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Based on observation and interview, the facility failed to ensure 2 of 4 first floor Emergency Room corridor means of egresses and 2 of over 10 basement corridor means of egress were continuously maintained free of obstructions. This deficient practice affects all patients in the facility who use the first floor emergency room, plus staff while in the basement.

Findings include:

Based on observation on 02/13/17 between 12:15 p.m. and 4:00 p.m. during a tour of the facility with Supervisor of Facilities Management, the maintenance hall corridor and the corridor near the northeast elevator room, both in the basement, had cardboard boxes, totes, crates, pallets, trash, wood, trash containers, carts, extra doors, and other items along these corridors. Furthermore, based on an observation with the Electrician on 02/14/17 at 10:30 p.m., the Emergency Room South Corridor and the Emergency Room South Center corridor had six metal nursing supply carts, three two clean linen carts, two soiled linen carts, one soiled biological hazard metal cart, and a metal changing scrub machine stored along the entire corridor walls. Based on an interview with the Electrician on 02/14/17 at 10:55 a.m., the items stored in the corridor are kept in the Emergency Room South Corridors permanently because the facility does not have room to store these items anywhere else. This was verified by the Supervisor of Facilities Management and Electrician at the time of observations and acknowledged by the Director of Facilities Management at the exit conference on 02/16/17 at 11:45 a.m.

Based on observation and interview, the facility failed to ensure 2 of 6 first floor fire door sets were arranged to automatically close and latch. LSC-101 2012 edition, 7.2.4.3.10 requires all fire door assemblies in horizontal exits shall be self-closing or automatic-closing. In addition NFPA-80 2010 edition, 6.1.4.3.1 states the fire door shall latch upon closing. This deficient could affect any number of patients, staff and visitors.

Findings include:

Based on observations during a tour of the first floor with the Electrician on 02/14/17 from 8:15 a.m. to 4:10 p.m., the first floor fire doors sets located Rear Surgery South Hall and the first floor fire door set at the Nuclear Medicine North Hall each failed to latch into the door frames on two separate attempts. Based on an interview at the time of observations, the two fire door set locations were identified by the Electrician as fire barrier walls where the 1980 and 1993 additions were located. This was verified by the Electrician at the time of observations and acknowledged by the Director of Facilities Management at the exit conference on 02/16/17 at 11:45 a.m.

Based on observation and interview, the facility failed to ensure 1 of 16 exit discharges were constructed of hard packed all-weather travel surface in accordance with CMS Survey and Certification Letter 05-38. This deficient practice could affect any number of patients, staff and visitors.

Findings include:

Based on observation during a tour of the facility with the Electrician on 02/14/17 from 8:15 a.m. to 4:10 p.m., the first floor Southeast Hall exit, which also led from the Basement Bed Control Hall, had an exit door marked with an illuminated exit sign and was also listed on the posted evacuation maps as an exit. Furthermore, the exit discharged onto a twelve foot by sixteen foot concrete pad and lacked a sidewalk leading to the southeast paved parking lot. This was verified by the Electrician at the time of observation and acknowledged by the Director of Facilities Management at the exit conference on 02/16/17 at 11:45 a.m.

Based on observation and interview, the facility failed to ensure 1 of 16 first floor exterior exit discharge was provided with illumination. For the purposes of this requirement, exit access shall include only designated stairs, aisle, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include on designated stairs, aisles, corridors, ramps, escalators, walkways and exit passageways leading to a public way. This deficient practice could affect any number of patients, staff and visitors.

Finding include:

Based on observation on 02/14/17 at 1:20 p.m. with the Electrician, the first floor Emergency Room South Hall exit discharged onto a paved parking lot. Furthermore, the outside of the building at the Emergency Room South Hall exit lacked exterior lighting. Based on interview at the time of observation with the Electrician, it was indicated the Emergency Room South Hall exit discharge was not provided with exterior lighting on the emergency power system. This was verified by the Electrician at the time of observation and acknowledged by the Director of Facilities Management at the exit conference on 02/16/17 at 11:45 a.m.

1. Based on observation and interview, the facility failed to ensure 116 of 116 battery backup lights were tested annually for 90 minutes over the past year to ensure the light would provide lighting during periods of power outages and a written record of visual inspections and tests was provided. LSC 19.2.9.1 requires emergency lighting shall be provided in accordance with Section 7.9. Section 7.9.3.1.1 (1) requires functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, (3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered and (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on record review on 02/13/17 at 1:20 p.m. with the Director of Facilities Management, the Emergency Light Checklist Log for 2016 and 2017 was reviewed and indicated a monthly test was conducted on the one hundred sixteen battery backup lights throughout the facility. Furthermore, there was no documentation on the Emergency Light Checklist Log for 2016 and 2017 to indicate an annual ninety minute test was conducted over the past year. Based on an interview at the time of record review, the Director of Facilities Management indicated an annual ninety minute test was not conducted on the one hundred and sixteen battery backup lights in the facility. The lack of annual ninety minute testing on the one hundred sixteen battery backup lights was verified by the Director of Facilities Management at the time of record review and acknowledged at the exit conference on 02/16/17 at 11:45 a.m.

2. Based on observation and interview, the facility failed to ensure 2 of 116 battery backup lights were functioning properly when tested to ensure the light would provide lighting during periods of power outages. LSC 19.2.9.1 requires emergency lighting shall be provided in accordance with Section 7.9. Section 7.9.3.1.1 (1) requires functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, (3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered and (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect patients, staff and visitors on the fourth floor north.

Findings include:

Based on observations on 02/14/17 between 9:00 a.m. and 10:00 a.m. during a tour of the facility with the Supervisor of Facilities Management, the two battery backup light sets located on the fourth floor north Short Hall and Classroom did not illuminate when tested. This was verified by the Supervisor of Facilities Management at the time of observations and acknowledged by the Director of Facilities Management at the exit conference on 02/16/17 at 11:45 a.m.

Based on observation and interview, the facility failed to ensure 15 of 15 battery backup lights were tested monthly and annually for 90 minutes over the past year to ensure the light would provide lighting during periods of power outages, and a written record of visual inspections and tests was provided. LSC 39.2.9.1 requires emergency lighting shall be provided in accordance with Section 7.9. Section 7.9.3.1.1 (1) requires functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, (3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered and (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all residents in the facility.

Findings include:

Based on record review on 02/15/17 at 11:30 a.m. with the Maintenance Mechanic, the Battery Operated Emergency Light Test Log for 2016 - 2017 was not available for review. The lack of annual testing of the fifteen battery operated exit lights was verified by the Maintenance Mechanic at the time of the observation and acknowledged by the Director of Facilities Management at the exit conference on 02/16/17 at 11:45 a.m.

Based on observation and interview, the facility failed to ensure 1 of 7 first floor stairway exits was provided with an illuminated exit sign and 1 of 22 first floor exits was provided with illuminated exit signs indicating the directional path of travel. LSC 7.10.1.2.1 requires exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access. LSC 7.10.1.5.1 requires access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to all occupants. This deficient practice could affect any number of patients, staff and visitors in the facility.

Findings include:

Based on observations on 02/14/17 during a tour of the first floor from 8:15 a.m. to 4:10 p.m. with the Electrician, the CAT scan Hall by radiology had an illuminated exit sign with no left turn arrow cut out showing the direction of travel to the Main Hall exit and had another illumined exit sign within two feet showing the direction of travel leading in the opposite direction. Furthermore, the first floor stairway exit, which discharged from the Basement Lab Hall lacked an illuminated exit sign. This was verified by the Electrician at the time of observations and acknowledged by the Director of Facilities Management at the exit conference on 02/16/17 at 11:45 a.m.

Based on observation and interview, the facility failed to ensure the protection of 5 of 7 stairway in accordance of 19.3.1. LSC 19.3.1 requires vertical opening shall be enclosed or protected in accordance with Section 8.6. LSC 8.6.1 requires every floor that separates stories in a building shall be constructed as a smoke barrier. LSC 8.7.1.3 requires doors in barriers required to have a fire resistive rating shall have a minimum ¾ hour fire protection rating and be self-closing or automatic closing. This deficient practice could affect patients, staff, and visitors in the second, third, and fourth floors of the north building.

Findings include:

Based on observations on 02/14/17 between 8:15 a.m. and 4:20 p.m. during a tour of the facility with the Supervisor of Facilities Management, the following was noted:
a. The 4th floor north Stairwell B door did not have a fire resistive rating tag provided
b. The 4th floor Long Hall a Section Stairwell door did not have a fire resistive rating tag provided
c. The 3rd floor north Stairwell B door did not have a fire resistive rating tag provided
d. The 3rd floor Long Hall Stairwell door did not have a fire resistive rating tag provided
e. The 2nd floor north Stairwell B door did not have a fire resistive rating tag provided
Based on interview at the time of observations, the Supervisor of Facilities Management acknowledged the previously mentioned stairwell doors were not provided with fire resistive rating tags.

Based on observation and interview, the facility failed to ensure 7 of over 45 hazardous areas, such as a combustible storage room over 50 square feet, soiled linen rooms, and a boiler room, were either provided with self-closing device which would cause the doors to automatically close and latch into the door frames or provided with a room with smoke partitions. This deficient practice affects any number of patients and staff and visitors.

Findings include:

Based on observations on 02/13/17 and 02/14/17 during a tour of the facility with the electrician from 8:15 a.m. to 4:30 p.m., the first floor Wound Center Hall soiled linen room door, the first floor Radiology Hall soiled linen room door and the first floor Women's Health Hall soiled linen room door each failed to self-close and latch into the door frames, leaving a three quarter inch to one inch gap in the closed position. Furthermore, the first floor Hyperbaric Chamber Hall fifty two square foot nursing supply room, the first floor Emergency Room Hall one hundred forty four square foot storage room, and the first floor one hundred eight square foot gift shop storage room each lacked a self-closing device on the doors and the first floor Surgery Hall had four, six foot by five foot metal carts with plastic and paper surgery supplies in cardboard boxes stored in the corridor. Finally, based on observation on 02/13/17 at 1:24 p.m. during a tour of the facility with the Supervisor of Facilities Management, the basement boiler room tunnel door did not close completely when tested. There was a four inch gap between the door and door frame when closed fully. This was due to the door frame being damaged on the latching side of the door. This was verified by the Electrician and the Supervisor of Facilities Management at the time of observations and acknowledged by the Director of Facilities Management at the exit conference on 02/16/17 at 11:45 a.m.

Based on observation and interview, the facility failed to ensure 24 of 1010 fire alarm system smoke detectors were installed in accordance with 19.3.4.1. NFPA 72, 17.7.4.1 requires in spaces served by air handling systems, detectors shall not be located where air flow prevents operation of the detectors. A.17.7.4.1 states detectors should not be located in a direct airflow or closer than 36 inches. This deficient practice could affect any number of patients, staff and visitors.

Findings include:

Based on observations on 02/13/17 between 12:00 p.m. and 4:15 p.m., and 02/14/17 between 8:15 a.m. and 4:20 p.m. during separate tours of the facility with the Electrician and Supervisor of Facilities Management, the following fire alarm system hard wired smoke detectors were located within two feet of supply air duct vents, return air duct vents, and ceiling fans;
a. first floor Wound Center Hall smoke detector near the vending machines
b. first floor Wound Center Hall receptionist office
c. first floor Cat-scan Hall waiting room smoke detector
d. first floor Women's Health Hall waiting room smoke detector
e. fourth floor Inpatient Surgery Hall soiled linen room smoke detector
f. fourth floor Inpatient Surgery Hall medicine room smoke detector
g. fourth floor Inpatient Surgery Hall nutrition room smoke detector
h. basement Telecommunication Closet smoke detector
i. basement Environmental Supply Closet smoke detector
j. basement corridor outside the #12 elevator equipment room smoke detector
k. Penthouse north - two doctor's sleeping rooms within one foot of two separate ceiling fans
l. fourth floor north - smoke detector in corridor outside north elevators
m. fourth floor north soiled utility room smoke detector
n. fourth floor north - smoke detector in corridor outside elevators 5 and 6
o. fourth floor north Nursery smoke detector
p. fourth floor north - hallway near short hall, smoke detector at A section smoke barrier doors
q. third floor north - smoke detector in corridor outside elevators 5 and 6
r. third floor north - smoke detector in corridor outside elevator 8
s. third floor north - smoke detector in corridor outside elevators 1 and 2
t. third floor north - smoke detector in corridor outside Nutrition Room
u. second floor north - smoke detector in corridor outside elevators 5 and 6
v. second floor north - smoke detector in Dialysis Unit near Nurses' Station
w. fourth floor south - smoke detector in corridor outside elevators C and D
x. first floor north - outside volunteer services office
y. second floor north - outside the Progressive Care Unit entrance doors

This was verified by the Electrician and Supervisor of Facilities Management at the time of observations and acknowledged by the Director of Environmental Services at the exit conference on 02/16/17 at 11:45 a.m.

Based on record review and interview, the facility failed to ensure 1 of 1 fire alarm systems was maintained in accordance with 9.6.1.3. LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained in accordance with NFPA 72, National Fire Alarm Code. NFPA 72, 14.5 requires testing shall be performed in accordance with the Table 14.4.5 Testing Frequencies. NFPA 72, 14.4.5.3.1 states sensitivity shall be checked within 1 year after installation. NFPA 72, 14.4.5.3.2 states sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3. NFPA 72, 14.4.5.3.5 states smoke detectors or smoke alarms found to have a sensitivity range shall be cleaned and recalibrated or to be replaced. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Maintenance Mechanic on 02/15/17 at 11:42 a.m., the smoke detector sensitivity testing for the facilities fire alarm system was not available for review for the forty seven smoke detectors in the facility. Based on interview at the time of record review, the Maintenance Mechanic acknowledged the aforementioned testing documentation was not available for review. This was acknowledged by the Director of Facilities Management at the exit conference on 02/16/17 at 11:45 a.m.

Based on record review and interview, the facility failed to ensure 1 of 1 fire alarm systems was maintained in accordance with 9.6.1.3. LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained in accordance with NFPA 72, National Fire Alarm Code. NFPA 72, 14.5 requires testing shall be performed in accordance with the Table 14.4.5 Testing Frequencies. NFPA 72, 14.4.5.3.1 states sensitivity shall be checked within 1 year after installation. NFPA 72, 14.4.5.3.2 states sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3. NFPA 72, 14.4.5.3.5 states smoke detectors or smoke alarms found to have a sensitivity range shall be cleaned and recalibrated or to be replaced. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Maintenance Mechanic on 02/15/17 at 12:10 p.m., the smoke detector sensitivity testing for the facilities fire alarm system was not available for review for the twenty seven smoke detectors in the facility. Based on interview at the time of record review, the Maintenance Mechanic acknowledged the aforementioned testing documentation was not available for review. This was acknowledged by the Director of Facilities Management at the exit conference on 02/16/17 at 11:45 a.m.

Based on record review and interview, the facility failed to ensure 1 of 1 fire alarm systems was maintained in accordance with 9.6.1.3. LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained in accordance with NFPA 72, National Fire Alarm Code. NFPA 72, 14.5 requires testing shall be performed in accordance with the Table 14.4.5 Testing Frequencies. NFPA 72, 14.4.5.3.1 states sensitivity shall be checked within 1 year after installation. NFPA 72, 14.4.5.3.2 states sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3. NFPA 72, 14.4.5.3.5 states smoke detectors or smoke alarms found to have a sensitivity range shall be cleaned and recalibrated or to be replaced. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Maintenance Mechanic on 02/15/17 at 9:50 a.m., the smoke detector sensitivity testing for the facilities fire alarm system was not available for review for the twenty one smoke detectors in the facility. Based on interview at the time of record review, the Maintenance Mechanic acknowledged the aforementioned testing documentation was not available for review. This was acknowledged by the Director of Facilities Management at the exit conference on 02/16/17 at 11:45 a.m.

1. Based on observation and interview, the facility failed to provide an automatic sprinkler system which provided complete coverage in 1 of 1 basement elevator equipment room. NFPA 13, 8.15.5.3 states automatic sprinklers in elevator machine rooms shall be ordinary or intermediate temperature rating. ASME/ANSI A17.1 permits sprinklers in elevator machine rooms when there is a means for disconnecting the main line power supply to the affected elevator automatically upon or prior to the application of water from the sprinkler located in the elevator machine room. This deficient practice could affect mostly staff and visitors while in the basement when using the #12 elevator.

Findings include:

Based on observation on 02/13/17 at 3:33 p.m. during a tour of the facility with the Supervisor of Facilities Management, the elevator equipment room for #12 elevator in the basement was not provided with sprinkler coverage. This was verified by the Supervisor of Facilities Management at the time of observation and acknowledged by the Director of Environmental Services at the exit conference on 02/16/17 at 11:45 a.m.

2. Based on observation and interview, the facility failed to ensure the spray pattern for sprinkler heads were not obstructed in 1 of 1 sump pit room in accordance with 19.3.5.1. NFPA 13, 2010 edition, Section 8.5.5.1 states sprinklers shall be located so as to minimize obstructions to discharge as defined in 8.5.5.2 and 8.5.5.3 or additional sprinklers shall be provided to ensure adequate coverage of the hazard. Sections 8.5.5.2 and 8.5.5.3 do not permit continuous or noncontinuous obstructions less than or equal to 18 inches below the sprinkler deflector or in a horizontal plane more than 18 inches below the sprinkler deflector that prevent the spray pattern from fully developing. This deficient practice could affect staff only.

Findings include:

Based on observation with the Maintenance Director on 02/13/17 at 3:33 p.m., the sump pit room in the basement located near elevator 12 had two sprinklers that were within 48 inches of each other. The Maintenance Director verified the sprinkler heads and provided the measurement listed at the time of observation. This was acknowledged by the Director of Facilities Management at the exit conference on 02/16/17 at 11:45 a.m.

Based on observation and interview, the facility failed to provide sprinkler coverage for 1 of 1 exterior canopies which was wider than 4 feet. NFPA 13, 2010 Edition, Section 8-15.7.2 states sprinklers shall be permitted to be omitted where the exterior roofs, canopies, balconies. Decks, or similar projections exceeding 4 feet in width, are noncombustible, limited combustible, or fire retardant-treated wood as defined in NFPA 703, Standards for Fire Retardant-Treated Wood and Fire-Retardant Coatings for Building Materials. This deficient practice could affect residents, staff and visitors using the main entrance.

Findings include:

Based on observation with the Maintenance Director on 11/07/2016 at 11:50 a.m., a canopy of canvas construction over a metal frame outside the main entrance was not provided with sprinkler protection. The canopy was attached to the building and extended over 30 feet from the building. Based on interview with the Maintenance Director at the time of the observation, and again at the exit conference, the facility did not have documentation available for review to verify the canopy material was inherently flame retardant and was not provided with sprinkler coverage. This was acknowledged by the Director of Facilities Management at the exit conference on 02/16/17 at 11:45 a.m.

1. Based on record review and interview, the facility failed to provide written documentation or other evidence the sprinkler system components had been inspected and tested for 1 of 4 quarters. NFPA 25, 4.3.1 requires records shall be made for all inspections, tests, and maintenance of the system components and shall be made available to the authority having jurisdiction upon request. 4.3.2 requires that records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date. NFPA 25, 5.2.5 requires that waterflow alarm devices shall be inspected quarterly to verify they are free of physical damage. NFPA 25, 5.3.3.1 requires the mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly. 5.3.3.2 requires vane-type and pressure switch-type waterflow alarm devices shall be tested semiannually. This deficient practice could affect patients in the facility.

Findings include:

Based on record review with the Director of Facilities Management on 02/13/17 at 1:15 p.m., the Ryan Fire Protection Inc. Reports of quarterly sprinkler inspection reports, the documentation provided for review indicated the following quarterly sprinkler inspection dates; 10/11/16, 06/15/16, 03/15/16 and 12/30/15. Furthermore, when asked if a first quarter sprinkler inspection was conducted for the year 2016, the Director of Facilities Management indicated there was no written documentation available to show the sprinkler system had been inspected during the first quarter of the year 2016. This was acknowledged by the Director of Facilities Management at the exit conference on 02/16/17 at 11:45 a.m.

2. Based on record review, observation and interview, the facility failed to document monthly sprinkler system inspections in accordance with NFPA 25. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.4.1 states gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained. Section 5.1.2 states valves and fire department connections shall be inspected, tested, and maintained in accordance with Chapter 13. Section 13.3.2.1.1 states valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly. This deficient practice could affect all patients in the facility.

Findings include:

Based on record review with the Director of Facilities Management on 02/13/17 at 1:15 p.m., the Ryan Fire Protection Inc. Reports of quarterly sprinkler inspections dated 10/11/16, 06/15/16, 03/15/16 and 12/30/15 indicated the basement sprinkler riser room twelve sprinkler gauges, six sprinkler system control valves and the outside front entrance fire department connection were visually inspected during each quarterly inspection. Based on an interview with the Director of Facilities Management on 02/13/17 at 1:35 p.m., it was indicated the facility does not perform monthly inspections on the twelve sprinkler system gauges, six control valves and the fire department connection. They are visually inspected during the quarterly sprinkler inspections. The lack of monthly sprinkler system gauge, control valve, and fire department connection inspections was acknowledged by the Director of Facilities Management at the exit conference on 02/16/17 at 11:45 a.m.

3. Based on observation and interview, the facility failed to ensure 5 of 5 private fire hydrants were continuously maintained in reliable operating condition and inspected and tested periodically. NFPA 25, 2011 Edition, the Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, Table 7.1.1.2 requires wet or dry barrel hydrants to be inspected annually and after each operation. This deficient practice could affect all patients in the facility.

Findings include:

Based on observation on 02/14/17 during a tour of the first floor with the electrician, the facility had five private dry fire hydrants located around the outside parking lot. Based on an interview with the Director of Facilities Management on 02/14/17 at 4:10 p.m., there is no documentation of an annual inspection for the five fire hydrants. The lack of an annual inspection for the five dry fire hydrants was acknowledged by the Director of Facilities Management at the exit conference on 02/16/17 at 11:45 a.m.

4. Based on observation and interview, the facility failed to ensure the ceiling in 2 of 10 sprinklered basement smoke compartments and 1 of 8 sprinklered second floor north smoke compartments was maintained to allow sprinkler heads to function to their full capability. This deficient practice could affect staff in the basement, and patients, staff and visitors on the second floor north building.

Findings include:

Based on observations on 02/13/17 between 12:00 p.m. and 4:15 p.m. and on 02/14/17 between 8:15 p.m. and 4:20 p.m. during a tour of the facility with the Supervisor of Facilities Management, the following was noted:
a. The drop ceiling in the corridor between the facility shop and the Bio Med Rooms was not complete. There was a fourteen inch gap on each side of the corridor without ceiling tiles. The corridor was approximately 75 feet long. Furthermore, there was no sprinkler coverage above the ceiling tiles with approximately 4 feet of interstitial space to the concrete deck above.
b. The "Coke in the Box Room", in the basement, had three ceiling tiles missing
c. The Telecom Room, in the basement, had five ceiling tiles missing
d. The IS room in the second floor north Dialysis Unit had three ceiling tiles missing
This was verified by the Supervisor of Facilities Management at the time of observations and acknowledged by the Director of Environmental Services at the exit conference on 02/16/17 at 11:45 a.m.

Based on record review and interview, the facility failed to provide written documentation or other evidence the sprinkler system components had been inspected and tested for 3 of 4 quarters. LSC 4.6.12.1 requires any device, equipment or system required for compliance with this Code be maintained in accordance with applicable NFPA requirements. Sprinkler systems shall be properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 4.3.1 requires records shall be made for all inspections, tests, and maintenance of the system components and shall be made available to the authority having jurisdiction upon request. 4.3.2 requires that records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date. NFPA 25, 5.2.5 requires that waterflow alarm devices shall be inspected quarterly to verify they are free of physical damage. NFPA 25, 5.3.3.1 requires the mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly. 5.3.3.2 requires vane-type and pressure switch-type waterflow alarm devices shall be tested semiannually. This deficient practice could affect all patients, staff, and visitors in the facility.

Findings include:

Based on review of the sprinkler system inspection records on 02/15/17 at 12:45 p.m. with the Maintenance Mechanic present, there were no quarterly sprinkler system inspection reports available for review for 2016 - 2017. During an interview at the time of record review, the Maintenance Mechanic acknowledged that only an annual inspection of the sprinkler system was being performed. This was acknowledged by the Director of Facilities Management at the exit conference on 02/16/17 at 11:45 a.m.

Based on record review and interview, the facility failed to provide written documentation or other evidence the sprinkler system components had been inspected and tested for 3 of 4 quarters. LSC 4.6.12.3 requires existing life safety features obvious to the public if not required by the Code, shall be either maintained or removed. Sprinkler systems shall be properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 4.3.1 requires records shall be made for all inspections, tests, and maintenance of the system components and shall be made available to the authority having jurisdiction upon request. 4.3.2 requires that records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date. NFPA 25, 5.2.5 requires that waterflow alarm devices shall be inspected quarterly to verify they are free of physical damage. NFPA 25, 5.3.3.1 requires the mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly. 5.3.3.2 requires vane-type and pressure switch-type waterflow alarm devices shall be tested semiannually. This deficient practice could affect all patients, staff, and visitors in the facility.

Findings include:

Based on review of the sprinkler system inspection records on 02/15/17 at 11:50 a.m. with the Maintenance Mechanic present, there were no quarterly sprinkler system inspection reports available for review for 2016 - 2017. During an interview at the time of record review, the Maintenance Mechanic acknowledged that only an annual inspection of the sprinkler system was being performed. This was acknowledged by the Director of Facilities Management at the exit conference on 02/16/17 at 11:45 a.m.

Based on observation and interview, the facility failed to inspect 3 of 3 portable fire extinguishers each month. LSC 39.3.5 states portable fire extinguishers shall be provided in every business occupancy in accordance with LSC 9.7.4.1. LSC 9.7.4.1 states portable fire extinguishers shall be selected, installed, inspected and maintained in accordance with NFPA 10. NFPA 10, Standard for Portable Fire Extinguishers, Section 7.2.1.2 states fire extinguishers shall be inspected either manually or by means of an electronic device / system at a minimum of 30-day intervals. Section 7.2.2 states periodic inspection or electronic monitoring of fire extinguishers shall include a check of at least the following items:
(1) Location in designated place
(2) No obstruction to access or visibility
(3) Pressure gauge reading or indicator in the operable range or position
(4) Fullness determined by weighing or hefting for self-expelling type extinguishers, cartridge-operated extinguishers, and pump tanks
(5) Condition of tires, wheels, carriage, hose, and nozzle for wheeled extinguishers
(6) Indicator for non-rechargeable extinguishers using push to-test pressure indicators.
Section 7.2.4.1 states personnel making manual inspections shall keep records of all fire extinguishers inspected, including those found to require corrective action. Section 7.2.4.3 requires where at least monthly manual inspections are conducted, the date the manual inspection was performed and the initials of the person performing the inspection shall be recorded. Section 7.2.4.4 requires where manual inspections are conducted, records for manual inspections shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or by an electronic method. Section 7.2.4.5 requires records shall be kept to demonstrate that at least the last 12 monthly inspections have been performed. This deficient practice could affect up to 9 patients, as well as staff and visitors within the facility.

Findings include:

Based on an observation with the Maintenance Mechanic on 12/14/17 at 10:37 a.m., the monthly inspection tag on the fire extinguishers located in the main lobby, in the center hallway, and at the employee entrance were missing their January 2017 monthly check. This was verified by the Maintenance Mechanic at the time of observations and acknowledged by the Director of Facilities Management at the exit conference on 02/16/17 at 11:45 a.m.

Based on observation and interview, the facility failed to ensure 13 of over 100 sets of doors to the corridor were equipped with either positive latches or latched into the door frame. This deficient practice could affect staff in the basement and 1 patient in room 4120.

Findings include:

Based on observations on 02/12/17 and 02/13/17 between 9:30 a.m. and 5:00 p.m. during tours of the facility with the Electrician and Supervisor of Facilities Management, the following sets of corridor doors were either not provided with positive latching hardware or failed to latch into the door frames;
a) basement doors leading into biomed
b) basement doors leading into the 04 mechanical room
c) basement doors leading into the supply room / purchasing
d) basement doors leading into the tele-com room
e) basement doors leading into the print shop
f) basement doors leading into the surgical supply room
g) basement doors leading into the environmental services storage closet
h) basement doors leading into the lower level mechanical room
i) basement doors leading into the break out room
j) basement doors leading into the facilities shop
k) doors to the C3 storage room
l) fourth floor patient room 4120
m) basement small leaf double door set in the maintenance shop
All aforementioned doors were acknowledged by the Supervisor of Facilities Management at the time of each observation and acknowledged by the Director of Facilities Management at the exit conference on 02/16/17 at 11:45 a.m.

Based on observation and interview, the facility failed to ensure the penetrations caused by the passage of wire and/or conduit or missing drywall through 17 of 36 first floor smoke barrier walls were protected to maintain the smoke resistance of each smoke barrier. LSC Section 19.3.7.5 requires smoke barriers to be constructed in accordance with LSC Section 8.5 and shall have a minimum ½ hour fire resistive rating. This deficient practice could affect any number of patients, staff and visitors.

Findings include:

Based on observations with the Electrician on 02/14/17 during a tour of the first floor smoke barrier walls above the drop ceiling assembly from 8:30 a.m. to 1:45 p.m., the following first floor smoke barrier walls above the drop ceiling assembly had unsealed penetrations or missing drywall:
a) The Radiology Waiting room to Main Hall smoke barrier wall had two electrical conduit penetrations and one cable bundle penetration with one half inch gaps around each penetration not fire stopped.
b) The CAT scan Hall smoke barrier wall by the waiting room had three, one half inch gaps around electrical conduit penetrations not fire stopped.
c) The X-Ray Hall smoke barrier wall by the ultrasound room had four, one half inch gaps around electrical conduit and copper water pipe penetrations not fire stopped.
d) The Hyperbaric Hall smoke barrier wall had three, one half inch open electrical conduit pipes open with no fire stopping.
e) The Wound Center Entrance Hall smoke barrier wall had a one inch circular area of drywall missing in the center of the smoke barrier wall.
f) The Magnetic Imaging Resonator Hall smoke barrier wall had a twelve inch by eight inch rectangular area of drywall missing, a six inch by six inch square area of drywall missing, and four, one half inch gaps around electrical conduit penetrations not fire stopped.
g) The Emergency Room Hall to radiology smoke barrier wall had a one half inch open electrical conduit with no fire stopping.
h) The Emergency Room Hall smoke barrier wall to fastback had a one half inch gap around an electrical conduit penetration not fire stopped.
i) The Emergency Room Hall Main Entrance smoke barrier wall had one half inch gap around an electrical conduit penetration not fire stopped.
j) The Endoscopy Hall smoke barrier wall had a twelve inch by eight inch rectangular area of drywall missing a six inch by six inch square area of drywall missing, and a one half inch gap around a square metal heating duct not fire stopped.
k) The Administration Hall smoke barrier wall to the Education Hall had a one inch gap around a cable bundle not fire stopped.
l) The Cafeteria Hall smoke barrier wall had a three inch gap around a cable bundle penetration not fire stopped.
m) The Surgery Rapid Eye Movement Hall smoke barrier wall had two, one foot by six inch areas filled with fiberglass insulation and a one half inch gap around a cable bundle penetration not fire stopped.
n) The Rear Surgery South Hall smoke barrier wall had a one foot by one foot area of drywall missing.
o) The Catheter Laboratory Hall smoke barrier wall had a two inch circular area of drywall missing.
p) The Cardiac Hall smoke barrier wall had a one half inch open conduit not fire stopped.
q) The Cardiac Waiting Room Hall smoke barrier wall had three copper water penetrations with a one half inch gap around each penetration not fire stopped.
This was verified by the Electrician at the time of observations and acknowledged by the Director of Facilities Management at the exit conference on 02/16/17 at 11:45 a.m.

1. Based on observation and interview, the facility failed to ensure 3 of 8 second floor sets of smoke barrier doors would restrict the movement of smoke for at least 20 minutes. LSC, Section 19.3.7.8 requires that doors in smoke barriers shall comply with LSC, Section 8.5.4. LSC, Section 8.5.4.1 requires doors in smoke barriers to close the opening leaving only the minimum clearance necessary for proper operation which is defined as 1/8 inch to restrict the movement of smoke. This deficient practice affects patients, as well as staff and visitors on the second floor north building.

Findings include:

Based on observations on 02/14/17 between 11:00 a.m. and 12:00 p.m. during a tour of the facility with the Supervisor of Facilities Management, the following was noted:
a. The smoke barrier doors on the second floor north building near the staff kitchen had a 1/4 inch gap between the doors when closed
b. The smoke barrier doors on the second floor north building to the Pedway connector had a 1/4 inch gap between the doors when closed.
This was verified by the Supervisor of Facilities Management at the time of observations and acknowledged by the Director of Environmental Services at the exit conference on 02/16/17 at 11:45 a.m.

2. Based on observation and interview, the facility failed to ensure 1 of 1 sets of smoke barrier doors on the second floor north building which swing in the same direction were equipped with the appropriate hardware to allow the door which must close first, always close first so both doors always close completely. Smoke barrier doors equipped with an astragal are required to have a coordinator to ensure the door which must close first always closes first. This deficient practice could affect patients, as well as staff and visitors on the second floor north building.

Findings include:

Based on observation on 02/14/17 at 11:32 a.m. during a tour of the facility with the Supervisor of Facilities Management, the set of smoke barrier doors on the second floor north building between the NHU and PCU connector swung in the same direction and were equipped with a rubber astragal on one of the doors. These smoke barrier doors lacked a coordinator to allow the astragal side to close second. When tested, these doors did not close in the correct sequence. This was verified by the Supervisor of Facilities Management at the time of observation and was acknowledged by the Director of Facilities Management at the exit conference on 02/16/17 at 11:45 a.m.

1. Based on observation and interview, the facility failed to ensure 1 of 1 sink area in the employee entrance break room and 9 of 9 sinks located in treatment rooms 1 through 9 were not provided with a ground fault circuit interrupter (GFCI) protection against electric shock. LSC sections 9.1.2 requires all electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code. NFPA 70, Article 210.8 Ground-Fault Circuit-Interrupter Protection for Personnel, in 210.8(A), Dwelling Units, requires ground-fault circuit-interrupter (GFCI) protection for all personnel in bathrooms and kitchens where the receptacles are intended to serve the countertop surfaces. (7) Sinks - Located in areas other than kitchens where receptacles are installed within 1.8 m. (6 ft.) of the outside edge of the sink. This deficient practice affects up to 8 patients and 8 staff.

Findings include:

Based on observation with the Maintenance Mechanic on 02/14/17 at 10:31 a.m., the employee entrance sink was approximately forty-two inches from the sink and the outlet nearest the sink was not a GFCI protected outlet. There were also sinks in each treatment room, numbered 1 through 9, that had sinks with non GFCI protected outlets all well within six feet of the sinks water source. When tested, these outlets did not pop a circuit breaker in a nearby circuit box. When asked if the outlets was GFCI protected, the Maintenance Mechanic advised that they were not. This was acknowledged by the Director of Facilities Management at the exit conference on 02/16/17 at 11:45 a.m.

2. Based on observation and interview, the facility failed to ensure 1 of 1 multiplug was not used as a substitute for fixed wiring according to 33.2.5.1. LSC 33.2.5.1 states utilities shall comply with Section 9.1. LSC 9.1.2 requires electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code. NFPA 70, 2011 Edition, Article 400.8 requires that, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice affects staff and up to 9 patients, as well as staff and visitors within the facility.

Findings include:

Based on observation with the Maintenance Mechanic on 12/14/17 at 11:40 a.m. a multiplug was discovered in the back storage room. Based on interview at the time of each observation, the Maintenance Mechanic acknowledged the aforementioned condition, and immediately removed the multiplug from use.

Based on observation and interview, the facility failed to ensure there were ground-fault circuit interrupters (GFCI) for 1 of over 100 patient wet locations. This deficient practice could affect any patients in the CAT scan room.

Findings include:

Based on observation on 02/14/17 at 1:55 p.m. with the Electrician, the CAT scan Room handwash sink had an electric outlet within two feet of the handwash basin and was not provided with a ground-fault circuit interrupter. Based on observation of the electric panels on the CAT scan Hall with the Electrician on 02/14/17 at 2:10 p.m., there were no ground fault circuit interrupter breaker in the electric panel for the CAT scan room. The lack of a ground-fault circuit interrupter provided for the CAT scan Room handwash basin was verified by the Electrician at the time of observation and acknowledged by the Director of Facilities Management at the exit conference on 02/16/17 at 11:45 a.m.

Based on observation and interview, the facility failed to ensure 8 of 8 elevators in the north building were provided with sprinkler coverage at the top of the elevators hoistway. NFPA 13, 2010 edition, at 8.15.5.4 states upright, pendent, or sidewall spray sprinklers shall be installed at the top of elevator hoistways. 8.15.5.5 The sprinkler required at the top of the elevator hoistway by 8.15.5.4 shall not be required where the hoistway for passenger elevators is noncombustible or limited-combustible and the car enclosure materials meet the requirements of ASME A17.1, Safety Code for Elevators and Escalators. A.8.15.5.4 Passenger elevator cars that have been constructed in accordance with ASME A17.1, Safety Code for Elevators and Escalators, Rule 204.2a (under A17.1a-1985 and later editions of the code) have limited combustibility. Materials exposed to the interior of the car and the hoistway, in their end-use composition, are limited to a flame spread index of 0 to 75 and a smoke developed index of 0 to 450, when tested in accordance with ASTM E 84, Standard Test Method of Surface Burning Characteristics of Building Materials. This deficient practice could affect any patient, staff, or visitor while using any of the facility's elevators.

Findings include:

Based on observation on 02/14/17 between 8:15 a.m. and 4:20 p.m. during a tour of the facility with the Supervisor of Facilities Management, all elevators in the north building were not provided with sprinkler coverage at the top of each elevators hoistway. This was verified by the Supervisor of Facilities Management at the time of observations and acknowledged by the Director of Environmental Services at the exit conference on 02/16/17 at 11:45 a.m.

1. Based on observation and interview, the facility failed to ensure 2 of 4 soiled linen chute doors were self-closing and smoke resistant. This deficient practice could affect patients, as well as staff and visitors while on the second and fourth floors.

Findings include:

Based on observations on 02/14/17 between 8:15 a.m. and 4:20 p.m. during a tour of the facility with the Supervisor of Facilities Management, the fourth floor north building soiled linen chute door did not close completely when tested. There was a two inch gap between the door and its frame. Furthermore, the second floor north building soiled linen chute door was provided with a self-closing device, however, it was not connected and the door stayed wide open when tested. This was verified by the Supervisor of Facilities Management at the time of observations and acknowledged by the Director of Environmental Services at the exit conference on 02/16/17 at 11:45 a.m.

2. Based on observation and interview, the facility failed to ensure 1 of 1 soiled linen chute in the south building was provided with automatic extinguishing protection. This deficient practice could affect patients, staff, and visitors in the facility.

Findings include:

Based on observation on 02/14/17 at 2:15 p.m. during a tour of the facility with the Supervisor of Facilities Management, the soiled linen chute in the south building was not provided with a sprinkler head or any other automatic extinguishing system at the top of the chute. This was verified by the Supervisor of Facilities Management at the time of observation and acknowledged by the Director of Environmental Services at the exit conference on 02/16/17 at 11:45 a.m.

Based on observation and interview, the facility failed to ensure 8 of 8 elevators in the north building were provided with sprinkler coverage at the top of the elevators hoistway. NFPA 13, 2010 edition, at 8.15.5.4 states upright, pendent, or sidewall spray sprinklers shall be installed at the top of elevator hoistways. 8.15.5.5 The sprinkler required at the top of the elevator hoistway by 8.15.5.4 shall not be required where the hoistway for passenger elevators is noncombustible or limited-combustible and the car enclosure materials meet the requirements of ASME A17.1, Safety Code for Elevators and Escalators. A.8.15.5.4 Passenger elevator cars that have been constructed in accordance with ASME A17.1, Safety Code for Elevators and Escalators, Rule 204.2a (under A17.1a-1985 and later editions of the code) have limited combustibility. Materials exposed to the interior of the car and the hoistway, in their end-use composition, are limited to a flame spread index of 0 to 75 and a smoke developed index of 0 to 450, when tested in accordance with ASTM E 84, Standard Test Method of Surface Burning Characteristics of Building Materials. This deficient practice could affect any patient, staff, or visitor while using any of the facility's elevators.

Findings include:

Based on observation on 02/14/17 between 8:15 a.m. and 4:20 p.m. during a tour of the facility with the Supervisor of Facilities Management, all elevators in the north building were not provided with sprinkler coverage at the top of each elevators hoistway. This was verified by the Supervisor of Facilities Management at the time of observations and acknowledged by the Director of Environmental Services at the exit conference on 02/16/17 at 11:45 a.m.

Based on record review and interview, the facility failed to provide 1 of 1 written emergency fire safety plan that incorporated all items listed in NFPA 101, Section 19.7.2.2.
1. Use of alarms.
2. Transmission of alarms to fire department.
3. Emergency phone call to fire department
4. Response to alarms.
5. Isolation of fire.
6. Evacuation of immediate area.
7. Evacuation of smoke compartment.
8. Preparation of floors and building for evacuation.
9. Extinguishment of fire.
This deficient practice affects all residents, staff and visitors in the event of an emergency.

Findings include:

Based on record review on 02/13/17 at 12:00 p.m. with the Director of Facilities Management, the facility's fire safety plan labeled Emergency Operations Plan lacked the use of the fire alarm system by staff and patients, the transmission of the alarms to the fire department, the emergency phone call to the fire department, staff response to alarms, isolation of fire, evacuation of the immediate area, evacuation of smoke compartments, preparation of floors and building for evacuation, and extinguishment of fire including kitchen staff use of the K Class fire extinguisher in relationship to the overhead hood extinguishing system. This was verified by the Director of Facilities Management at the time of record review and acknowledged by the Director of Facilities Management at exit conference on 02/16/17 at 11:45 a.m.

Based on record review and interview, the facility failed to ensure 4 of 12 fire drills included the verification of transmission of the fire alarm signal to the monitoring station in fire drills conducted between 6:00 a.m. and 9:00 p.m. for the last 4 quarters. LSC 19.7.1.4 requires fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. This deficient practice affects all patients, staff and visitors.

Findings include:

Based on record review with the Director of Facilities Management on 02/13/17 at 2:10 p.m., the Fire Drill Reports conducted on third shift on 01/27/16 at 11:39 p.m., 04/24/16 at 11:33 p.m., 07/27/16 at 2:38 a.m., and 10/26/16 at 4:00 a.m. lacked documentation to indicate transmission of fire alarm signal was received by the security monitoring company. Based on an interview at the time of record review, the Director of Facilities Management indicated third shift fire drills do not activate the fire alarm system and the fire alarm system is not activated the day after third shift silent drills are conducted. This was acknowledged by the Director of Facilities Management at the exit conference on 02/16/17 at 11:45 a.m.

Based on record review, observation and interview, the facility failed to ensure 3 of 3 rooms where space heaters were used were equipped with a heating element which would not exceed 212 degrees Fahrenheit (F) in accordance with 19.7.8. LSC 19.7.8 requires portable space-heating elements do not exceed 212 degrees. This deficient practice could affect any number of patients, staff and visitors.

Findings include:

Based on observations on 02/13/17 during a tour of the basement from 12:30 p.m. to 4:30 p.m. with the Director of Maintenance and on 02/14/17 during a tour of the first floor from 8:15 a.m. to 4:10 p.m., the basement pharmacy, the first floor Security Office, and the first floor Wound Center Program Manager office each had an electric space heater in use. Furthermore, based on observation of the attached manufacture label on each space heater with the Director of Maintenance and Electrician on 02/14/17 from 2:20 p.m. to 2:45 p.m., the space heaters lacked documentation of the temperature rating of the heating element. Furthermore, based on an interview with the Director of Facilities Management on 02/14/17 at 4:00 p.m., the facility provided Space Heater Policy indicated space heaters were allowed in staff rooms only but the Director of Facilities Management failed to provide documentation on the temperature rating of heating elements for the space heaters in use. This was acknowledged by the Director of Facilities Management at the exit conference on 02/16/17 at 11:45 a.m.

Based on record review and interview, the facility failed to maintain a complete written record of monthly generator load testing for 12 of the last 12 months. NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, Chapter 8.4.2 requires diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods: (1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer (2) Under operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on record review with the Director of Facilities Management on 02/13/17 at 1:50 p.m., the Monthly Generator Log tests for the past year indicated a thirty minute monthly test over the past year. Furthermore, there was no indication of a percent of load or operating temperatures on the Monthly Generator Log over the past year. Based on an interview at the time of record review, the Director of Facilities Management stated neither the percent of load nor the operating temperature were recorded on the Monthly Generator Log. This was acknowledged by the Director of Facilities Management at the exit conference on 02/16/17 at 11:45 a.m.

Based on observation and interview, the facility failed to ensure power strips and extension cords were not used as a substitute for fixed wiring in 6 of over 30 smoke compartments. LSC 19.5.1.1 requires utilities to comply with Section 9.1. LSC 9.1.2 requires electrical wiring and equipment to comply with NFPA 70, National Electrical Code. NFPA 70, Article 400-8 requires, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice could affect mostly staff throughout the facility.

Findings include:

Based on observations on 02/13/17 between 12:00 p.m. and 4:14 p.m., and 02/14/17 between 8:15 a.m. and 4:20 p.m. during a tour of the facility with the Supervisor of Facilities Management, the following was noted:
a. The Bio Med Breakroom had a toaster oven and microwave plugged into a power strip
b. The Laundry room Breakroom had a microwave and refrigerator plugged into a power strip
c. The fourth floor north building Employee Lounge had a microwave plugged into a power strip
d. The third floor north building Hospitalist Office had a microwave and refrigerator plugged into a power strip
e. The third floor north building PICC room had a microwave and refrigerator plugged into a power strip
f. The second floor north building Director of Cardiology Office had a microwave and refrigerator plugged into a power strip
g. The second floor north building Employee Breakroom had a microwave plugged into a power strip
h. The second floor north building 2C Med Room had a refrigerator plugged into an extension cord
i. The second floor north building Dialysis Unit kitchen/med room had a microwave and refrigerator plugged into a power strip
This was verified by the Supervisor of Facilities Management at the time of observations and acknowledged by the Director of Environmental Services at the exit conference on 02/16/17 at 11:45 a.m.

Based on observation and interview, the facility failed to ensure 4 of 4 cylinders of nonflammable gases such as oxygen were properly secured from falling. NFPA 99, Health Care Facilities Code, 2012 Edition, Section 11.3.2 states storage for nonflammable gases greater than 8.5 cubic meters (300 cubic feet) but less than 85 cubic meters (3000 cubic feet) shall comply with 11.3.2.1 through 11.3.2.3. NFPA 99, Section 11.3.2.6 states cylinder or container restraints shall comply with 11.6.2.3. Section 11.6.2.3(11) states freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart. This deficient practice could affect patients, staff and visitors while in the Dialysis Unit.

Findings include:

Based on observation on 02/14/17 at 11:52 a.m. during a tour of the facility with the Supervisor of Facilities Management, four 'E' type oxygen cylinders were standing upright on the floor of Room 211 in the Dialysis Unit and were not properly chained or supported in a proper cylinder stand or cart. This was verified by the Supervisor of Facilities Management at the time of observation and acknowledged by the Director of Environmental Services at the exit conference on 02/16/17 at 11:45 a.m.