HospitalInspections.org

Based on observations, the facility failed to ensure that all corridor doors latched properly when closed. This deficiency has the potential to affect more than a very limited amount of patients/residents, staff, and visitors in one of five smoke compartment.

The findings include:

The waiting room door on the newer hospital addition was exercised at 1:35 p.m. on 4/9/14. The corridor door failed to latch properly. The latching mechanism would not align with the strike plate.

Based on observation, the facility failed to ensure floor construction rating between floors in a building of Type V (111) construction was maintained at not less than a 1-hour fire resistance and had breached the two hour barrier of the elevator shaft. These deficiencies could affect more than a very limited amount of patients/residents, employees and visitors in two of five smoke compartments.

Findings include:

1. The Emergency Room janitor's closet was observed at 1:20 p.m. on 4/9/14. Data cable was observed to be extending through the ceiling into the attic space which came first through the main floor from the lower level. The penetrations through the attic space and main floor were not sealed with a product to maintain the floors and ceilings at not less than one hour fire resistance.

2. The two hour fire wall which encloses the elevator was observed at 1:40 p.m. on 4/9/14.
a) There were elevator pit penetrations for wiring from the sump pump into the elevator control room. A three inch hole through the gypsum board fire wall had been made for wiring pass through, and was not sealed to maintain the 2-hour fire barrier.
b) The gypsum board joint tape on three separate seams of the elevator shaft east wall was coming loose where water damage had occurred in the past.

Based on observations, the facility failed to ensure that exit signs properly denoted the way to the means of egress. This deficiency had the potential to affect numerous patients/residents, staff members and visitors in two of five smoke compartments.

Findings include:

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 per section 7.10.1.2 of the Life Safety Code.

1. The east exit from the Activities Area was reviewed at 2:41 p.m. on 4/9/14. The east exit from the Activities Area back to the exit corridor lacked an exit sign.

2. The exit access corridor between the data room and the elevator was reviewed at 4:01 p.m. on 4/9/14. The space lacked an exit sign indicating exit(s) direction after passing through the double doors by the data room.

Based on observations, the facility failed to ensure that the fire and smoke resistance rating of wall and ceiling assemblies in a building of Type V (111) construction were maintained. This deficiency could affect all patients/residents, staff, and visitors.

The findings include:

1. The Emergency Room janitor's closet was observed at 1:20 p.m. on 4/9/14. Data cables extended through the closet ceiling and were not sealed properly to maintain the ceiling assembly.

2. The area around the nursing station was observed at 2:35 p.m. on 4/9/14.
a) The hand wash sink wall was not completed with joint tape and compound on the gypsum wallboard.
b) The sink drain pipe lacked a beauty ring to cover the hole in the gypsum wall board.

3. The fire wall separating the basement corridor ramp and north/south corridor was observed at 2:45 p.m. on 4/9/14. There were network cables through the gypsum wallboard which had not been sealed properly to maintain the 2-hour fire resistance of fire walls.

4. The Information Technology (IT) data rooms were observed at 3:00 p.m. on 4/9/14. Both the upper and lower IT data rooms lacked some ceiling tile in the ceiling grid and neither maintenance nor IT technicians were working in the area.

Based on observations, the facility failed to ensure that all doors protecting hazardous areas were self-closing. These deficiencies have the potential to affect a very limited number of of staff in one of three smoke compartments on the lower level.

The findings include:

In accordance with Section 19.3.2.1, any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 square feet (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 square feet (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door. The deficiency could affect a very limited number of staff, residents or guests in one of four smoke compartments within the facility.

1. The basement environmental services storeroom was observed at 3:50 p.m. on 4/9/14. The storeroom was much larger than 50 square feet, and contained combustible stored items. There was no self-closing device on the corridor door to this room.

2. The storeroom next to the environmental services store room was observed at 3:55 p.m. on 4/9/14. This room was larger than 50 square feet, and contained combustible stored items. The door to this hazardous location was not self-closing.

3. The basement oxygen storeroom was observed at 4:00 p.m. on 4/9/14. The corridor door to this hazardous area was not self-closing.

Based on observations, the facility failed to provide for a hard surface path from an exit discharge to the public way. This deficiency had a potential to affect more than a very limited number of residents, staff and visitors in the facility, as most of the residents used the dining area for meals.

Findings include:

A hard surface path from the exit discharge to the public way shall be provided in climates where weather such as snow or ice or heavy rain may hinder evacuation across lawn or soil surfaces per section 7.7.1 of the Life Safety Code and interpretations from the Centers for Medicare and Medicaid Service.

In accordance with NFPA 101 and Section 7.1.6.3, walking surfaces shall be nominally level. The slope of a walking surface in the direction of travel shall not exceed 1 in 20 unless the ramp requirements of 7.2.5 are met. The slope perpendicular to the direction of travel shall not exceed 1 in 48.

1. The east exit discharge from the dining room opened onto a lawn area as observed at 12:30 p.m. on 4/9/14.
a) No hard surface path lead from this exit discharge continuously to the public way.
b) There was a three foot by three foot cement pad just outside the dining room doorway. The pad was not level and tipped toward the east. Walking surfaces must slope no more than 1 in 48.

Based on observations, the facility failed to document that battery powered emergency lights were tested on a monthly and annual basis. This deficiency could affect all patients/residents, staff, and visitors.

The findings include:

In accordance with Section 4.6.12.2, existing life safety features obvious to the public, if not required by the Code, shall be either maintained properly or removed.

A functional test shall be conducted on every required emergency battery-powered lighting system at 30-day intervals for not less than 30 seconds per section 7.9.3 of the Life Safety Code. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than one and one-half hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

The records for the battery pack emergency lighting were reviewed at 11:20 a.m. on 4/9/14. The facility had no records of a 30 second monthly test or 90 minute annual test done on the two facility battery pack lighting units.

Based on record review and interview with maintenance staff, the facility failed to assure that fire drills were held at least quarterly on all shifts. This deficiency has the potential to affect all patients/residents, visitors and staff in five of five smoke compartments.

The findings include:

In accordance with NFPA 101 Life Safety Code, 2000 Edition, and Section 19.7.1.2, fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Annex A.19.7.1.2 also adds the following clarification: many health care occupancies conduct fire drills without disturbing patients by choosing the location of the simulated emergency in advance and by closing the doors to patients ' rooms or wards in the vicinity prior to initiation of the drill. The purpose of a fire drill is to test and evaluate the efficiency, knowledge, and response of institutional personnel in implementing the facility fire emergency plan. Its purpose is not to disturb or excite patients. Fire drills should be scheduled on a random basis to ensure that personnel in health care facilities are drilled not less than once in each 3-month period.
Drills should consider the ability to move patients to an adjacent smoke compartment. Relocation can be practiced using simulated patients or empty wheelchairs.

The fire drills were reviewed on 4/9/14 at 11:00 a.m. The first quarter of 2013 was missing the day and night shift fire drills, the second quarter was missing the day and night shift fire drills, the third quarter was missing the day and night shift fire drills. The first quarter of 2014 was missing the day and night fire drills. There were only 2 out of 10 completed fire drills in the last five quarters.

An interview of maintenance staff indicated no other fire drills were conducted for 2013-14.

Based on observation, the facility failed to ensure that the location of the Fire Alarm Control Panel (FACP) circuit disconnecting means shall be permanently identified at the appropriate breaker in red. The deficiency could affect all patients/residents, staff and visitors.

Findings include:

In accordance with Section 1-5.2.5.2 of NFPA 72, (1999 Edition); the connections to the light and power service for the Fire Alarm Control Panel (FACP) shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall be marked in red, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

The FACP and connecting services were reviewed at 11:30 a.m. on 4/9/14. Circuit breaker #9 on electrical panel CR2 was not identified in red.

Based on observation, the facility failed to provide complete coverage of a building of Type V (111) construction type by the automatic fire sprinkler system. This failure had the potential to affect more than a very limited amount of patients/residents, staff and visitors.

Findings include:

Sprinklers shall be installed under exterior roofs or canopies exceeding 4 feet in width per section 5-13.8.1 of NFPA 13, 1999 Edition. Exception: Sprinklers are permitted to be omitted where the canopy or roof is of noncombustible or limited combustible construction.

The roof canopy above the main north entrance was observed at 2:00 p.m. on 4/9/14. The canopy was larger than four feet in width and was made of combustible construction.

Based on observations, the facility failed to maintain the sprinkler system and its components in accordance with the NFPA 13 and 25. This deficiency had the potential to affect more than a very limited number of patients/residents, staff and visitors.

Findings include:

In accordance with NFPA 25, 1998 Edition, and Section 7-3.8; other devices, such as check valves, detector check valves, and backflow preventers, that are installed in the water supply piping system shall be inspected and maintained so that they do not impede the flow of water and fire main pressure. (See Chapter 9 for inspection and maintenance requirements.)

Secondly, 9-6.2.1 All backflow preventers installed in fire protection system piping shall be tested annually in accordance with the following:
(a) A forward flow test shall be conducted at the system demand, including hose stream demand, where hydrants or inside hose stations are located downstream of the backflow preventer.
(b) A backflow performance test, as required by the authority having jurisdiction, shall be conducted at the completion of the forward flow test.
Exception No. 1: For backflow preventers sized 2 in. (50.8 mm) and under, it shall be acceptable to conduct the forward flow test without measuring flow, where the test outlet is of a size to flow the system demand.
Exception No. 2: Where water rationing shall be enforced during shortages lasting more than 1 year, an internal inspection of the backflow preventer to ensure the check valves will fully open shall be acceptable in lieu of conducting the annual forward flow test.
Exception No. 3: Where connections of a size sufficient to conduct a full flow test are not available, tests shall be completed at the maximum flow rate possible.
Exception No. 4: The forward flow test shall not be required where annual fire pump testing causes the system demand to flow through the backflow preventer device.

1. The sprinkler riser and surrounding area were observed at 11:30 a.m. on 4/9/14. The backflow preventer had not received an annual inspection by the sprinkler contractor in 2013 or thus far in 2014. The annual inspection for the sprinkler system was performed by the contractor on 8/23/2013, but there was no information that the annual inspection was performed for the sprinkler backflow prevention device.

In accordance with 3-2.7.2 of NFPA 13, 1999 Edition; escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

In addition, NFPA 25, 1998, and Section 2-2.1.2 states that unacceptable obstructions to spray patterns shall be corrected.

2. An escutcheon ring was loose from the ceiling in the long term stairwell, exposing a 1/4 inch gap as observed at 2:08 p.m. on 4/9/14.

3. An escutcheon ring was loose on the ceiling of the employee break room, exposing a 1/4 inch gap around the sprinkler piping, as observed at 2:10 p.m. on 4/9/14.

4. Two escutcheon rings in the family area of the long term care unit were loose, exposing a 1/2 inch gap around the sprinkler piping, as observed at 2:20 p.m. on 4/9/14.

5. Four escutcheon rings were not tight to the ceiling in the Medication room in the long term care, exposing a 1/4 inch gap around the sprinkler piping, as observed at 2:26 p.m. on 4/9/14.

6. The clean utility room in the upper level of the hospital had one escutcheon ring which was down 3/8 of an inch, exposing a gap around the sprinkler piping, as observed at 2:38 p.m. on 4/9/14.

7. One escutcheon ring was down from the ceiling in room 108 of the long term care, exposing a gap of 1/4 inch gap around the sprinkler piping, as observed at 2:40 p.m. on 4/9/14.

8. One escutcheon ring was down 1/4 inch on the ceiling of the corridor, between long term care rooms 109 and 11, as observed at 2:40 p.m. on 4/9/14.

9. There were five escutcheon rings missing from the classroom in the old hospital basement, as observed at 3:45 p.m. on 4/9/14

Based on observations and staff interview, the facility failed to ensure that portable fire extinguishers were maintained in accordance with the standards of NFPA 10. This deficiency had the potential to affect more than a very limited number of patients/residents, staff, and visitors. Six, ABC fire extinguishers and one K fire extinguisher were examined during the course of the survey. Two of the six ABC fire extinguishers were blocked.

Findings include:

In accordance to Section 1-6.6 of NFPA 10, 1998 Edition, fire extinguishers shall not be obstructed or obscured from view.

1. The Activities Area was observed at 2:41 p.m. on 4/9/14. A large chair was blocking direct access to the fire extinguisher cabinet.

2. The north entrance to the long term care was observed at 2:42 p.m. on 4/9/14. A large chair arrangement blocked direct access to the fire extinguisher cabinet.

Based on review of service records, the facility failed to assure that the kitchen hood exhaust system was inspected and/or cleaned on a semiannual basis. This deficiency could potentially affect all of patients/residents, staff, and visitors.

Findings include:

In accordance with NFPA 96, 1998 Edition and Section 8-3.1; hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1.

Secondly, per NFPA 96 and Section 8-3.1.1; upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Section 8-3.

Finally, in accordance with NFPA 96 and Section 8-3.1.2, when a vent cleaning service is used, a certificate showing date of inspection or cleaning shall 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.

Service records for the kitchen hood cleaning were reviewed at 10:30 a.m. on 4/9/14. No documentation was available indicating the hood had been cleaned by a professional cleaning company or staff properly trained to do so at least twice annually. A professional cleaning company last cleaned the hood in February of 2013, another cleaning was due in July of 2013, with one following in January of 2014, so at least two have been missed in the last year.

Based on observations, the facility failed to store oxygen cylinders in accordance with the standards of NFPA 99, 1999 Edition. This deficiency had potential to affect more than a very limited number of patients/residents, staff, and visitors in one of five smoke compartments.

Findings include:

1. The oxygen storeroom in the hospital basement was observed at 3:52 p.m. on 4/9/14. The storeroom had more than 3,000 cubic feet of oxygen stored within.
a) the storeroom was not directly vented to the outside,
b) the door to the room did not have a self-closing device on the door,
d) the electrical switch and outlets were not above the required five feet level, and
e) the large tanks were not properly secured.1&2
?NFPA 99 and Section 4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement);
(a) * Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
1. Sources of heat in storage locations shall be protected or located so that cylinders or compressed gases shall not be heated to the activation point of integral safety devices. In no case shall the temperature of the cylinders exceed 130?F (54?C). Care shall be exercised when handling cylinders that have been exposed to freezing temperatures or containers that contain cryogenic liquids to prevent injury to the skin.
2. * Enclosures shall be provided for supply systems cylinder storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour and shall not communicate directly with anesthetizing locations. Other nonflammable (inert) medical gases may be stored in the enclosure. Flammable gases shall not be stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose.
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.
5. Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials [see also 4-3.1.1.2(a)7].
6. Cylinders containing compressed gases and containers for volatile liquids shall be kept away from radiators, steam piping, and like sources of heat.
7. Combustible materials, such as paper, cardboard, plastics, and fabrics, shall not be stored or kept near supply system cylinders or manifolds containing oxygen or nitrous oxide. Racks for cylinder storage shall be permitted to be of wooden construction. Wrappers shall be removed prior to storage.
Exception: Shipping crates or storage cartons for cylinders.
8. When cylinder valve protection caps are supplied, they shall be secured tightly in place unless the cylinder is connected for use.
9. Containers shall not be stored in a tightly closed space such as a closet [see 8-2.1.2.3(c)].
10. Location of Supply Systems.
a. Except as permitted by 4-3.1.1.2(a)10c, supply systems for medical gases or mixtures of these gases having total capacities (connected and in storage) not exceeding the quantities specified in 4-3.1.1.2(b)1 and 2 shall be located outdoors in an enclosure used only for this purpose or in a room or enclosure used only for this purpose situated within a building used for other purposes.
b. Storage facilities that are outside, but adjacent to a building wall, shall be in accordance with NFPA 50, Standard for Bulk Oxygen Systems at Consumer Sites.
c. Locations for supply systems shall not be used for storage purposes other than for containers of nonflammable gases. Storage of full or empty containers shall be permitted. Other nonflammable medical gas supply systems or storage locations shall be permitted to be in the same location with oxygen or nitrous oxide or both. However, care shall be taken to provide adequate ventilation to dissipate such other gases in order to prevent the development of oxygen-deficient atmospheres in the event of functioning of cylinder or manifold pressure-relief devices.
d. Air compressors and vacuum pumps shall be located separately from cylinder patient gas systems or cylinder storage enclosures. Air compressors shall be installed in a designated mechanical equipment area, adequately ventilated and with required services.
11. Construction and Arrangement of Supply System Locations.
a. Walls, floors, ceilings, roofs, doors, interior finish, shelves, racks, and supports of and in the locations cited in 4-3.1.1.2(a)10a shall be constructed of noncombustible or limited-combustible materials.
b. Locations for supply systems for oxygen, nitrous oxide, or mixtures of these gases shall not communicate with anesthetizing locations or storage locations for flammable anesthetizing agents.
c. Enclosures for supply systems shall be provided with doors or gates that can be locked.
d. Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft (1.5 m) above the floor to avoid physical damage.
e. Where enclosures (interior or exterior) for supply systems are located near sources of heat, such as furnaces, incinerators, or boiler rooms, they shall be of construction that protects cylinders from reaching temperatures exceeding 130?F (54?C). Open electrical conductors and transformers shall not be located in close proximity to enclosures. Such enclosures shall not be located adjacent to storage tanks for flammable or combustible liquids.
f. Smoking shall be prohibited in supply system enclosures.
g. Heating shall be by steam, hot water, or other indirect means. Cylinder temperatures shall not exceed 130?F (54?C).
(b) Additional Storage Requirements for Nonflammable Gases Greater Than 3000 ft3 (85 m3).
1. Oxygen supply systems or storage locations having a total capacity of more than 20,000 ft3 (566 m3) (NTP), including unconnected reserves on hand at the site, shall comply with NFPA 50, Standard for Bulk Oxygen Systems at Consumer Sites.
2. Nitrous oxide supply systems or storage locations having a total capacity of 3200 lb (1452 kg) [28,000 ft3 (793 m3) (NTP)] or more, including unconnected reserves on hand at the site, shall comply with CGA Pamphlet G-8.1, Standard for the Installation of Nitrous Oxide Systems at Consumer Sites.
3. The walls, floors, and ceilings of locations for supply systems of more than 3000 ft3 (85 m3) total capacity (connected and in storage) separating the supply system location from other occupancies in a building shall have a fire resistance rating of at least 1 hour. This shall also apply to a common wall or walls of a supply system location attached to a building having other occupancy.
4. Locations for supply systems of more than 3000 ft3 (85 m3) total capacity (connected and in storage) shall be vented to the outside by a dedicated mechanical ventilation system or by natural venting. If natural venting is used, the vent opening or openings shall be a minimum of 72 in.2 (0.05 m2) in total free area.
(c) Storage Requirements for Nonflammable Gases Less Than 3000 ft3 (85 m3). Doors to such locations shall be provided with louvered openings having a minimum of 72 in.2 (0.05 m2) in total free area. Where the location of the supply system door opens onto an exit access corridor, louvered openings shall not be used, and the requirements of 4-3.1.1.2(b)3 and 4 and the dedicated mechanical ventilation system required in 4-3.1.1.2(b)4 shall be complied with.
In accordance with NFPA 99 and Section 4-3.1.1.2(b)(4), locations for supply systems of more than 3000 ft3 (85 m3) total capacity (connected and in storage) shall be vented to the outside by a dedicated mechanical ventilation system or by natural venting. If natural venting is used, the vent opening or openings shall be a minimum of 72 square inches (0.05 m2) in total free area.

2. NFPA 99 and Section 4-3.5.2.2 Storage of Cylinders and Containers Level 1.
(a) * Facility authorities, in consultation with medical staff and other trained personnel, shall provide and enforce regulations for the storage and handling of cylinders and containers of oxygen and nitrous oxide in storage rooms of approved construction, and for the safe handling of these agents in anesthetizing locations. Storage locations for flammable inhalation anesthetic agents, established in any operating or delivery suite, shall be limited by space allocation and regulation to not more than a 48-hour normal requirement for any such suite. In storage locations, cylinders shall be properly secured in racks or adequately fastened. No cylinders containing oxygen or nitrous oxide, other than those connected to anesthetic apparatus, shall be kept or stored in anesthetizing locations.
(b) Nonflammable Gases.
1. Storage shall be planned so that cylinders can be used in the order in which they are received from the supplier.
2. If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.
3. Cylinders stored in the open shall be protected against extremes of weather and from the ground beneath to prevent rusting. During winter, cylinders stored in the open shall be protected against accumulations of ice or snow. In summer, cylinders stored in the open shall be screened against continuous exposure to direct rays of the sun in those localities where extreme temperatures prevail.

Based on observations, interview with maintenance staff and review of fire alarm service reports, the facility failed to provide documentation of fusible link fire dampers testing had been conducted every 4 years and fire dampers were not impeded by added equipment. This deficiency could affect all patients/residents, staff, and visitors in all five smoke compartments of the building.

The findings include:

At least every 4 years, fusible links (where applicable) shall be removed from all fire or fire/smoke combination dampers and the dampers shall be operated to verify that they fully close and moving parts shall be lubricated as necessary per section 3-4.7 of NFPA 90A, 1999 edition. Fusible links shall be replaced if they are found to be broken or damaged.

1. Documentation of fusible link dampers was reviewed at 10:30 a.m. on 4/9/14. There was no documentation that the fusible link assemblies had been tested on a 4-year rotation.

An interview with the maintenance staff determined the lack of knowledge of this requirement.

2. In accordance with NFPA 90A and Section 3-4.5.1; all fire dampers and ceiling dampers shall close automatically, and they shall remain closed upon the operation of a listed fusible link or other approved heat-actuated device located where readily affected by an abnormal rise of temperature in the air duct.

The basement east fire wall in the valve room was reviewed at 2:46 p.m. on 4/9/14. A fan unit was fund attached to the fire damper, thus blocking the duct from being able to close immediately in the case of an emergency. The fan unit was wired to be in the on position at all times, thus creating a continuous penetration in a fire wall which was designed into the building.

Based on observations, the facility failed to post precautionary signs in oxygen storage areas. The deficiency could affect more than a very limited amount of patients/residents, staff and visitors in one of five smoke compartments.

The findings include:

In accordance with NFPA 99, 1999 Edition, and Section 8-3.1.11.3, a precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:
CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

1. The main floor medical gas store room was observed at 1:17 p.m. on 4/9/14. The storeroom was accessed from the outside of the building on its south side. The door to this storeroom did not have a sign meeting the requirements of Section 8-3.1.11.3.

2. The basement oxygen storeroom was observed at 3:52 p.m. on 4/9/14. The door to this room did not have a sign meeting the requirements of Section 8-3.1.11.3., although 20 plus K/J size cylinders were stored in the room,

Based on observations, the facility failed to maintain requirements of NFPA 70, 1999 Edition and electrical requirements set forth by CMS. This deficiency had potential to affect a very limited number of patients/residents, staff, and visitors in the building.

Findings include:

In accordance with 240-4 of the NFPA 70, 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99 (1999 Edition) and interpretations from CMS, extension cords or multiple adaptors used in health care shall be protected against over-current conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS). One means is by providing power taps or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings. The limited use of circuit breaker protected power tap is acceptable, provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to a power tap. These items must be directly connected to an appropriate receptacle.

In accordance with Article 110-13(a) of NFPA 70, electrical equipment shall be firmly secured to the surface on which it is mounted (if not temporary in service).

In accordance with NFPA 70 and Article 400-10. Pull at Joints and Terminals; flexible cords and cables shall be connected to devices and to fittings so that tension will not be transmitted to joints or terminals.
Exception: Listed portable single pole devices that are intended to accommodate such tension at their terminals, shall be permitted to be used with single conductor flexible cable.
FPN: Some methods of preventing pull on a cord from being transmitted to joints or terminals are knotting the cord, winding with tape, and fittings designed for the purpose.

In accordance with Article 370.28(c) of NFPA 70, all pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Article 250-110.

Flexible cords shall not be run through doorways, windows or similar openings per Article 400-8 of NFPA 70.

Live parts of electric equipment operating at 50 volts or more shall be guarded against accidental contact by approved enclosures per Article 110-27 of NFPA 70.

No overcurrent device shall be connected in series with any conductor that is intentionally grounded Article 240-22 of NFPA 70. UL listing guidelines for relocatable power taps/power strips, being XBYS, notes that these strips are not intended to be series connected or daisy chained to other power strips or extension cords.

1. The laboratory office was observed at 1:25 p.m. on 4/9/14. A microwave oven was plugged into a surge cord.

2. The elevator pit was observed at 1:40 p.m. on 4/9/14.
a) The sump pump electrical cords extended through the wall into the elevator mechanical room and is not in an electrical conduit, and
b) additionally, an electrical cover was missing on the south wall of the elevator shaft.

3. In the clean utility room of swing bed area, the ice-machine was plugged into a power strip, as observed at 2:38 p.m. on 4/9/14.

4. In room 115, a power strip was suspended from its cord on the south wall, as observed at 2:38 p.m. on 4/9/14. The power strip neither touched the ground nor was supported.

5. In room 110 a white extension cord was in use to a fan, as observed at 2:39 p.m. on 4/9/14.

6. In the basement shop there were two extension cords in-use, as observed at 3:40 p.m. on 4/9/14. Also, one junction box on the ceiling was missing its cover.

7. The basement purchasing office contained two power strips connected in series, (plugged into one another), as observed at 4:00 p.m. on 4/9/14.

8. In the Information Technology (IT) office, a refrigerator was found plugged into a power strip, as observed at 4:15 p.m. on 4/9/14.

9. In the basement shop office, a multi-plug adaptor was in-use on the south wall as observed at 5:00 p.m. on 4/9/14.

Based on review of the fire watch policy, the facility did not have a fire watch policy which included contacting the authority having jurisdiction which includes the Certification Bureau whenever a fire watch was instituted for the sprinkler system. This deficiency has the potential to affect all patients/residents, staff, and visitors.

Findings include:

The fire policies and procedures for the facility were received by facsimile and reviewed on 4/15/14 at 11:17 a.m. The present policy did not include the requirement stated in 9.7.6.1 of NFPA 101 that notification be made to the authorities having jurisdiction when a fire watch was instituted. A fire watch must be initiated when any portion or the entire fire sprinkler system is not operable for more than 4 hours in a 24 hour period. The Certification Bureau being one of those authorities that need to be notified at 406-444-4170 and specifically stated in the policy when the fire watch is initiated and ends.

Based on review of the fire watch policy, the facility did not have a fire watch policy which included contacting the authority having jurisdiction including the Certification Bureau whenever a fire watch was instituted for the fire alarm system. This deficiency has the potential to affect all patients/residents, staff, and visitors.

The findings include:

The fire policies and procedures for the facility were received by facsimile and reviewed on 4/15/14 at 11:17 a.m.. The present policy did not include the requirement stated in 9.6.1.8 of NFPA 101 that notification be made to the authorities having jurisdiction when a fire watch has been initiated. A fire watch much be initiated when any portion or the entire fire alarm system is not operable for more than 4 hours in a 24 hour period. The Certification Bureau being one of those authorities that need to be notified at 406-444-4170 and specifically stated in the policy when the fire watch is initiated and ends.

Based on observation, the facility failed to ensure that an Alcohol Based Hand Rub (ABHR) dispenser was not installed directly over an ignition source in one of five smoke compartments. This deficiency has the potential to affect more than a very limited amount of patients/residents, staff, and visitors.

Findings include:

Center for Medicaid Services (CMS) interpretations Survey & Certification (S&C)-05-33 letter issued on June 9, 2005, ABHR dispensers shall meet the NFPA amendment to the 2000 Life Safety Code regarding the installation of ABHR dispensers in exit corridors and on interior walls. The Certification Bureau enforces that ABHR dispensers be offset by at least one inch and not mounted directly above any electrical source.

During observation in the Medication room on 4/9/14 at 2:30 p.m., an ABHR was installed approximately five inches above the light switch.

Based on observations, the facility failed to ensure that all corridor doors latched properly when closed. This deficiency has the potential to affect more than a very limited amount of patients/residents, staff, and visitors in one of five smoke compartment.

The findings include:

The waiting room door on the newer hospital addition was exercised at 1:35 p.m. on 4/9/14. The corridor door failed to latch properly. The latching mechanism would not align with the strike plate.

Based on observation, the facility failed to ensure floor construction rating between floors in a building of Type V (111) construction was maintained at not less than a 1-hour fire resistance and had breached the two hour barrier of the elevator shaft. These deficiencies could affect more than a very limited amount of patients/residents, employees and visitors in two of five smoke compartments.

Findings include:

1. The Emergency Room janitor's closet was observed at 1:20 p.m. on 4/9/14. Data cable was observed to be extending through the ceiling into the attic space which came first through the main floor from the lower level. The penetrations through the attic space and main floor were not sealed with a product to maintain the floors and ceilings at not less than one hour fire resistance.

2. The two hour fire wall which encloses the elevator was observed at 1:40 p.m. on 4/9/14.
a) There were elevator pit penetrations for wiring from the sump pump into the elevator control room. A three inch hole through the gypsum board fire wall had been made for wiring pass through, and was not sealed to maintain the 2-hour fire barrier.
b) The gypsum board joint tape on three separate seams of the elevator shaft east wall was coming loose where water damage had occurred in the past.

Based on observations, the facility failed to ensure that exit signs properly denoted the way to the means of egress. This deficiency had the potential to affect numerous patients/residents, staff members and visitors in two of five smoke compartments.

Findings include:

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 per section 7.10.1.2 of the Life Safety Code.

1. The east exit from the Activities Area was reviewed at 2:41 p.m. on 4/9/14. The east exit from the Activities Area back to the exit corridor lacked an exit sign.

2. The exit access corridor between the data room and the elevator was reviewed at 4:01 p.m. on 4/9/14. The space lacked an exit sign indicating exit(s) direction after passing through the double doors by the data room.

Based on observations, the facility failed to ensure that the fire and smoke resistance rating of wall and ceiling assemblies in a building of Type V (111) construction were maintained. This deficiency could affect all patients/residents, staff, and visitors.

The findings include:

1. The Emergency Room janitor's closet was observed at 1:20 p.m. on 4/9/14. Data cables extended through the closet ceiling and were not sealed properly to maintain the ceiling assembly.

2. The area around the nursing station was observed at 2:35 p.m. on 4/9/14.
a) The hand wash sink wall was not completed with joint tape and compound on the gypsum wallboard.
b) The sink drain pipe lacked a beauty ring to cover the hole in the gypsum wall board.

3. The fire wall separating the basement corridor ramp and north/south corridor was observed at 2:45 p.m. on 4/9/14. There were network cables through the gypsum wallboard which had not been sealed properly to maintain the 2-hour fire resistance of fire walls.

4. The Information Technology (IT) data rooms were observed at 3:00 p.m. on 4/9/14. Both the upper and lower IT data rooms lacked some ceiling tile in the ceiling grid and neither maintenance nor IT technicians were working in the area.

Based on observations, the facility failed to ensure that all doors protecting hazardous areas were self-closing. These deficiencies have the potential to affect a very limited number of of staff in one of three smoke compartments on the lower level.

The findings include:

In accordance with Section 19.3.2.1, any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 square feet (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 square feet (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door. The deficiency could affect a very limited number of staff, residents or guests in one of four smoke compartments within the facility.

1. The basement environmental services storeroom was observed at 3:50 p.m. on 4/9/14. The storeroom was much larger than 50 square feet, and contained combustible stored items. There was no self-closing device on the corridor door to this room.

2. The storeroom next to the environmental services store room was observed at 3:55 p.m. on 4/9/14. This room was larger than 50 square feet, and contained combustible stored items. The door to this hazardous location was not self-closing.

3. The basement oxygen storeroom was observed at 4:00 p.m. on 4/9/14. The corridor door to this hazardous area was not self-closing.

Based on observations, the facility failed to provide for a hard surface path from an exit discharge to the public way. This deficiency had a potential to affect more than a very limited number of residents, staff and visitors in the facility, as most of the residents used the dining area for meals.

Findings include:

A hard surface path from the exit discharge to the public way shall be provided in climates where weather such as snow or ice or heavy rain may hinder evacuation across lawn or soil surfaces per section 7.7.1 of the Life Safety Code and interpretations from the Centers for Medicare and Medicaid Service.

In accordance with NFPA 101 and Section 7.1.6.3, walking surfaces shall be nominally level. The slope of a walking surface in the direction of travel shall not exceed 1 in 20 unless the ramp requirements of 7.2.5 are met. The slope perpendicular to the direction of travel shall not exceed 1 in 48.

1. The east exit discharge from the dining room opened onto a lawn area as observed at 12:30 p.m. on 4/9/14.
a) No hard surface path lead from this exit discharge continuously to the public way.
b) There was a three foot by three foot cement pad just outside the dining room doorway. The pad was not level and tipped toward the east. Walking surfaces must slope no more than 1 in 48.

Based on observations, the facility failed to document that battery powered emergency lights were tested on a monthly and annual basis. This deficiency could affect all patients/residents, staff, and visitors.

The findings include:

In accordance with Section 4.6.12.2, existing life safety features obvious to the public, if not required by the Code, shall be either maintained properly or removed.

A functional test shall be conducted on every required emergency battery-powered lighting system at 30-day intervals for not less than 30 seconds per section 7.9.3 of the Life Safety Code. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than one and one-half hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

The records for the battery pack emergency lighting were reviewed at 11:20 a.m. on 4/9/14. The facility had no records of a 30 second monthly test or 90 minute annual test done on the two facility battery pack lighting units.

Based on record review and interview with maintenance staff, the facility failed to assure that fire drills were held at least quarterly on all shifts. This deficiency has the potential to affect all patients/residents, visitors and staff in five of five smoke compartments.

The findings include:

In accordance with NFPA 101 Life Safety Code, 2000 Edition, and Section 19.7.1.2, fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Annex A.19.7.1.2 also adds the following clarification: many health care occupancies conduct fire drills without disturbing patients by choosing the location of the simulated emergency in advance and by closing the doors to patients ' rooms or wards in the vicinity prior to initiation of the drill. The purpose of a fire drill is to test and evaluate the efficiency, knowledge, and response of institutional personnel in implementing the facility fire emergency plan. Its purpose is not to disturb or excite patients. Fire drills should be scheduled on a random basis to ensure that personnel in health care facilities are drilled not less than once in each 3-month period.
Drills should consider the ability to move patients to an adjacent smoke compartment. Relocation can be practiced using simulated patients or empty wheelchairs.

The fire drills were reviewed on 4/9/14 at 11:00 a.m. The first quarter of 2013 was missing the day and night shift fire drills, the second quarter was missing the day and night shift fire drills, the third quarter was missing the day and night shift fire drills. The first quarter of 2014 was missing the day and night fire drills. There were only 2 out of 10 completed fire drills in the last five quarters.

An interview of maintenance staff indicated no other fire drills were conducted for 2013-14.

Based on observation, the facility failed to ensure that the location of the Fire Alarm Control Panel (FACP) circuit disconnecting means shall be permanently identified at the appropriate breaker in red. The deficiency could affect all patients/residents, staff and visitors.

Findings include:

In accordance with Section 1-5.2.5.2 of NFPA 72, (1999 Edition); the connections to the light and power service for the Fire Alarm Control Panel (FACP) shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall be marked in red, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

The FACP and connecting services were reviewed at 11:30 a.m. on 4/9/14. Circuit breaker #9 on electrical panel CR2 was not identified in red.

Based on observation, the facility failed to provide complete coverage of a building of Type V (111) construction type by the automatic fire sprinkler system. This failure had the potential to affect more than a very limited amount of patients/residents, staff and visitors.

Findings include:

Sprinklers shall be installed under exterior roofs or canopies exceeding 4 feet in width per section 5-13.8.1 of NFPA 13, 1999 Edition. Exception: Sprinklers are permitted to be omitted where the canopy or roof is of noncombustible or limited combustible construction.

The roof canopy above the main north entrance was observed at 2:00 p.m. on 4/9/14. The canopy was larger than four feet in width and was made of combustible construction.

Based on observations, the facility failed to maintain the sprinkler system and its components in accordance with the NFPA 13 and 25. This deficiency had the potential to affect more than a very limited number of patients/residents, staff and visitors.

Findings include:

In accordance with NFPA 25, 1998 Edition, and Section 7-3.8; other devices, such as check valves, detector check valves, and backflow preventers, that are installed in the water supply piping system shall be inspected and maintained so that they do not impede the flow of water and fire main pressure. (See Chapter 9 for inspection and maintenance requirements.)

Secondly, 9-6.2.1 All backflow preventers installed in fire protection system piping shall be tested annually in accordance with the following:
(a) A forward flow test shall be conducted at the system demand, including hose stream demand, where hydrants or inside hose stations are located downstream of the backflow preventer.
(b) A backflow performance test, as required by the authority having jurisdiction, shall be conducted at the completion of the forward flow test.
Exception No. 1: For backflow preventers sized 2 in. (50.8 mm) and under, it shall be acceptable to conduct the forward flow test without measuring flow, where the test outlet is of a size to flow the system demand.
Exception No. 2: Where water rationing shall be enforced during shortages lasting more than 1 year, an internal inspection of the backflow preventer to ensure the check valves will fully open shall be acceptable in lieu of conducting the annual forward flow test.
Exception No. 3: Where connections of a size sufficient to conduct a full flow test are not available, tests shall be completed at the maximum flow rate possible.
Exception No. 4: The forward flow test shall not be required where annual fire pump testing causes the system demand to flow through the backflow preventer device.

1. The sprinkler riser and surrounding area were observed at 11:30 a.m. on 4/9/14. The backflow preventer had not received an annual inspection by the sprinkler contractor in 2013 or thus far in 2014. The annual inspection for the sprinkler system was performed by the contractor on 8/23/2013, but there was no information that the annual inspection was performed for the sprinkler backflow prevention device.

In accordance with 3-2.7.2 of NFPA 13, 1999 Edition; escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

In addition, NFPA 25, 1998, and Section 2-2.1.2 states that unacceptable obstructions to spray patterns shall be corrected.

2. An escutcheon ring was loose from the ceiling in the long term stairwell, exposing a 1/4 inch gap as observed at 2:08 p.m. on 4/9/14.

3. An escutcheon ring was loose on the ceiling of the employee break room, exposing a 1/4 inch gap around the sprinkler piping, as observed at 2:10 p.m. on 4/9/14.

4. Two escutcheon rings in the family area of the long term care unit were loose, exposing a 1/2 inch gap around the sprinkler piping, as observed at 2:20 p.m. on 4/9/14.

5. Four escutcheon rings were not tight to the ceiling in the Medication room in the long term care, exposing a 1/4 inch gap around the sprinkler piping, as observed at 2:26 p.m. on 4/9/14.

6. The clean utility room in the upper level of the hospital had one escutcheon ring which was down 3/8 of an inch, exposing a gap around the sprinkler piping, as observed at 2:38 p.m. on 4/9/14.

7. One escutcheon ring was down from the ceiling in room 108 of the long term care, exposing a gap of 1/4 inch gap around the sprinkler piping, as observed at 2:40 p.m. on 4/9/14.

8. One escutcheon ring was down 1/4 inch on the ceiling of the corridor, between long term care rooms 109 and 11, as observed at 2:40 p.m. on 4/9/14.

9. There were five escutcheon rings missing from the classroom in the old hospital basement, as observed at 3:45 p.m. on 4/9/14

Based on observations and staff interview, the facility failed to ensure that portable fire extinguishers were maintained in accordance with the standards of NFPA 10. This deficiency had the potential to affect more than a very limited number of patients/residents, staff, and visitors. Six, ABC fire extinguishers and one K fire extinguisher were examined during the course of the survey. Two of the six ABC fire extinguishers were blocked.

Findings include:

In accordance to Section 1-6.6 of NFPA 10, 1998 Edition, fire extinguishers shall not be obstructed or obscured from view.

1. The Activities Area was observed at 2:41 p.m. on 4/9/14. A large chair was blocking direct access to the fire extinguisher cabinet.

2. The north entrance to the long term care was observed at 2:42 p.m. on 4/9/14. A large chair arrangement blocked direct access to the fire extinguisher cabinet.

Based on review of service records, the facility failed to assure that the kitchen hood exhaust system was inspected and/or cleaned on a semiannual basis. This deficiency could potentially affect all of patients/residents, staff, and visitors.

Findings include:

In accordance with NFPA 96, 1998 Edition and Section 8-3.1; hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1.

Secondly, per NFPA 96 and Section 8-3.1.1; upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Section 8-3.

Finally, in accordance with NFPA 96 and Section 8-3.1.2, when a vent cleaning service is used, a certificate showing date of inspection or cleaning shall 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.

Service records for the kitchen hood cleaning were reviewed at 10:30 a.m. on 4/9/14. No documentation was available indicating the hood had been cleaned by a professional cleaning company or staff properly trained to do so at least twice annually. A professional cleaning company last cleaned the hood in February of 2013, another cleaning was due in July of 2013, with one following in January of 2014, so at least two have been missed in the last year.

Based on observations, the facility failed to store oxygen cylinders in accordance with the standards of NFPA 99, 1999 Edition. This deficiency had potential to affect more than a very limited number of patients/residents, staff, and visitors in one of five smoke compartments.

Findings include:

1. The oxygen storeroom in the hospital basement was observed at 3:52 p.m. on 4/9/14. The storeroom had more than 3,000 cubic feet of oxygen stored within.
a) the storeroom was not directly vented to the outside,
b) the door to the room did not have a self-closing device on the door,
d) the electrical switch and outlets were not above the required five feet level, and
e) the large tanks were not properly secured.1&2
?NFPA 99 and Section 4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement);
(a) * Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
1. Sources of heat in storage locations shall be protected or located so that cylinders or compressed gases shall not be heated to the activation point of integral safety devices. In no case shall the temperature of the cylinders exceed 130?F (54?C). Care shall be exercised when handling cylinders that have been exposed to freezing temperatures or containers that contain cryogenic liquids to prevent injury to the skin.
2. * Enclosures shall be provided for supply systems cylinder storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour and shall not communicate directly with anesthetizing locations. Other nonflammable (inert) medical gases may be stored in the enclosure. Flammable gases shall not be stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose.
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.
5. Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials [see also 4-3.1.1.2(a)7].
6. Cylinders containing compressed gases and containers for volatile liquids shall be kept away from radiators, steam piping, and like sources of heat.
7. Combustible materials, such as paper, cardboard, plastics, and fabrics, shall not be stored or kept near supply system cylinders or manifolds containing oxygen or nitrous oxide. Racks for cylinder storage shall be permitted to be of wooden construction. Wrappers shall be removed prior to storage.
Exception: Shipping crates or storage cartons for cylinders.
8. When cylinder valve protection caps are supplied, they shall be secured tightly in place unless the cylinder is connected for use.
9. Containers shall not be stored in a tightly closed space such as a closet [see 8-2.1.2.3(c)].
10. Location of Supply Systems.
a. Except as permitted by 4-3.1.1.2(a)10c, supply systems for medical gases or mixtures of these gases having total capacities (connected and in storage) not exceeding the quantities specified in 4-3.1.1.2(b)1 and 2 shall be located outdoors in an enclosure used only for this purpose or in a room or enclosure used only for this purpose situated within a building used for other purposes.
b. Storage facilities that are outside, but adjacent to a building wall, shall be in accordance with NFPA 50, Standard for Bulk Oxygen Systems at Consumer Sites.
c. Locations for supply systems shall not be used for storage purposes other than for containers of nonflammable gases. Storage of full or empty containers shall be permitted. Other nonflammable medical gas supply systems or storage locations shall be permitted to be in the same location with oxygen or nitrous oxide or both. However, care shall be taken to provide adequate ventilation to dissipate such other gases in order to prevent the development of oxygen-deficient atmospheres in the event of functioning of cylinder or manifold pressure-relief devices.
d. Air compressors and vacuum pumps shall be located separately from cylinder patient gas systems or cylinder storage enclosures. Air compressors shall be installed in a designated mechanical equipment area, adequately ventilated and with required services.
11. Construction and Arrangement of Supply System Locations.
a. Walls, floors, ceilings, roofs, doors, interior finish, shelves, racks, and supports of and in the locations cited in 4-3.1.1.2(a)10a shall be constructed of noncombustible or limited-combustible materials.
b. Locations for supply systems for oxygen, nitrous oxide, or mixtures of these gases shall not communicate with anesthetizing locations or storage locations for flammable anesthetizing agents.
c. Enclosures for supply systems shall be provided with doors or gates that can be locked.
d. Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft (1.5 m) above the floor to avoid physical damage.
e. Where enclosures (interior or exterior) for supply systems are located near sources of heat, such as furnaces, incinerators, or boiler rooms, they shall be of construction that protects cylinders from reaching temperatures exceeding 130?F (54?C). Open electrical conductors and transformers shall not be located in close proximity to enclosures. Such enclosures shall not be located adjacent to storage tanks for flammable or combustible liquids.
f. Smoking shall be prohibited in supply system enclosures.
g. Heating shall be by steam, hot water, or other indirect means. Cylinder temperatures shall not exceed 130?F (54?C).
(b) Additional Storage Requirements for Nonflammable Gases Greater Than 3000 ft3 (85 m3).
1. Oxygen supply systems or storage locations having a total capacity of more than 20,000 ft3 (566 m3) (NTP), including unconnected reserves on hand at the site, shall comply with NFPA 50, Standard for Bulk Oxygen Systems at Consumer Sites.
2. Nitrous oxide supply systems or storage locations having a total capacity of 3200 lb (1452 kg) [28,000 ft3 (793 m3) (NTP)] or more, including unconnected reserves on hand at the site, shall comply with CGA Pamphlet G-8.1, Standard for the Installation of Nitrous Oxide Systems at Consumer Sites.
3. The walls, floors, and ceilings of locations for supply systems of more than 3000 ft3 (85 m3) total capacity (connected and in storage) separating the supply system location from other occupancies in a building shall have a fire resistance rating of at least 1 hour. This shall also apply to a common wall or walls of a supply system location attached to a building having other occupancy.
4. Locations for supply systems of more than 3000 ft3 (85 m3) total capacity (connected and in storage) shall be vented to the outside by a dedicated mechanical ventilation system or by natural venting. If natural venting is used, the vent opening or openings shall be a minimum of 72 in.2 (0.05 m2) in total free area.
(c) Storage Requirements for Nonflammable Gases Less Than 3000 ft3 (85 m3). Doors to such locations shall be provided with louvered openings having a minimum of 72 in.2 (0.05 m2) in total free area. Where the location of the supply system door opens onto an exit access corridor, louvered openings shall not be used, and the requirements of 4-3.1.1.2(b)3 and 4 and the dedicated mechanical ventilation system required in 4-3.1.1.2(b)4 shall be complied with.
In accordance with NFPA 99 and Section 4-3.1.1.2(b)(4), locations for supply systems of more than 3000 ft3 (85 m3) total capacity (connected and in storage) shall be vented to the outside by a dedicated mechanical ventilation system or by natural venting. If natural venting is used, the vent opening or openings shall be a minimum of 72 square inches (0.05 m2) in total free area.

2. NFPA 99 and Section 4-3.5.2.2 Storage of Cylinders and Containers Level 1.
(a) * Facility authorities, in consultation with medical staff and other trained personnel, shall provide and enforce regulations for the storage and handling of cylinders and containers of oxygen and nitrous oxide in storage rooms of approved construction, and for the safe handling of these agents in anesthetizing locations. Storage locations for flammable inhalation anesthetic agents, established in any operating or delivery suite, shall be limited by space allocation and regulation to not more than a 48-hour normal requirement for any such suite. In storage locations, cylinders shall be properly secured in racks or adequately fastened. No cylinders containing oxygen or nitrous oxide, other than those connected to anesthetic apparatus, shall be kept or stored in anesthetizing locations.
(b) Nonflammable Gases.
1. Storage shall be planned so that cylinders can be used in the order in which they are received from the supplier.
2. If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.
3. Cylinders stored in the open shall be protected against extremes of weather and from the ground beneath to prevent rusting. During winter, cylinders stored in the open shall be protected against accumulations of ice or snow. In summer, cylinders stored in the open shall be screened against continuous exposure to direct rays of the sun in those localities where extreme temperatures prevail.

Based on observations, interview with maintenance staff and review of fire alarm service reports, the facility failed to provide documentation of fusible link fire dampers testing had been conducted every 4 years and fire dampers were not impeded by added equipment. This deficiency could affect all patients/residents, staff, and visitors in all five smoke compartments of the building.

The findings include:

At least every 4 years, fusible links (where applicable) shall be removed from all fire or fire/smoke combination dampers and the dampers shall be operated to verify that they fully close and moving parts shall be lubricated as necessary per section 3-4.7 of NFPA 90A, 1999 edition. Fusible links shall be replaced if they are found to be broken or damaged.

1. Documentation of fusible link dampers was reviewed at 10:30 a.m. on 4/9/14. There was no documentation that the fusible link assemblies had been tested on a 4-year rotation.

An interview with the maintenance staff determined the lack of knowledge of this requirement.

2. In accordance with NFPA 90A and Section 3-4.5.1; all fire dampers and ceiling dampers shall close automatically, and they shall remain closed upon the operation of a listed fusible link or other approved heat-actuated device located where readily affected by an abnormal rise of temperature in the air duct.

The basement east fire wall in the valve room was reviewed at 2:46 p.m. on 4/9/14. A fan unit was fund attached to the fire damper, thus blocking the duct from being able to close immediately in the case of an emergency. The fan unit was wired to be in the on position at all times, thus creating a continuous penetration in a fire wall which was designed into the building.

Based on observations, the facility failed to post precautionary signs in oxygen storage areas. The deficiency could affect more than a very limited amount of patients/residents, staff and visitors in one of five smoke compartments.

The findings include:

In accordance with NFPA 99, 1999 Edition, and Section 8-3.1.11.3, a precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:
CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

1. The main floor medical gas store room was observed at 1:17 p.m. on 4/9/14. The storeroom was accessed from the outside of the building on its south side. The door to this storeroom did not have a sign meeting the requirements of Section 8-3.1.11.3.

2. The basement oxygen storeroom was observed at 3:52 p.m. on 4/9/14. The door to this room did not have a sign meeting the requirements of Section 8-3.1.11.3., although 20 plus K/J size cylinders were stored in the room,

Based on observations, the facility failed to maintain requirements of NFPA 70, 1999 Edition and electrical requirements set forth by CMS. This deficiency had potential to affect a very limited number of patients/residents, staff, and visitors in the building.

Findings include:

In accordance with 240-4 of the NFPA 70, 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99 (1999 Edition) and interpretations from CMS, extension cords or multiple adaptors used in health care shall be protected against over-current conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS). One means is by providing power taps or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings. The limited use of circuit breaker protected power tap is acceptable, provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to a power tap. These items must be directly connected to an appropriate receptacle.

In accordance with Article 110-13(a) of NFPA 70, electrical equipment shall be firmly secured to the surface on which it is mounted (if not temporary in service).

In accordance with NFPA 70 and Article 400-10. Pull at Joints and Terminals; flexible cords and cables shall be connected to devices and to fittings so that tension will not be transmitted to joints or terminals.
Exception: Listed portable single pole devices that are intended to accommodate such tension at their terminals, shall be permitted to be used with single conductor flexible cable.
FPN: Some methods of preventing pull on a cord from being transmitted to joints or terminals are knotting the cord, winding with tape, and fittings designed for the purpose.

In accordance with Article 370.28(c) of NFPA 70, all pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Article 250-110.

Flexible cords shall not be run through doorways, windows or similar openings per Article 400-8 of NFPA 70.

Live parts of electric equipment operating at 50 volts or more shall be guarded against accidental contact by approved enclosures per Article 110-27 of NFPA 70.

No overcurrent device shall be connected in series with any conductor that is intentionally grounded Article 240-22 of NFPA 70. UL listing guidelines for relocatable power taps/power strips, being XBYS, notes that these strips are not intended to be series connected or daisy chained to other power strips or extension cords.

1. The laboratory office was observed at 1:25 p.m. on 4/9/14. A microwave oven was plugged into a surge cord.

2. The elevator pit was observed at 1:40 p.m. on 4/9/14.
a) The sump pump electrical cords extended through the wall into the elevator mechanical room and is not in an electrical conduit, and
b) additionally, an electrical cover was missing on the south wall of the elevator shaft.

3. In the clean utility room of swing bed area, the ice-machine was plugged into a power strip, as observed at 2:38 p.m. on 4/9/14.

4. In room 115, a power strip was suspended from its cord on the south wall, as observed at 2:38 p.m. on 4/9/14. The power strip neither touched the ground nor was supported.

5. In room 110 a white extension cord was in use to a fan, as observed at 2:39 p.m. on 4/9/14.

6. In the basement shop there were two extension cords in-use, as observed at 3:40 p.m. on 4/9/14. Also, one junction box on the ceiling was missing its cover.

7. The basement purchasing office contained two power strips connected in series, (plugged into one another), as observed at 4:00 p.m. on 4/9/14.

8. In the Information Technology (IT) office, a refrigerator was found plugged into a power strip, as observed at 4:15 p.m. on 4/9/14.

9. In the basement shop office, a multi-plug adaptor was in-use on the south wall as observed at 5:00 p.m. on 4/9/14.

Based on review of the fire watch policy, the facility did not have a fire watch policy which included contacting the authority having jurisdiction which includes the Certification Bureau whenever a fire watch was instituted for the sprinkler system. This deficiency has the potential to affect all patients/residents, staff, and visitors.

Findings include:

The fire policies and procedures for the facility were received by facsimile and reviewed on 4/15/14 at 11:17 a.m. The present policy did not include the requirement stated in 9.7.6.1 of NFPA 101 that notification be made to the authorities having jurisdiction when a fire watch was instituted. A fire watch must be initiated when any portion or the entire fire sprinkler system is not operable for more than 4 hours in a 24 hour period. The Certification Bureau being one of those authorities that need to be notified at 406-444-4170 and specifically stated in the policy when the fire watch is initiated and ends.

Based on review of the fire watch policy, the facility did not have a fire watch policy which included contacting the authority having jurisdiction including the Certification Bureau whenever a fire watch was instituted for the fire alarm system. This deficiency has the potential to affect all patients/residents, staff, and visitors.

The findings include:

The fire policies and procedures for the facility were received by facsimile and reviewed on 4/15/14 at 11:17 a.m.. The present policy did not include the requirement stated in 9.6.1.8 of NFPA 101 that notification be made to the authorities having jurisdiction when a fire watch has been initiated. A fire watch much be initiated when any portion or the entire fire alarm system is not operable for more than 4 hours in a 24 hour period. The Certification Bureau being one of those authorities that need to be notified at 406-444-4170 and specifically stated in the policy when the fire watch is initiated and ends.