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Based on observations, the facility failed to ensure that vertical openings between floors were sealed and/or enclosed by fire resistive construction. The deficiency could affect one of three smoke compartments on the main level.

The findings include:

In accordance with Section 18.3.1.1 of NFPA 101, 2000 Edition, any vertical opening shall be enclosed or protected in accordance with 8.2.5.
Secondly, Section 8.2.5.4 states that the fire resistance rating for the enclosure of floor openings shall be not less than as follows (see 7.1.3.2.1 for enclosure of exits):
(1) Enclosures connecting four stories or more in new construction - 2-hour fire barriers
(2) Other enclosures in new construction - 1-hour fire barriers
(3) Existing enclosures in existing buildings - 1/2-hour fire barriers
(4) As specified in Chapter 26 for lodging and rooming houses, in Chapter 28 for new hotels, and in Chapter 30 for new apartment buildings

The Information Technology (IT) closet 1545 a and b was observed at 2:20 p.m. on 3/10/14. Two, four inch conduits, which had been poured into the concrete between the two levels of the building, were not sealed where IT cables extended through the conduit.

Based on observations and an interview, the facility failed to maintain the fire resistance rating of smoke barriers. The deficiency could affect two of three smoke compartments on the main level.

The findings include:

In accordance with Section 8.3.6.1 of NFPA 101, 2000 Edition; pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service 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.

1. The communication closet 1545, with two sets of double doors on the main level, was observed at 2:20 p.m. on 3/10/14. There were five conduits through the floor which were not sealed. An interview with maintenance staff confirmed that the conduits did extend to and from other smoke compartments.

2. The communication closet 1627, near the chapel on the main floor, was observed at 4:20 p.m. on 3/10/14. There were eight conduits in the floor which were not sealed and contained IT wiring. An interview with maintenance staff confirmed that the conduits did extend to and from other smoke compartments.

Based on staff interview and record review, the facility failed to maintain the battery-powered emergency lights in the generator transfer switch room. This deficiency could affect a limited number of patients, staff and visitors in the building.

Findings include:

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

Records for the emergency lighting were reviewed at 11:30 a.m. on 3/10/14. There were no weekly or annual testing being done by maintenance staff on the battery pack emergency lighting fixtures at the generator or the transfer switch locations.

Interview with maintenance staff concluded that they did not know about the requirement and did not have a preventive maintenance (PM) assignment for the job.

Based on review of the fire drill reports, the facility failed to assure that fire drills were held on each shift at least quarterly. This deficiency affects all the patients in all smoke compartments.


The findings include:

The fire drill reports were reviewed at the facility on 3/10/14. The facility has two shifts and fire drills affect response of the staff for a fire anywhere in the building. The shift hours are 7 a.m. to 7 p.m. (day shift); and 7 p.m. to 7 a.m. (night shift). No documentation was available that during the fourth quarter of 2013 (October, November & December) fire drills were held on the night shift.

Based on observation and staff interview, the facility failed to ensure complete sprinkler coverage. This deficiency has the potential to affect more than a very limited number of patients, staff, and visitors.

Findings include:

In accordance with NFPA 101 and Section 18.3.5.1, where required by 18.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.6. There is an automatic sprinkler system, installed in accordance with NFPA 13 (1999 Edition), Standard for the Installation of Sprinkler Systems, with approved components, devices, and equipment, to provide complete coverage of all portions of the facility.

The dining room adjacent to the main kitchen was observed at 3:20 p.m. on 3/10/14. There was an alcove where the pop machines were tucked into which was not sprinkled. The space measured three feet in depth by eleven feet three inches in length by six feet in height. The main ceiling for the kitchen was ten feet in height with ceiling mounted sprinklers. The closest sprinkler head was nine feet away from the alcove. There was light fixtures which hung from the ceiling which limited the spray pattern for the ceiling mounted sprinkler system, these fixtures were approximately five feet across and circular in design. One was placed near the sprinkler head which could cover the non sprinkled alcove area. By design no water could get to the alcove area where the three machines had been placed.

Interview with maintenance staff at this same time concluded that the space above the pop machines was missed by the designer and sprinkler installer.

Based on surveyor observations and staff interview, the facility failed to maintain the sprinkler system and all its components in accordance with the standards of NFPA 13, 1999 Edition. The deficiency could affect all patients, staff, and visitors in all smoke compartments for the building.

Findings include:

In accordance with NFPA 25, inspections for quarterly, semi-annual and annual requirement shall be maintained as required under Tables 2-1 and 9-1.

1. The quarterly sprinkler inspection reports were reviewed at 11:30 a.m. on 3/10/14. There was no annual inspection identified as all four reports were marked on the forms as quarterly inspections by the sprinkler contractor.

Interview with maintenance staff at this same time concluded that he had not requested an annual to be done in the contractual agreement.

2. The reports for the fire pump were reviewed at 11:30 a.m. on 3/10/14. There was no annual performed on the fire pump.

Interview with maintenance staff at this same time concluded that he had not requested an annual to be done in the contractual agreement for the fire pump.

Based on record review, the facility failed to perform semi-annual cleaning of the hood system in the kitchen. The deficiency could affect all patients, staff, and visitors.

Findings include:

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

Type or Volume of Cooking Frequency Frequency
Systems serving solid fuel cooking operations Monthly
Systems serving high-volume cooking operations
such as 24-hour cooking, charbroiling or wok cooking Quarterly
Systems serving moderate-volume cooking operations Semiannually
Systems serving low-volume cooking operations, such
as churches, day camps, seasonal businesses, or senior
centers Annually

Record review was completed for the kitchen hood inspection and cleaning at 11:30 a.m. on 3/10/14. All departments had moved into the new facility in June of 2012. Review of cleaning records showed that the only cleaning of the hood by a professional company occurred on 8/1/13. Two such cleanings should have occurred by that time, so at least one had been missed in Jan/Feb of 2013. A follow-up cleaning should have been done in February of 2014.

Based on observations and staff interview, the facility failed to provide documentation that the window curtains in use were flame resistant in accordance with the standards of NFPA 701 or had been treated with a flame resistant product made for fabrics. The deficiency could affect one of three smoke compartments on the main level.

Findings include:

In accordance with 18.7.5.1 and 10.3.1 of the Life Safety Code; draperies, curtains or other loosely hanging fabrics in health care occupancies shall be flame resistant as demonstrated by testing in accordance with NFPA 701.

The sleep room 1617 was observed at 3:15 p.m. on 3/10/14. A curtain had been installed over the window between the observation room and the sleep room, this curtain had no documentation that it met the standards for the requirements in NFPA 701 for flame resistance ratings.

Interview with maintenance staff at this same time, concluded that one of the sleep study staff must have brought the window covering from home and installed it over the window.

Based on observation, the facility failed to protect a gas meter from vehicle damage. The gas meter is directly behind the imaging truck/trailer back-in area. The deficiency could affect all who use the facility.

Findings include:

The gas meter on the north side of the building was observed at 2:00 p.m. on 3/10/14. The meter and gas lines had no bollards to protect them from vehicle damage. There was concrete poured all the way up to the edge of the building for the purpose of parking the imaging truck/trailer. The imaging trailer was parked within eight feet of the unprotected gas lines.

Based on observations, the facility failed to maintain the electrical system and/or its components in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition or interpretations from the Centers for Medicare and Medicaid Services (CMS). The deficiencies could affect all smoke compartments.

The findings include:

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

In accordance with Article 370.28(c) of NFPA 70 (1999 Edition) all pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Article 250-110.

In accordance with Article 110-13(a) of NFPA 70 (1999 Edition) electrical equipment shall be firmly secured to the surface on which it is mounted (if not temporary in service).

1. Room 1427 was observed at 3:05 p.m. on 3/10/14. A refrigerator was plugged into a power strip.

2. Room 1011, a business office near the main entry, was observed at 3:45 p.m. on 3/10/14. An white extension cord was in-use to a floor heater under the desk.

3. The cardiopulmonary department was observed at 5:00 p.m. on 3/10/14. A power strip was not mounted, but hanging by the cord.

4. The electrical closet on second floor was observed at 8:00 a.m. on 3/11/14. There were two covers missing on an electrical box directly above the corridor door to this room.

5. Room 2018 on the second floor was observed at 8:20 a.m. on 3/11/14. An extension cord was in-use to a lamp.

Based on observations, the facility failed to ensure that vertical openings between floors were sealed and/or enclosed by fire resistive construction. The deficiency could affect one of three smoke compartments on the main level.

The findings include:

In accordance with Section 18.3.1.1 of NFPA 101, 2000 Edition, any vertical opening shall be enclosed or protected in accordance with 8.2.5.
Secondly, Section 8.2.5.4 states that the fire resistance rating for the enclosure of floor openings shall be not less than as follows (see 7.1.3.2.1 for enclosure of exits):
(1) Enclosures connecting four stories or more in new construction - 2-hour fire barriers
(2) Other enclosures in new construction - 1-hour fire barriers
(3) Existing enclosures in existing buildings - 1/2-hour fire barriers
(4) As specified in Chapter 26 for lodging and rooming houses, in Chapter 28 for new hotels, and in Chapter 30 for new apartment buildings

The Information Technology (IT) closet 1545 a and b was observed at 2:20 p.m. on 3/10/14. Two, four inch conduits, which had been poured into the concrete between the two levels of the building, were not sealed where IT cables extended through the conduit.

Based on observations and an interview, the facility failed to maintain the fire resistance rating of smoke barriers. The deficiency could affect two of three smoke compartments on the main level.

The findings include:

In accordance with Section 8.3.6.1 of NFPA 101, 2000 Edition; pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service 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.

1. The communication closet 1545, with two sets of double doors on the main level, was observed at 2:20 p.m. on 3/10/14. There were five conduits through the floor which were not sealed. An interview with maintenance staff confirmed that the conduits did extend to and from other smoke compartments.

2. The communication closet 1627, near the chapel on the main floor, was observed at 4:20 p.m. on 3/10/14. There were eight conduits in the floor which were not sealed and contained IT wiring. An interview with maintenance staff confirmed that the conduits did extend to and from other smoke compartments.

Based on staff interview and record review, the facility failed to maintain the battery-powered emergency lights in the generator transfer switch room. This deficiency could affect a limited number of patients, staff and visitors in the building.

Findings include:

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

Records for the emergency lighting were reviewed at 11:30 a.m. on 3/10/14. There were no weekly or annual testing being done by maintenance staff on the battery pack emergency lighting fixtures at the generator or the transfer switch locations.

Interview with maintenance staff concluded that they did not know about the requirement and did not have a preventive maintenance (PM) assignment for the job.

Based on review of the fire drill reports, the facility failed to assure that fire drills were held on each shift at least quarterly. This deficiency affects all the patients in all smoke compartments.


The findings include:

The fire drill reports were reviewed at the facility on 3/10/14. The facility has two shifts and fire drills affect response of the staff for a fire anywhere in the building. The shift hours are 7 a.m. to 7 p.m. (day shift); and 7 p.m. to 7 a.m. (night shift). No documentation was available that during the fourth quarter of 2013 (October, November & December) fire drills were held on the night shift.

Based on observation and staff interview, the facility failed to ensure complete sprinkler coverage. This deficiency has the potential to affect more than a very limited number of patients, staff, and visitors.

Findings include:

In accordance with NFPA 101 and Section 18.3.5.1, where required by 18.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.6. There is an automatic sprinkler system, installed in accordance with NFPA 13 (1999 Edition), Standard for the Installation of Sprinkler Systems, with approved components, devices, and equipment, to provide complete coverage of all portions of the facility.

The dining room adjacent to the main kitchen was observed at 3:20 p.m. on 3/10/14. There was an alcove where the pop machines were tucked into which was not sprinkled. The space measured three feet in depth by eleven feet three inches in length by six feet in height. The main ceiling for the kitchen was ten feet in height with ceiling mounted sprinklers. The closest sprinkler head was nine feet away from the alcove. There was light fixtures which hung from the ceiling which limited the spray pattern for the ceiling mounted sprinkler system, these fixtures were approximately five feet across and circular in design. One was placed near the sprinkler head which could cover the non sprinkled alcove area. By design no water could get to the alcove area where the three machines had been placed.

Interview with maintenance staff at this same time concluded that the space above the pop machines was missed by the designer and sprinkler installer.

Based on surveyor observations and staff interview, the facility failed to maintain the sprinkler system and all its components in accordance with the standards of NFPA 13, 1999 Edition. The deficiency could affect all patients, staff, and visitors in all smoke compartments for the building.

Findings include:

In accordance with NFPA 25, inspections for quarterly, semi-annual and annual requirement shall be maintained as required under Tables 2-1 and 9-1.

1. The quarterly sprinkler inspection reports were reviewed at 11:30 a.m. on 3/10/14. There was no annual inspection identified as all four reports were marked on the forms as quarterly inspections by the sprinkler contractor.

Interview with maintenance staff at this same time concluded that he had not requested an annual to be done in the contractual agreement.

2. The reports for the fire pump were reviewed at 11:30 a.m. on 3/10/14. There was no annual performed on the fire pump.

Interview with maintenance staff at this same time concluded that he had not requested an annual to be done in the contractual agreement for the fire pump.

Based on record review, the facility failed to perform semi-annual cleaning of the hood system in the kitchen. The deficiency could affect all patients, staff, and visitors.

Findings include:

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

Type or Volume of Cooking Frequency Frequency
Systems serving solid fuel cooking operations Monthly
Systems serving high-volume cooking operations
such as 24-hour cooking, charbroiling or wok cooking Quarterly
Systems serving moderate-volume cooking operations Semiannually
Systems serving low-volume cooking operations, such
as churches, day camps, seasonal businesses, or senior
centers Annually

Record review was completed for the kitchen hood inspection and cleaning at 11:30 a.m. on 3/10/14. All departments had moved into the new facility in June of 2012. Review of cleaning records showed that the only cleaning of the hood by a professional company occurred on 8/1/13. Two such cleanings should have occurred by that time, so at least one had been missed in Jan/Feb of 2013. A follow-up cleaning should have been done in February of 2014.

Based on observations and staff interview, the facility failed to provide documentation that the window curtains in use were flame resistant in accordance with the standards of NFPA 701 or had been treated with a flame resistant product made for fabrics. The deficiency could affect one of three smoke compartments on the main level.

Findings include:

In accordance with 18.7.5.1 and 10.3.1 of the Life Safety Code; draperies, curtains or other loosely hanging fabrics in health care occupancies shall be flame resistant as demonstrated by testing in accordance with NFPA 701.

The sleep room 1617 was observed at 3:15 p.m. on 3/10/14. A curtain had been installed over the window between the observation room and the sleep room, this curtain had no documentation that it met the standards for the requirements in NFPA 701 for flame resistance ratings.

Interview with maintenance staff at this same time, concluded that one of the sleep study staff must have brought the window covering from home and installed it over the window.

Based on observation, the facility failed to protect a gas meter from vehicle damage. The gas meter is directly behind the imaging truck/trailer back-in area. The deficiency could affect all who use the facility.

Findings include:

The gas meter on the north side of the building was observed at 2:00 p.m. on 3/10/14. The meter and gas lines had no bollards to protect them from vehicle damage. There was concrete poured all the way up to the edge of the building for the purpose of parking the imaging truck/trailer. The imaging trailer was parked within eight feet of the unprotected gas lines.

Based on observations, the facility failed to maintain the electrical system and/or its components in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition or interpretations from the Centers for Medicare and Medicaid Services (CMS). The deficiencies could affect all smoke compartments.

The findings include:

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

In accordance with Article 370.28(c) of NFPA 70 (1999 Edition) all pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Article 250-110.

In accordance with Article 110-13(a) of NFPA 70 (1999 Edition) electrical equipment shall be firmly secured to the surface on which it is mounted (if not temporary in service).

1. Room 1427 was observed at 3:05 p.m. on 3/10/14. A refrigerator was plugged into a power strip.

2. Room 1011, a business office near the main entry, was observed at 3:45 p.m. on 3/10/14. An white extension cord was in-use to a floor heater under the desk.

3. The cardiopulmonary department was observed at 5:00 p.m. on 3/10/14. A power strip was not mounted, but hanging by the cord.

4. The electrical closet on second floor was observed at 8:00 a.m. on 3/11/14. There were two covers missing on an electrical box directly above the corridor door to this room.

5. Room 2018 on the second floor was observed at 8:20 a.m. on 3/11/14. An extension cord was in-use to a lamp.