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Based on observation, the facility failed to ensure building construction was maintained as evidenced by penetrations in walls or ceilings. This could result in the spread of smoke or fire, in the event of a fire, affecting 2 of 5 smoke compartments.

Findings:

During the facility tour on 4/17/12, the wall and ceiling construction in the hospital was observed:

1. At 4:45 p.m., there was a one inch by four inch triangular shaped penetration in the ceiling tile for the Medical Records hallway outside of data processing.

2. At 4:46 p.m., there were three 1/2 inch diameter penetrations where the edges of the ceiling tiles were broken.

During the facility tour on 4/18/12, the wall and ceiling construction in the hospital was observed:

3. At 9:25 a.m., there was a 3/8 inch diameter penetration around the plumbing for the rinse sink in the kitchen area.

4. At 10:58 a.m., there was a 3/8 inch wide by 4 inch long penetration between the ceiling tiles in the data processing area.

5. At 10:59 a.m., there was a one inch by two inch penetration in the ceiling tile next to a 3/4 inch conduit near the back of the data processing area.

During the facility tour and interview on 4/19/12, the wall and ceiling construction in Clinic I was observed:

6. At 10:53 a.m., there was a 1 1/2 inch diameter penetration in the common wall between the materials receiving and the maintenance shop. Maintenance Staff 1 explained that the opening was orginally created to install the roll-up door spindle shaft.

Based on observation, the facility failed to maintain corridor doors according to NFPA 101. This was evidenced by doors that failed to latch, and by doors that were obstructed from closing. This affected three of five smoke compartments and could result in the spread of smoke and fire, in the event of a fire.

7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

Findings:

During the facility tour and interview with Maintenance Staff 1 on 4/18/12, the facility corridor doors were observed.

Hospital
1. At 10:44 a.m., the door to Room 8 failed to latch in three of three attempts. Maintenance Staff 1 state that the strike plate was set too far back which prevented the door latch from engaging.

2. At 10:48 a.m., the door to Room 6 failed to latch in three of three attempts. Maintenance Staff 1 state that the strike plate was set too far back and which prevented the door latch from engaging.

3. At 11:28 a.m., the strike latch in the men's staff locker room door failed to latch. The latching hardware was taped down with surgical tape.

4. At 11:53 a.m., the door to the Emergency Department Trauma Room failed to latch in three of three attempts.

5. At 12:33 p.m., the Emergency Department Storage Room was equipped with a gate latch. Maintenance Staff 1 stated it is used to hold the door open while moving supplies in and out of the room.

Based on observation and interview, the facility failed to ensure that smoke barrier walls are constructed in accordance with NFPA 101, 2000 edition. This was evidenced by penetrations in smoke barrier walls in the hospital. This could result in the spread of smoke from one compartment to another, in the event of a fire, affecting four of five smoke compartments.

8.3.6.1., Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.

Findings:

During the facility tour with Maintenance Staff 1 on 4/17/12, the hospital smoke barrier walls were observed.

1. At 4 p.m., there was an approximately 4 inch by 8 inch penetration through the smoke barrier wall near Room 8. An abandoned ventilation duct that passed through the attic smoke barrier wall was cut away on both sides and re-purposed into a communications cable sleeve.

2. At 4:36 p.m., there were three penetrations in the smoke barrier wall separating medical records from Rooms 4 and 5. There were two 1/4 inch penetrations around half inch diameter bundles of cable over the main corridor and an approximately one inch diameter penetration above a three inch pipe passing through the smoke barrier wall between Room 5 and data processing.

3. At 4:50 p.m., there were three penetrations in the smoke barrier doors between ER and the Nurse Station area. There was a half inch penetration around a bundle of communication cables, a half inch penetration around a half inch conduit, and a one inch penetration above a one inch diameter bundle of communication cables.

4. At 4:52 p.m., there was a half inch penetration around a half inch conduit in the smoke barrier wall across from the Nurse Station.

During the facility tour of the basement with Maintenance Staff 1 on 4/18/12, the smoke barrier between first floor surgery and the basement equipment room was observed.

5. At 12:48 p.m., there were two four inch diameter penetrations visible through the concrete floor from below the X-ray area. There was no fire caulking or smoke sealant visible.

6. At 12:50 p.m., there were three six inch diameter penetrations in the wall at the ceiling above the domestic water tank in the basement. There was no fire caulking or smoke sealant visible.

7. At 12:55 p.m., there were one six inch and two three inch diameter penetrations in the ceiling above the hot water recirculation pumps. There was no fire caulking or smoke sealant visible.

Based on observation, the facility failed to ensure hazardous areas are protected in accordance with NFPA 100, 2000 edition. This was evidenced by a kitchen dry goods storage, medical records, and a soiled linen areas with no self closing door or a doors that were obstructed from closing or latching. This could result in the spread of smoke and fire, in the event of a fire, affecting two of five smoke compartments.

Findings:

During the facility tour and interview with Maintenance Staff 1 on 4/18/12, the hazardous areas of the facility were observed.

1. At 9:15 a.m., the kitchen dry goods storage area was greater than 300 square feet with more than 40 linear feet of wall space covered in wood shelving. This area contained abundant storage of combustible cardboard, paper and plastic serving ware and cups. The corridor door was equipped with a metal hook and chain. According to Maintenance Staff 1 this was used to hold the door in the open position while bringing in supplies. The inner partition door to the kitchen was not equipped with an automatic or self closing device and remained in the open position. The storage room is considered a hazardous area.

2. At 10:11 a.m., the corridor door to the soiled linen storage did not latch. This was located across from the nurse station.

3. At 11:02 a.m., the door to the medical records room on the east side of the corridor was not automatic or self closing. The room was greater than 200 square feet and contained 14 cases of paper records

4. At 11:08 a.m., the door to the medical records room on the west side of the corridor was not automatic or self closing. The room was greater than 200 square feet and was stocked with abundant quantities of open file storage for paper records.

5. At 12:27 p.m., the medical records storage room next to the entrance to the skilled nursing hallway failed to latch when allowed to close from the fully open position. The door was obstructed by the door frame in two of two attempts.

Based on observation, the facility failed to ensure exit signs were provided directing occupants to the nearest path of egress. This was evidenced by a no sign marking the paths of egress. This could result in a delay in evacuation, in the event of fire, affecting one of three smoke compartments.

NFPA 101.
7.10.2* Directional Signs. A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.

Findings:

During the facility tour with Maintenance Staff 1 on 4/18/12, the exit signs were observed.

Hospital
1. At 12:17 p.m., there was no self illuminated exit sign marking the path of egress from the radiology dressing area.

2. At 12:25 p.m., there was no exit sign marking the path of egress in either direction at the smoke barrier wall next to Rooms 1 & 8. When the doors were closed the exit signs marking a path of egress were not visible.

During the off-site facilities tours and interview with Maintenance Staff 1 on 4/19/12 the exit signs were observed.

North-side Clinic
3. At 9:10 a.m., there were two battery back-up exit lights, one at the entrance and one in the hallway. Neither operated when the test button was depressed. Maintenance Staff 1 opened the cover on both units and the batteries were observed to be disconnected. He indicated they were not checked after they were originally installed.

Home Health Agency and Hospice
4. At 2:46 p.m., in the hallway on the first floor there was no sign marking the path of egress to the nearest exit. Maintenance Staff 1 confirmed the observation.

Based on record review and interview, the facility failed to prepare staff to respond to fire emergencies at the clinic sites. This was evidenced by the facility's failure to conduct site specific fire drills for staff at Clinic I, Clinic II, the Northside Clinic, and at the Homehealth and Hospice locations. This affected staff and clients at four clinic locations and could result in a delayed response to a fire emergency.

NFPA 101, 2000 edition
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.
19.7.2.1 For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy ' s fire safety plan.
19.7.2.2 A written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
19.7.2.3 All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

Findings:

During record review with Maintenance Staff 1 on 4/17/12 the emergency preparedness of all facilities and staff was observed and discussed. At 1:21 p.m., fire drill records were reviewed. There were no fire drills conducted for the Clinics and off-site locations specific to those buildings. Maintenace Staff 1 mentioned that staff at Clinic I will come over to participate in the hospital fire drills but he does not perform fire drills at the Clinic sites. There was no record indicating a fire drill was conducted for Clinic I, ClinicII, Northside Clinic, and for Home Health and Hospice.

Based on record review, observation, and interview, the facility failed to ensure inspection and testing of the smoke detectors at the clinic locations were in accordance with the manufacturers' specifications and NFPA 72. This was evidenced by no records of annual smoke detector testing, no smoke detector sensitivity testing, by no weekly push button testing for battery operated single station detectors, and by no canned smoke maintained on-site for testing the detectors. This could result in a device failure going unnoticed and a delay responding to a fire emergency affecting three of four clinic locations.

NFPA 72 National Fire Alarm Code 1999 Edition
7.2.2. Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2
13. Initiating Devices (g) Smoke Detectors - The detectors shall be tested in place to ensure smoke entry into the sensing chamber and an alarm response. Testing with smoke or listed aerosol approved by the manufacturer shall be permitted as acceptable test methods. Other methods approved by the manufacturer that ensure smoke entry into the sensing chamber shall be permitted.

7-3.2.1 states, "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 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.

Table 7-3.2 Testing Frequencies
h. All Smoke Detectors - Functional Test Annually

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)

Findings:

During record review and interview on 4/17/12 with Facilities Staff 1, the smoke detector testing records were requested.

1. At 1:22 p.m., there were no smoke detector testing records for three clinics equipped with smoke detectors. Clinic I, the Northside Clinic and the Home Health / Hospice smoke detectors were not tested in accordance with the manufacturers recommendation and NFPA 72. The vendor documents for the hospital smoke detector testing was the only record available.

2. There was no documented verfication of sytem based detector signals received at an off-site monitoring location.

During fire alarm system testing on 4/18/12, canned smoke was requested for fire alarm system testing.

3. At 2:30 p.m., there was no canned smoke available for smoke detector testing. No smoke dectector testing could be performed at the hospital facility and three clinic locations. Maintenance Staff 1 stated the only remaining canned smoke container was empty.

During the facility tour of clinic locations the smoke detectors were observed.

4. At 9:07 on 4/19/12 there were two battery operated smoke detectors at the Northside Clinic that could be readily viewed. These both had manufacturers instructions on the cover stating to "test weekly."

Based on observation, record review, and interview the facility failed to maintain the fire sprinkler system and to ensure testing could be performed according to NFPA 25. This was evidenced by no vendor testing documents for the South Riser residual pressure, no pressure gauge installed on the main drain, no ability to demonstrate the required testing during a Life Safety Code Inspection.

Finding:

During record review on 4/17/12 the fire sprinkler system vendor testing reports were reviewed.

1. At 2:32 p.m., vendor records indicated the main drain residual test could not be performed due to no pressure gauge installed on the South Riser.

During the fire alarm and fire sprinkler system testing on 4/18/12, the South Fire Sprinkler Riser was observed. This riser served the medical records area.

2. At 2:59 p.m., the inspector test for the South Riser could not performed. The inspector test valve was located inside a wall cabinet in the Data Processing room and the water discharge could not be located but it appeared to be plumbed into a drain pipe.

3. At 3:01 p.m., there was no water pressure gauge mounted on the south automatic sprinkler system riser. The main drain residual pressure test could not be performed without the pressure gauge readings. The South Riser was located inside a wall cabinet within the Data Processing area and the water discharge could not be located. They appeared to plumbed into a drain pipe.

During an interview on 4/17/12 at 2:35 p.m., Maintenance Staff 1 stated that the pressure gauge repair wasn't performed because it had not been identified as a required repair on the sprinkler system testing summary report.

During an interview on 4/18/12 at 3:02 p.m., Maintenance Staff 1 requested that we "not" test the main drain and the inspector test valve located inside the data processing area. He was concerned about the possibility of flooding the Medical Records area. He stated that he did not know if there was a problem but he was concerned that the vendors had not been testing this riser. Since he could not locate the discharge he did not want to risk a flood.

Based on record review, observation and interview, the facility failed to maintain the automatic fire sprinkler system in a reliable operating condition. This was evidenced by non-secured control and isolation valves, and missing signs indicating the purpose of the automatic fire sprinkler system components, an obstructed sprinkler head, and missing spare sprinkler heads. This could result in a delay responding to an equipment malfunction and a delay in extinguishing a fire. This affected three of four smoke compartments.

NFPA 25 1998 Edition Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems
2-2.1.3 The supply of spare sprinklers shall be inspected annually for the following:
(a) The proper number and type of sprinklers
2-4.1.4 A supply of at least 6 spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. The cabinet shall be so located that it will not exposed to moisture, dust, corrosion or a temperature exceeding 100 degrees F (38 degrees C).

Findings:

During the facility tour with Maintenance Staff 1 the complete automatic sprinkler system was observed.

Hospital
4/18/12
1. At 9:06 a.m., there was no lock and chain securing the backflow isolation valves for the fire sprinkler system.

2. At 9:09 a.m., there was no sign indicating the back flow isolation valves for the fire sprinkler system. These were located in the north parking area inside a protective boxed cover that was painted green. The cover was not lalled as to the purpose of the valves that were inside. It did indicated a fire department connections within.

3. At 9:15 a.m., there were no signs at the North Riser indicating the purpose of the valves and devices. These included the Inspector Test Valve, the Main Drain Valve, the main check valves and the areas served by three branch lines from the riser.

4. At 9:50 a.m, there was a sprinkler head in the kitchen dry goods storage area that was obstructed by a fluorescent light. The top of the four foot long fluorescent light was the same height as the upright sprinkler deflector. The ceiling mounted light fixture was approximately four inches to one side of the sprinkler head.

5. At 11:16 a.m., the location of the facility fire sprinkler system standpipe was not readily apparent. The sprinkler valve room was accessed through a door inside the data storage area inside the medical records storage area. The cabinet door and the door for the sprinkler valve room was not identified with a sign as required.

6. At 3:08 p.m., there was no spare fast response sprinkler heads in the storage box. The fast acting type with the green frangible bulb was used in the MRI trailer canopy.

7. At 3:17 p.m., there was no chain and lock on the isolation valve at the riser branch line for the skilled nursing facility porch.

Based on observation, the facility failed to ensure fire extinguishers were maintained at the North-side Clinic. This was evidenced by two fire extinguishers with no current inspection tags. This could result in a delay in extinguishing a fire if the fire extinguisher failed to operate as required. This affected three staff and two clients visiting the Clinic.

9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

4-3.1* Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more requent intervals when circumstances require.
4-3.2* Procedures. Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) *Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

Finding:

During the facility tour with Maintenance Staff 1 on 4/19/12, the fire extinguishers were observed.

At 8:54 a.m., there was no annual inspection tag and no current monthly initials on two of two fire extinguishers during the last year. The last inspection was performed on 5/10/11.

Based on record review, observation and interview, the facility failed to maintain fire dampers in the HVAC (Heating Ventilation and Air Conditioning) system. This was evidenced by the presence of fusible link fire dampers and motorized fire smoke dampers with no maintenance and testing documents. This could result in a failure of the damper to operate properly and allow the spread of fire or smoke. This affected five of five smoke compartments.

NFPA 90A Standard for the Installation of Air-conditioning 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 fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Findings:

During record review on 4/17/12 fire damper records were requested.

1. At 9:20 a.m., there were no records available for fire damper inspection and testing.

2. At 11:07 a.m., major remodel plans stamped as approved dated 5/19/97 indicated fire dampers that were located in the ducting for the rooftop AC (air conditioning) Units #5 and #6 .

During the facility tours and interviews on 4/17/12 fusible link dampers were observed in the supply and return air registers at dozens of corridor and room locations.

3. At 4:38 p.m., there were motorized fire dampers observed in the nurse station area above the ceiling. Maintenance Staff 1 visually confirmed the motorized fire dampers.

4. At 4:40 p.m., Maintenance Staff 1 visually confirmed that there were fusible link fire dampers located through-out the hospital facility in most of the rooms and corridors.

Based on record review, observation and interview, the facility failed to maintain the kitchen exhaust system in accordance with NFPA 96. This was evidenced by an accumulation of greasy soot in the kitchen range hood exhaust duct and by no records of steam cleaning performed. This could result in an uncontrolled fire above the suppression system in the range hood and the spread of fire and smoke affecting one of five smoke compartments.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations 1998 Edition

Table 8-3.1 Exhaust System Inspection Schedule
Type or Volume of Cooking Frequency Frequency
Systems serving moderate-volume cooking Semiannually
operations

Findings:

During record review with Maintenance Staff 1 on 4/17/12, the kitchen range hood and exhaust system cleaning records were requested.

1. At 2:57 p.m., the kitchen hood fire suppression system was last performed on 10/16/11 and did not indicate any safety issue with the accumulation of greasy soot in the exhaust duct.

2. At 3 p.m., there was no vendor records of kitchen range hood and exhaust system cleaning available.

During the kitchen tour with Maintenance Staff 1 and EVS (Environmental Services) Staff 1 on 4/18/12, the kitchen range hood and exhaust duct was observed.

3. At 9:37 a.m., there was a heavy layer of soot, approximately 1/4 inch thick, in the duct above the grease filter inside the kitchen range hood. There was a visible layer of grease around the cable connecting to the fusible link. The fusible link itself appeared to be clean.

During an interview with EVS Staff 1 on 4/18/12 the inspection and cleaning process was described.

4. EVS 1 indicated that kitchen staff only clean the hood area and the grease filters. He did not have a vendor contracted to do the cleaning and was not aware of the problem. He did not inspect since there was a vendor doing the semi-annual hood suppression system inspection.

Based on observation, the facility failed to ensure that high temperature space heaters were kept out of health care occupancies and where allowed were used in approved manor. This could result in the spread of fire or smoke affecting one of five smoke compartments in the hospital and two of four clinics.

Findings:

During the facility tour and interviews with Maintenance Staff 1 on 4/18/12, the use of portable space heating was observed.

Hospital
1. At 10:48 a.m., there was a high temperature heater that had been placed against the fabric of a sofa in Room 5. This was a 1500 watt portable space heater. The print on the side cautioned that this was a high temperature heater and that it must be kept at least 3 feet away from furniture and drapes. The heater was turned off but left plugged in and there was no one in the room. Maintenance Staff 1 commented that this may have been left there by Hospice Staff.

2. At 3:55 p.m., there was a high temperature heater plugged into a multi-outlet extension cord which was routed under a door from the women's locker room to the shower room. The heater was turned off but it was positioned against a plastic trash container that contained paper trash. Nursing staff volunteered a statement that the shower room was too cold and needed some heat.

Clinic I
3. At 4:30 p.m., there was a high temperature heater sitting below the admitting desk. There were combustible materials within three feet of the space heater. Maintenance Staff 1 commented that it was disconnected.

4. At 4:36 p.m., there was a high temperature heater sitting under a cabinet in the office along the west end of the clinic. A plastic trash container was sitting within three feet of the space heater. The side of the plastic trash container was melted. Office Staff commented that the heater and the partially melted trash were left in the office prior to moving in.

Based on observation, the facility failed to ensure that the correct extinguisher type was provided for their heli-pad. This was evidenced by the failure to provide fire extinguishers of the type and rating required to protect the heli-pad. This affected hospital patients that are transported from this location. There was a potential to fail to extinguish a fuel fire leading to harm to the patients.

Findings:

During the facility tour with Maintenance Staff 1 on 4/18/12, the heli-pad was observed.

At 11:45 a.m., the closest fire extinguisher for the heli-pad was located at the area between the Emergency Room entrance and the MRI trailer. The only fire extinguisher available for the heli-pad was a CO2 extinguisher. There was no foam type fire extinguisher for suppression of jet fuel fires. This was confirmed by Maintenance Staff 1.

Based on observation and record review, the facility failed to maintain the emergency eye wash and emergency shower in the laboratory in the Clinic 1 building. This was evidenced by no records of periodic testing and an eye station that was not readily accessible. This could result in a delay responding to exposure to injurious or corrosive materials.

Findings:

During the facility tour and record review, the laboratory emergency eye wash station and emergency shower were observed.

1. At 4 p.m., the eye wash station was mounted to a sink gooseneck shaped faucet. The eye flush nozzles were rotated approximately 45 degrees which would have caused an obstruction for the eyes and difficulty positioning the face over the water nozzles.

2. At 4:01 p.m., inspection and test records were requested. Maintenance Staff 1 stated that there was no periodic operational tests being performed.

Based on observation, the facility failed to ensure electrical wiring and equipment are in accordance with NFPA 70 and NFPA 99. This was evidenced by the use of an extension cords, wiring connections through a doorway. This affected three of five smoke compartments two of four clinics and could increase the risk of electrical fire.

9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

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

Findings:

4/18/12
Hospital

During the facility tour with Maintenance Staff 1 on 4/18/12 the electrical devices and wiring connections were observed.

1. At 10:26 a.m., in Room 12 there were two beds and an oxygen saturation monitor plugged into multi-outlet extension cord by Bed A.

2. At 10:29 a.m., in Room 11 there was a bed plugged into a multi-outlet extension cord which was plugged into a wall outlet.

3. At 10:33 a.m., in Room 10 there was a bed plugged into a multi-outlet extension cord which was plugged into a wall outlet

4. At 10:42 a.m., in Room 8 there was a bed plugged into a multi-outlet extension cord which was plugged into a second multi-outlet extension cord which was plugged into a wall outlet.

5. At 10:46 a.m., in Room 7 there was a bed plugged into a multi-outlet extension cord which was plugged into a wall outlet

6. At 11:21 a.m., there was a portable space heating appliance with the power cord run under a door between the women's staff locker room and the shower room. The power cord was plugged into a multi-outlet extension cord which was plugged into a wall outlet.

7. At 11:10 a.m., there was a coffee pot plugged into an approximately 16 foot long white extension cord which was plugged into a wall outlet in the coding room.

8. At 11:41 a.m., there was a patient vitals monitor plugged into a multi-outlet extension cord which was plugged into the wall outlet behind the gurney in Emergency Room B.

9. At 12:25 a.m., there was a micro-wave and a coffee maker plugged into a multi-outlet extension cord which was plugged into a wall outlet in the break room for X-ray staff.

Clinic I

10. At 4:27 p.m., there was a white and a black extension cord run under the medical records storage areas. There was a fan in the center of the area that was not plugged in and had no outlet.

11. At 4:43 p.m., there was a micro-wave and a water cooler plugged into a multi-outlet extension cord in the employee lounge.

12. At 4:44 p.m., there was a refrigerator plugged into a multi-outlet extension cord. in teh employee lounge.

4/19/12
Northside Clinic

13. At 9:18 a.m., there was a microwave, a coffee pot, a toaster, and a coffee grinder plugged into a multi-outlet extension cord which was plugged into the wall outlet in the employee lounge area. Clinic Staff stated that breaker trips when the micro-wave is run with any other device. Maintenance Staff 1 confirmed that the circuit was overloaded.

14. At 9:28 a.m., a medication refrigerator in the medical supply room was plugged into a multi-outlet extension cord which was plugged into the wall outlet.

4/19/12
Home Health and Hospice

15. At 11:50 a.m., there was refrigerator plugged into a a beige extension cord behind the receptionist desk area.

16. At 12:08 p.m., there was a desk top computer system plugged into a multi-outlet extension cord which was plugged into a second multi-outlet extension cord which was plugged into a wall outlet in the clerical office.

Based on observation, the facility failed to ensure building construction was maintained as evidenced by penetrations in walls or ceilings. This could result in the spread of smoke or fire, in the event of a fire, affecting 2 of 5 smoke compartments.

Findings:

During the facility tour on 4/17/12, the wall and ceiling construction in the hospital was observed:

1. At 4:45 p.m., there was a one inch by four inch triangular shaped penetration in the ceiling tile for the Medical Records hallway outside of data processing.

2. At 4:46 p.m., there were three 1/2 inch diameter penetrations where the edges of the ceiling tiles were broken.

During the facility tour on 4/18/12, the wall and ceiling construction in the hospital was observed:

3. At 9:25 a.m., there was a 3/8 inch diameter penetration around the plumbing for the rinse sink in the kitchen area.

4. At 10:58 a.m., there was a 3/8 inch wide by 4 inch long penetration between the ceiling tiles in the data processing area.

5. At 10:59 a.m., there was a one inch by two inch penetration in the ceiling tile next to a 3/4 inch conduit near the back of the data processing area.

During the facility tour and interview on 4/19/12, the wall and ceiling construction in Clinic I was observed:

6. At 10:53 a.m., there was a 1 1/2 inch diameter penetration in the common wall between the materials receiving and the maintenance shop. Maintenance Staff 1 explained that the opening was orginally created to install the roll-up door spindle shaft.

Based on observation, the facility failed to maintain corridor doors according to NFPA 101. This was evidenced by doors that failed to latch, and by doors that were obstructed from closing. This affected three of five smoke compartments and could result in the spread of smoke and fire, in the event of a fire.

7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

Findings:

During the facility tour and interview with Maintenance Staff 1 on 4/18/12, the facility corridor doors were observed.

Hospital
1. At 10:44 a.m., the door to Room 8 failed to latch in three of three attempts. Maintenance Staff 1 state that the strike plate was set too far back which prevented the door latch from engaging.

2. At 10:48 a.m., the door to Room 6 failed to latch in three of three attempts. Maintenance Staff 1 state that the strike plate was set too far back and which prevented the door latch from engaging.

3. At 11:28 a.m., the strike latch in the men's staff locker room door failed to latch. The latching hardware was taped down with surgical tape.

4. At 11:53 a.m., the door to the Emergency Department Trauma Room failed to latch in three of three attempts.

5. At 12:33 p.m., the Emergency Department Storage Room was equipped with a gate latch. Maintenance Staff 1 stated it is used to hold the door open while moving supplies in and out of the room.

Based on observation and interview, the facility failed to ensure that smoke barrier walls are constructed in accordance with NFPA 101, 2000 edition. This was evidenced by penetrations in smoke barrier walls in the hospital. This could result in the spread of smoke from one compartment to another, in the event of a fire, affecting four of five smoke compartments.

8.3.6.1., Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.

Findings:

During the facility tour with Maintenance Staff 1 on 4/17/12, the hospital smoke barrier walls were observed.

1. At 4 p.m., there was an approximately 4 inch by 8 inch penetration through the smoke barrier wall near Room 8. An abandoned ventilation duct that passed through the attic smoke barrier wall was cut away on both sides and re-purposed into a communications cable sleeve.

2. At 4:36 p.m., there were three penetrations in the smoke barrier wall separating medical records from Rooms 4 and 5. There were two 1/4 inch penetrations around half inch diameter bundles of cable over the main corridor and an approximately one inch diameter penetration above a three inch pipe passing through the smoke barrier wall between Room 5 and data processing.

3. At 4:50 p.m., there were three penetrations in the smoke barrier doors between ER and the Nurse Station area. There was a half inch penetration around a bundle of communication cables, a half inch penetration around a half inch conduit, and a one inch penetration above a one inch diameter bundle of communication cables.

4. At 4:52 p.m., there was a half inch penetration around a half inch conduit in the smoke barrier wall across from the Nurse Station.

During the facility tour of the basement with Maintenance Staff 1 on 4/18/12, the smoke barrier between first floor surgery and the basement equipment room was observed.

5. At 12:48 p.m., there were two four inch diameter penetrations visible through the concrete floor from below the X-ray area. There was no fire caulking or smoke sealant visible.

6. At 12:50 p.m., there were three six inch diameter penetrations in the wall at the ceiling above the domestic water tank in the basement. There was no fire caulking or smoke sealant visible.

7. At 12:55 p.m., there were one six inch and two three inch diameter penetrations in the ceiling above the hot water recirculation pumps. There was no fire caulking or smoke sealant visible.

Based on observation, the facility failed to ensure hazardous areas are protected in accordance with NFPA 100, 2000 edition. This was evidenced by a kitchen dry goods storage, medical records, and a soiled linen areas with no self closing door or a doors that were obstructed from closing or latching. This could result in the spread of smoke and fire, in the event of a fire, affecting two of five smoke compartments.

Findings:

During the facility tour and interview with Maintenance Staff 1 on 4/18/12, the hazardous areas of the facility were observed.

1. At 9:15 a.m., the kitchen dry goods storage area was greater than 300 square feet with more than 40 linear feet of wall space covered in wood shelving. This area contained abundant storage of combustible cardboard, paper and plastic serving ware and cups. The corridor door was equipped with a metal hook and chain. According to Maintenance Staff 1 this was used to hold the door in the open position while bringing in supplies. The inner partition door to the kitchen was not equipped with an automatic or self closing device and remained in the open position. The storage room is considered a hazardous area.

2. At 10:11 a.m., the corridor door to the soiled linen storage did not latch. This was located across from the nurse station.

3. At 11:02 a.m., the door to the medical records room on the east side of the corridor was not automatic or self closing. The room was greater than 200 square feet and contained 14 cases of paper records

4. At 11:08 a.m., the door to the medical records room on the west side of the corridor was not automatic or self closing. The room was greater than 200 square feet and was stocked with abundant quantities of open file storage for paper records.

5. At 12:27 p.m., the medical records storage room next to the entrance to the skilled nursing hallway failed to latch when allowed to close from the fully open position. The door was obstructed by the door frame in two of two attempts.

Based on observation, the facility failed to ensure exit signs were provided directing occupants to the nearest path of egress. This was evidenced by a no sign marking the paths of egress. This could result in a delay in evacuation, in the event of fire, affecting one of three smoke compartments.

NFPA 101.
7.10.2* Directional Signs. A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.

Findings:

During the facility tour with Maintenance Staff 1 on 4/18/12, the exit signs were observed.

Hospital
1. At 12:17 p.m., there was no self illuminated exit sign marking the path of egress from the radiology dressing area.

2. At 12:25 p.m., there was no exit sign marking the path of egress in either direction at the smoke barrier wall next to Rooms 1 & 8. When the doors were closed the exit signs marking a path of egress were not visible.

During the off-site facilities tours and interview with Maintenance Staff 1 on 4/19/12 the exit signs were observed.

North-side Clinic
3. At 9:10 a.m., there were two battery back-up exit lights, one at the entrance and one in the hallway. Neither operated when the test button was depressed. Maintenance Staff 1 opened the cover on both units and the batteries were observed to be disconnected. He indicated they were not checked after they were originally installed.

Home Health Agency and Hospice
4. At 2:46 p.m., in the hallway on the first floor there was no sign marking the path of egress to the nearest exit. Maintenance Staff 1 confirmed the observation.

Based on record review and interview, the facility failed to prepare staff to respond to fire emergencies at the clinic sites. This was evidenced by the facility's failure to conduct site specific fire drills for staff at Clinic I, Clinic II, the Northside Clinic, and at the Homehealth and Hospice locations. This affected staff and clients at four clinic locations and could result in a delayed response to a fire emergency.

NFPA 101, 2000 edition
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.
19.7.2.1 For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy ' s fire safety plan.
19.7.2.2 A written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
19.7.2.3 All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

Findings:

During record review with Maintenance Staff 1 on 4/17/12 the emergency preparedness of all facilities and staff was observed and discussed. At 1:21 p.m., fire drill records were reviewed. There were no fire drills conducted for the Clinics and off-site locations specific to those buildings. Maintenace Staff 1 mentioned that staff at Clinic I will come over to participate in the hospital fire drills but he does not perform fire drills at the Clinic sites. There was no record indicating a fire drill was conducted for Clinic I, ClinicII, Northside Clinic, and for Home Health and Hospice.

Based on record review, observation, and interview, the facility failed to ensure inspection and testing of the smoke detectors at the clinic locations were in accordance with the manufacturers' specifications and NFPA 72. This was evidenced by no records of annual smoke detector testing, no smoke detector sensitivity testing, by no weekly push button testing for battery operated single station detectors, and by no canned smoke maintained on-site for testing the detectors. This could result in a device failure going unnoticed and a delay responding to a fire emergency affecting three of four clinic locations.

NFPA 72 National Fire Alarm Code 1999 Edition
7.2.2. Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2
13. Initiating Devices (g) Smoke Detectors - The detectors shall be tested in place to ensure smoke entry into the sensing chamber and an alarm response. Testing with smoke or listed aerosol approved by the manufacturer shall be permitted as acceptable test methods. Other methods approved by the manufacturer that ensure smoke entry into the sensing chamber shall be permitted.

7-3.2.1 states, "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 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.

Table 7-3.2 Testing Frequencies
h. All Smoke Detectors - Functional Test Annually

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)

Findings:

During record review and interview on 4/17/12 with Facilities Staff 1, the smoke detector testing records were requested.

1. At 1:22 p.m., there were no smoke detector testing records for three clinics equipped with smoke detectors. Clinic I, the Northside Clinic and the Home Health / Hospice smoke detectors were not tested in accordance with the manufacturers recommendation and NFPA 72. The vendor documents for the hospital smoke detector testing was the only record available.

2. There was no documented verfication of sytem based detector signals received at an off-site monitoring location.

During fire alarm system testing on 4/18/12, canned smoke was requested for fire alarm system testing.

3. At 2:30 p.m., there was no canned smoke available for smoke detector testing. No smoke dectector testing could be performed at the hospital facility and three clinic locations. Maintenance Staff 1 stated the only remaining canned smoke container was empty.

During the facility tour of clinic locations the smoke detectors were observed.

4. At 9:07 on 4/19/12 there were two battery operated smoke detectors at the Northside Clinic that could be readily viewed. These both had manufacturers instructions on the cover stating to "test weekly."

Based on observation, record review, and interview the facility failed to maintain the fire sprinkler system and to ensure testing could be performed according to NFPA 25. This was evidenced by no vendor testing documents for the South Riser residual pressure, no pressure gauge installed on the main drain, no ability to demonstrate the required testing during a Life Safety Code Inspection.

Finding:

During record review on 4/17/12 the fire sprinkler system vendor testing reports were reviewed.

1. At 2:32 p.m., vendor records indicated the main drain residual test could not be performed due to no pressure gauge installed on the South Riser.

During the fire alarm and fire sprinkler system testing on 4/18/12, the South Fire Sprinkler Riser was observed. This riser served the medical records area.

2. At 2:59 p.m., the inspector test for the South Riser could not performed. The inspector test valve was located inside a wall cabinet in the Data Processing room and the water discharge could not be located but it appeared to be plumbed into a drain pipe.

3. At 3:01 p.m., there was no water pressure gauge mounted on the south automatic sprinkler system riser. The main drain residual pressure test could not be performed without the pressure gauge readings. The South Riser was located inside a wall cabinet within the Data Processing area and the water discharge could not be located. They appeared to plumbed into a drain pipe.

During an interview on 4/17/12 at 2:35 p.m., Maintenance Staff 1 stated that the pressure gauge repair wasn't performed because it had not been identified as a required repair on the sprinkler system testing summary report.

During an interview on 4/18/12 at 3:02 p.m., Maintenance Staff 1 requested that we "not" test the main drain and the inspector test valve located inside the data processing area. He was concerned about the possibility of flooding the Medical Records area. He stated that he did not know if there was a problem but he was concerned that the vendors had not been testing this riser. Since he could not locate the discharge he did not want to risk a flood.

Based on record review, observation and interview, the facility failed to maintain the automatic fire sprinkler system in a reliable operating condition. This was evidenced by non-secured control and isolation valves, and missing signs indicating the purpose of the automatic fire sprinkler system components, an obstructed sprinkler head, and missing spare sprinkler heads. This could result in a delay responding to an equipment malfunction and a delay in extinguishing a fire. This affected three of four smoke compartments.

NFPA 25 1998 Edition Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems
2-2.1.3 The supply of spare sprinklers shall be inspected annually for the following:
(a) The proper number and type of sprinklers
2-4.1.4 A supply of at least 6 spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. The cabinet shall be so located that it will not exposed to moisture, dust, corrosion or a temperature exceeding 100 degrees F (38 degrees C).

Findings:

During the facility tour with Maintenance Staff 1 the complete automatic sprinkler system was observed.

Hospital
4/18/12
1. At 9:06 a.m., there was no lock and chain securing the backflow isolation valves for the fire sprinkler system.

2. At 9:09 a.m., there was no sign indicating the back flow isolation valves for the fire sprinkler system. These were located in the north parking area inside a protective boxed cover that was painted green. The cover was not lalled as to the purpose of the valves that were inside. It did indicated a fire department connections within.

3. At 9:15 a.m., there were no signs at the North Riser indicating the purpose of the valves and devices. These included the Inspector Test Valve, the Main Drain Valve, the main check valves and the areas served by three branch lines from the riser.

4. At 9:50 a.m, there was a sprinkler head in the kitchen dry goods storage area that was obstructed by a fluorescent light. The top of the four foot long fluorescent light was the same height as the upright sprinkler deflector. The ceiling mounted light fixture was approximately four inches to one side of the sprinkler head.

5. At 11:16 a.m., the location of the facility fire sprinkler system standpipe was not readily apparent. The sprinkler valve room was accessed through a door inside the data storage area inside the medical records storage area. The cabinet door and the door for the sprinkler valve room was not identified with a sign as required.

6. At 3:08 p.m., there was no spare fast response sprinkler heads in the storage box. The fast acting type with the green frangible bulb was used in the MRI trailer canopy.

7. At 3:17 p.m., there was no chain and lock on the isolation valve at the riser branch line for the skilled nursing facility porch.

Based on observation, the facility failed to ensure fire extinguishers were maintained at the North-side Clinic. This was evidenced by two fire extinguishers with no current inspection tags. This could result in a delay in extinguishing a fire if the fire extinguisher failed to operate as required. This affected three staff and two clients visiting the Clinic.

9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

4-3.1* Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more requent intervals when circumstances require.
4-3.2* Procedures. Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) *Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

Finding:

During the facility tour with Maintenance Staff 1 on 4/19/12, the fire extinguishers were observed.

At 8:54 a.m., there was no annual inspection tag and no current monthly initials on two of two fire extinguishers during the last year. The last inspection was performed on 5/10/11.

Based on record review, observation and interview, the facility failed to maintain fire dampers in the HVAC (Heating Ventilation and Air Conditioning) system. This was evidenced by the presence of fusible link fire dampers and motorized fire smoke dampers with no maintenance and testing documents. This could result in a failure of the damper to operate properly and allow the spread of fire or smoke. This affected five of five smoke compartments.

NFPA 90A Standard for the Installation of Air-conditioning 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 fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Findings:

During record review on 4/17/12 fire damper records were requested.

1. At 9:20 a.m., there were no records available for fire damper inspection and testing.

2. At 11:07 a.m., major remodel plans stamped as approved dated 5/19/97 indicated fire dampers that were located in the ducting for the rooftop AC (air conditioning) Units #5 and #6 .

During the facility tours and interviews on 4/17/12 fusible link dampers were observed in the supply and return air registers at dozens of corridor and room locations.

3. At 4:38 p.m., there were motorized fire dampers observed in the nurse station area above the ceiling. Maintenance Staff 1 visually confirmed the motorized fire dampers.

4. At 4:40 p.m., Maintenance Staff 1 visually confirmed that there were fusible link fire dampers located through-out the hospital facility in most of the rooms and corridors.

Based on record review, observation and interview, the facility failed to maintain the kitchen exhaust system in accordance with NFPA 96. This was evidenced by an accumulation of greasy soot in the kitchen range hood exhaust duct and by no records of steam cleaning performed. This could result in an uncontrolled fire above the suppression system in the range hood and the spread of fire and smoke affecting one of five smoke compartments.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations 1998 Edition

Table 8-3.1 Exhaust System Inspection Schedule
Type or Volume of Cooking Frequency Frequency
Systems serving moderate-volume cooking Semiannually
operations

Findings:

During record review with Maintenance Staff 1 on 4/17/12, the kitchen range hood and exhaust system cleaning records were requested.

1. At 2:57 p.m., the kitchen hood fire suppression system was last performed on 10/16/11 and did not indicate any safety issue with the accumulation of greasy soot in the exhaust duct.

2. At 3 p.m., there was no vendor records of kitchen range hood and exhaust system cleaning available.

During the kitchen tour with Maintenance Staff 1 and EVS (Environmental Services) Staff 1 on 4/18/12, the kitchen range hood and exhaust duct was observed.

3. At 9:37 a.m., there was a heavy layer of soot, approximately 1/4 inch thick, in the duct above the grease filter inside the kitchen range hood. There was a visible layer of grease around the cable connecting to the fusible link. The fusible link itself appeared to be clean.

During an interview with EVS Staff 1 on 4/18/12 the inspection and cleaning process was described.

4. EVS 1 indicated that kitchen staff only clean the hood area and the grease filters. He did not have a vendor contracted to do the cleaning and was not aware of the problem. He did not inspect since there was a vendor doing the semi-annual hood suppression system inspection.

Based on observation, the facility failed to ensure that high temperature space heaters were kept out of health care occupancies and where allowed were used in approved manor. This could result in the spread of fire or smoke affecting one of five smoke compartments in the hospital and two of four clinics.

Findings:

During the facility tour and interviews with Maintenance Staff 1 on 4/18/12, the use of portable space heating was observed.

Hospital
1. At 10:48 a.m., there was a high temperature heater that had been placed against the fabric of a sofa in Room 5. This was a 1500 watt portable space heater. The print on the side cautioned that this was a high temperature heater and that it must be kept at least 3 feet away from furniture and drapes. The heater was turned off but left plugged in and there was no one in the room. Maintenance Staff 1 commented that this may have been left there by Hospice Staff.

2. At 3:55 p.m., there was a high temperature heater plugged into a multi-outlet extension cord which was routed under a door from the women's locker room to the shower room. The heater was turned off but it was positioned against a plastic trash container that contained paper trash. Nursing staff volunteered a statement that the shower room was too cold and needed some heat.

Clinic I
3. At 4:30 p.m., there was a high temperature heater sitting below the admitting desk. There were combustible materials within three feet of the space heater. Maintenance Staff 1 commented that it was disconnected.

4. At 4:36 p.m., there was a high temperature heater sitting under a cabinet in the office along the west end of the clinic. A plastic trash container was sitting within three feet of the space heater. The side of the plastic trash container was melted. Office Staff commented that the heater and the partially melted trash were left in the office prior to moving in.

Based on observation, the facility failed to ensure that the correct extinguisher type was provided for their heli-pad. This was evidenced by the failure to provide fire extinguishers of the type and rating required to protect the heli-pad. This affected hospital patients that are transported from this location. There was a potential to fail to extinguish a fuel fire leading to harm to the patients.

Findings:

During the facility tour with Maintenance Staff 1 on 4/18/12, the heli-pad was observed.

At 11:45 a.m., the closest fire extinguisher for the heli-pad was located at the area between the Emergency Room entrance and the MRI trailer. The only fire extinguisher available for the heli-pad was a CO2 extinguisher. There was no foam type fire extinguisher for suppression of jet fuel fires. This was confirmed by Maintenance Staff 1.

Based on observation and record review, the facility failed to maintain the emergency eye wash and emergency shower in the laboratory in the Clinic 1 building. This was evidenced by no records of periodic testing and an eye station that was not readily accessible. This could result in a delay responding to exposure to injurious or corrosive materials.

Findings:

During the facility tour and record review, the laboratory emergency eye wash station and emergency shower were observed.

1. At 4 p.m., the eye wash station was mounted to a sink gooseneck shaped faucet. The eye flush nozzles were rotated approximately 45 degrees which would have caused an obstruction for the eyes and difficulty positioning the face over the water nozzles.

2. At 4:01 p.m., inspection and test records were requested. Maintenance Staff 1 stated that there was no periodic operational tests being performed.

Based on observation, the facility failed to ensure electrical wiring and equipment are in accordance with NFPA 70 and NFPA 99. This was evidenced by the use of an extension cords, wiring connections through a doorway. This affected three of five smoke compartments two of four clinics and could increase the risk of electrical fire.

9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

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

Findings:

4/18/12
Hospital

During the facility tour with Maintenance Staff 1 on 4/18/12 the electrical devices and wiring connections were observed.

1. At 10:26 a.m., in Room 12 there were two beds and an oxygen saturation monitor plugged into multi-outlet extension cord by Bed A.

2. At 10:29 a.m., in Room 11 there was a bed plugged into a multi-outlet extension cord which was plugged into a wall outlet.

3. At 10:33 a.m., in Room 10 there was a bed plugged into a multi-outlet extension cord which was plugged into a wall outlet

4. At 10:42 a.m., in Room 8 there was a bed plugged into a multi-outlet extension cord which was plugged into a second multi-outlet extension cord which was plugged into a wall outlet.

5. At 10:46 a.m., in Room 7 there was a bed plugged into a multi-outlet extension cord which was plugged into a wall outlet

6. At 11:21 a.m., there was a portable space heating appliance with the power cord run under a door between the women's staff locker room and the shower room. The power cord was plugged into a multi-outlet extension cord which was plugged into a wall outlet.

7. At 11:10 a.m., there was a coffee pot plugged into an approximately 16 foot long white extension cord which was plugged into a wall outlet in the coding room.

8. At 11:41 a.m., there was a patient vitals monitor plugged into a multi-outlet extension cord which was plugged into the wall outlet behind the gurney in Emergency Room B.

9. At 12:25 a.m., there was a micro-wave and a coffee maker plugged into a multi-outlet extension cord which was plugged into a wall outlet in the break room for X-ray staff.

Clinic I

10. At 4:27 p.m., there was a white and a black extension cord run under the medical records storage areas. There was a fan in the center of the area that was not plugged in and had no outlet.

11. At 4:43 p.m., there was a micro-wave and a water cooler plugged into a multi-outlet extension cord in the employee lounge.

12. At 4:44 p.m., there was a refrigerator plugged into a multi-outlet extension cord. in teh employee lounge.

4/19/12
Northside Clinic

13. At 9:18 a.m., there was a microwave, a coffee pot, a toaster, and a coffee grinder plugged into a multi-outlet extension cord which was plugged into the wall outlet in the employee lounge area. Clinic Staff stated that breaker trips when the micro-wave is run with any other device. Maintenance Staff 1 confirmed that the circuit was overloaded.

14. At 9:28 a.m., a medication refrigerator in the medical supply room was plugged into a multi-outlet extension cord which was plugged into the wall outlet.

4/19/12
Home Health and Hospice

15. At 11:50 a.m., there was refrigerator plugged into a a beige extension cord behind the receptionist desk area.

16. At 12:08 p.m., there was a desk top computer system plugged into a multi-outlet extension cord which was plugged into a second multi-outlet extension cord which was plugged into a wall outlet in the clerical office.