged into a multi-outlet extension cord in the OR staff lounge in Building 3.

14. At 2:40 p.m. on January 10, 2012, in the Endoscopy procedure room of Building 3, the surgery table was plugged into a multi-outlet extension cord, TrippLite LR6-2645 which was laying on the floor. This was plugged into a multi-outlet extension cord, TrippLite LR6-2645 in the anesthesia equipment which was plugged into an electrical outlet at the ceiling column.

15. At 3:15 p.m. on January 10, 2012, in OR #2 in Building 3, there was a surgery table, a pressure cuff monitor, plugged into a multi-outlet extension cord, SL Wabu Model #SLHC6-21/UL HC6, which was plugged into an electrical outlet in the ceiling column.

16. At 4:30 p.m. on January 10, 2012, there was a laboratory refrigerator for pathology specimen storage in the Building 3 Lab that was plugged into a 15 foot extension cord which was plugged into a counter top power strip electrical outlet in Room 1-214.

17. At 4:38 p.m. on January 10, 2012, there was a laboratory refrigerator with reagent storage plugged into a yellow colored 25 foot long three-way extension cord in Building 3.

18. At 11:55 a.m. on January 12, 2012, there was a microwave and a refrigerator plugged into a multi-outlet extension cord which was plugged into a wall outlet in Building 5 Emergency Department doctor ' s sleeping room.

19. At 1:50 p.m. on January 12, 2012, there was a multi-outlet extension cord which that was attached to the wall in Building 5 Emergency Department ' s admitting area. The wall outlet was pushed back into the outlet box.

20. At 4:01 p.m. on January 12, 2012, there was an extension cord in Building 5 that was run from behind a desk to a wall outlet in the Radiology Reading Room.

21. At 5:30 p.m. on January 12, 2012, at 5:30 p.m., five of six product data sheets provided by Staff 58 failed to indicate that the wiring devices in the Operating Rooms in Building 3 were UL approved for use on patient care equipment.