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The facility did not ensure that hazardous areas were either separated by construction providing at least a one hour fire resistance rating or protected by an automatic extinguishing system, where the sprinkler option is used the areas shall be separated by smoke resisting partitions and self-closing doors as required by 19.3.2.1


On 06/26/2012 & 06/27/12 at 11:00am and times throughout the survey the surveyor and the Interim Director of Facilities observed that doors throughout the facility protecting supply rooms and mechanical rooms had door hardware that had been replaced and the holes left by hardware were not sealed, also the main lab door failed to fully close and latch and the door to the main boiler room/mechanical room was damaged to the core and had holes from missing hardware.

The facility did not ensure that emergency lighting is provided in accordance with LSC 7.9 & 19.2.9.1.

On 06/27/12 at 11:30 AM, the surveyor s were not provided with documentation from the Interim Director of Facilities to indicate that the battery backup emergency lights throughout the Nirenberg Building-Wound Care Center and Main Campus were tested for 30 seconds a month as required; i.e. no documentation provided of monthly, emergency light inspections or deficiencies discovered (if any).

The facility did not ensure that fire drills were held at unexpected times under varying conditions at least quarterly on each shift as required by the referenced LSC.

On 06/27/12 at 09:30 AM, the surveyor was provided with documentation from the Vice President/Evergreen Health Care Center Administrator to indicate that the fire drill conducted on 05/23/23 at the Nirenberg Building-Wound Care Center was conducted without sounding the building ' s fire alarm; i.e. staff at facility under impression that simulated fire scenario meant simulated fire alarm activation.

The facility did not ensure that the required fire alarm system was in accordance with NFPA 72, National Fire Alarm Code,

On 06/27/12 at 11:30 AM, the surveyor s were not provided with documentation from the Interim Director of Facilities to indicate that the fire alarm system at the Nirenberg Building-Wound Care Center was installed, tested, inspected or maintained in accordance with the National Fire Alarm Code, as required by sections 9.6 & 19.3.4 of the referenced Life Safety Code i.e. no electronic or written records of testing were available and no records of maintenance were kept readily available or deficiencies discovered (if any).

The facility did not ensure that a fire alarm system required for life safety is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. The system has an approved maintenance and testing program complying with applicable requirements of NFPA 70 and 72.

On 06/27/12 at 11:30 AM, the surveyor s were not provided with documentation from the Interim Director of Facilities to indicate that the fire alarm system at the Main Campus was tested, inspected or maintained in accordance with the National Fire Alarm Code, as required by sections 9.6 & 19.3.4 of the referenced Life Safety Code; i.e. no electronic or written records of testing were available and no records of maintenance were kept readily available or deficiencies discovered (if any) and The Main Campus fire alarm had points disabled, in trouble, and supervisory alarms that had been acknowledged with no corrective action in progress.

The facility did not ensure that all required smoke detectors, including those activating door hold open devices, were approved, maintained, inspected and tested in accordance with the manufacturer's specifications as require by the referenced LSC.

a. On 06/27/12 at 11:30 AM, the surveyor s were not provided with documentation from the Interim Director of Facilities to indicate that the smoke detection system at the Nirenberg Building-Wound Care Center and Main Campus was being inspected and tested on an annual basis as required in NFPA 72 and as part of the facility's preventive maintenance program; i.e. no electronic or written records of testing were available and no records of maintenance were kept readily available or deficiencies discovered (if any).

b. On 06/27/12 at 11:30 AM, the surveyor s were not provided with documentation from the Interim Director of Facilities to indicate that smoke detector sensitivity testing at the Nirenberg Building-Wound Care Center and Main Campus was being performed according to and/or in compliance with NFPA 72 - 7-3.2.1 and as part of the facility's preventive maintenance program i.e. no electronic or written records of testing were available and no records smoke detector sensitivity testing were kept readily available or deficiencies discovered (if any).

The facility did not ensure that the required automatic sprinkler system was continuously maintained in reliable operating condition and was inspected and tested periodically as required by the referenced LSC.

a. On 06/27/12 at 11:30 AM, the surveyor s were not provided with documentation from the Interim Director of Facilities to indicate that the automatic sprinkler system at the Nirenberg Building-Wound Care Center and Main Campus had been inspected on a quarterly basis during the past twelve (12) months by an authorized service company per NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems;. i.e. no electronic or written records of testing/inspection were available and what was available indicated deficiencies that were not corrected and/or records of the repairs or maintenance were not kept readily available for deficiencies;

b. On 06/27/12 at 11:30 AM, the surveyor s were not provided with documentation from the Interim Director of Facilities to indicate that the automatic sprinkler system at the Nirenberg Building-Wound Care Center and Main Campus had last been trip tested per NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems;. i.e. no electronic or written records of testing/inspection were available and no records of maintenance were kept readily available or deficiencies discovered (if any);

c. On 06/27/12 at 11:30 AM, the surveyor s were not provided with documentation from the Interim Director of Facilities to indicate that the automatic sprinkler system at the Nirenberg Building-Wound Care Center and Main Campus had preventative maintenance conducted on it that is required every 5 (five) years by sections 2-1, 9-4.1.2 & 9-4.2.1 of NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems; i.e. no record of obstruction investigation, (interior), strainer, filter & orifice inspection or (interior) check valve inspections;

The facility did not ensure that the facility ' s air conditioning and ventilation equipment was in accordance with NFPA 90A: Standard for the Installation of Air Conditioning and Ventilation Systems as required by the referenced LSC.

On 06/27/12 at 11:30 AM, the surveyor s were not provided with documentation from the Interim Director of Facilities to indicate that the mechanical fire dampers throughout the Nirenberg Building-Wound Care Center were inspected or maintained as required in NFPA 90A 3-4.7; i.e. no documentation provided of fire damper inspection/maintenance or deficiencies discovered (if any).

The facility did not ensure that the design, installation and use of its commercial cooking equipment was in accordance with NFPA 96: Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations as required by the referenced LSC.


On 06/27/12 at 11:30 AM, The surveyor was not provided with documentation from the Interim Director of Facilities that the Kitchen hood extinguishment system had been inspected within the past six (6) months (last inspection date: 09/28/11).

The facility did not ensure that piped in medical gas systems are in compliance with NFPA 99, 4.1, 4.1.1.

On 06/27/12 at 11:30 AM, the surveyor s were not provided with documentation from the Interim Director of Facilities to indicate that the piped-in, medical gas system at the Nirenberg Building-Wound Care Center was installed in accordance with Chapter 4 of NFPA 99 " Health Care Facility ' s " ; i.e. no documentation provided of the installation (installer) test report or installers state license to perform work.

The facility did not ensure that penetrations of smoke barriers by ducts are protected in accordance with LSC 8.3.5.

On 06/27/12 at 11:30 AM, the surveyor s were not provided with documentation from the Interim Director of Facilities to indicate that the smoke dampers throughout the Nirenberg Building-Wound Care Center and the Main Campus were inspected at least annually, as required by NFPA 72, " National Fire Alarm & Signal Code " , Table # 7-3.2; i.e. no documentation provided of smoke damper inspections or deficiencies discovered (if any).

The facility did not ensure that electrical receptacle outlets in patient areas were maintained as required in NFPA 99 "Health Care Facilities" Section 3-3.3.3 and 3-3.4.2.3, and as part of the facilities preventive maintenance program.

a. On 06/27/12 at 11:30 AM, the surveyor s were not provided with documentation from the Interim Director of Facilities to indicate that electrical receptacle outlets in patient areas are inspected annually as required in NFPA 99, Section 3-3.3.3 and 3-3.4.2.3, and as part of the facilities preventive maintenance program.

The facility did not ensure that Emergency and Standby Power Systems were being inspected and maintained as required in NFPA 110 "Standard for Emergency and Standby Power Systems".

b. On 04/27/06 at 10:00 AM, The surveyor was not provided with documentation from the Interim Director of Facilities to indicate the emergency generators were being maintained as required by NFPA 110 "Standard for Emergency and Standby Power Systems" Chapter 6 section 1.1 i.e. no Level 1 on the 285 KW generator and No Level 2 maintenance conducted on the 750 KW rental Generator.

The facility did not ensure that hazardous areas were either separated by construction providing at least a one hour fire resistance rating or protected by an automatic extinguishing system, where the sprinkler option is used the areas shall be separated by smoke resisting partitions and self-closing doors as required by 19.3.2.1


On 06/26/2012 & 06/27/12 at 11:00am and times throughout the survey the surveyor and the Interim Director of Facilities observed that doors throughout the facility protecting supply rooms and mechanical rooms had door hardware that had been replaced and the holes left by hardware were not sealed, also the main lab door failed to fully close and latch and the door to the main boiler room/mechanical room was damaged to the core and had holes from missing hardware.

The facility did not ensure that emergency lighting is provided in accordance with LSC 7.9 & 19.2.9.1.

On 06/27/12 at 11:30 AM, the surveyor s were not provided with documentation from the Interim Director of Facilities to indicate that the battery backup emergency lights throughout the Nirenberg Building-Wound Care Center and Main Campus were tested for 30 seconds a month as required; i.e. no documentation provided of monthly, emergency light inspections or deficiencies discovered (if any).

The facility did not ensure that fire drills were held at unexpected times under varying conditions at least quarterly on each shift as required by the referenced LSC.

On 06/27/12 at 09:30 AM, the surveyor was provided with documentation from the Vice President/Evergreen Health Care Center Administrator to indicate that the fire drill conducted on 05/23/23 at the Nirenberg Building-Wound Care Center was conducted without sounding the building ' s fire alarm; i.e. staff at facility under impression that simulated fire scenario meant simulated fire alarm activation.

The facility did not ensure that the required fire alarm system was in accordance with NFPA 72, National Fire Alarm Code,

On 06/27/12 at 11:30 AM, the surveyor s were not provided with documentation from the Interim Director of Facilities to indicate that the fire alarm system at the Nirenberg Building-Wound Care Center was installed, tested, inspected or maintained in accordance with the National Fire Alarm Code, as required by sections 9.6 & 19.3.4 of the referenced Life Safety Code i.e. no electronic or written records of testing were available and no records of maintenance were kept readily available or deficiencies discovered (if any).

The facility did not ensure that a fire alarm system required for life safety is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. The system has an approved maintenance and testing program complying with applicable requirements of NFPA 70 and 72.

On 06/27/12 at 11:30 AM, the surveyor s were not provided with documentation from the Interim Director of Facilities to indicate that the fire alarm system at the Main Campus was tested, inspected or maintained in accordance with the National Fire Alarm Code, as required by sections 9.6 & 19.3.4 of the referenced Life Safety Code; i.e. no electronic or written records of testing were available and no records of maintenance were kept readily available or deficiencies discovered (if any) and The Main Campus fire alarm had points disabled, in trouble, and supervisory alarms that had been acknowledged with no corrective action in progress.

The facility did not ensure that all required smoke detectors, including those activating door hold open devices, were approved, maintained, inspected and tested in accordance with the manufacturer's specifications as require by the referenced LSC.

a. On 06/27/12 at 11:30 AM, the surveyor s were not provided with documentation from the Interim Director of Facilities to indicate that the smoke detection system at the Nirenberg Building-Wound Care Center and Main Campus was being inspected and tested on an annual basis as required in NFPA 72 and as part of the facility's preventive maintenance program; i.e. no electronic or written records of testing were available and no records of maintenance were kept readily available or deficiencies discovered (if any).

b. On 06/27/12 at 11:30 AM, the surveyor s were not provided with documentation from the Interim Director of Facilities to indicate that smoke detector sensitivity testing at the Nirenberg Building-Wound Care Center and Main Campus was being performed according to and/or in compliance with NFPA 72 - 7-3.2.1 and as part of the facility's preventive maintenance program i.e. no electronic or written records of testing were available and no records smoke detector sensitivity testing were kept readily available or deficiencies discovered (if any).

The facility did not ensure that the required automatic sprinkler system was continuously maintained in reliable operating condition and was inspected and tested periodically as required by the referenced LSC.

a. On 06/27/12 at 11:30 AM, the surveyor s were not provided with documentation from the Interim Director of Facilities to indicate that the automatic sprinkler system at the Nirenberg Building-Wound Care Center and Main Campus had been inspected on a quarterly basis during the past twelve (12) months by an authorized service company per NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems;. i.e. no electronic or written records of testing/inspection were available and what was available indicated deficiencies that were not corrected and/or records of the repairs or maintenance were not kept readily available for deficiencies;

b. On 06/27/12 at 11:30 AM, the surveyor s were not provided with documentation from the Interim Director of Facilities to indicate that the automatic sprinkler system at the Nirenberg Building-Wound Care Center and Main Campus had last been trip tested per NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems;. i.e. no electronic or written records of testing/inspection were available and no records of maintenance were kept readily available or deficiencies discovered (if any);

c. On 06/27/12 at 11:30 AM, the surveyor s were not provided with documentation from the Interim Director of Facilities to indicate that the automatic sprinkler system at the Nirenberg Building-Wound Care Center and Main Campus had preventative maintenance conducted on it that is required every 5 (five) years by sections 2-1, 9-4.1.2 & 9-4.2.1 of NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems; i.e. no record of obstruction investigation, (interior), strainer, filter & orifice inspection or (interior) check valve inspections;

The facility did not ensure that the facility ' s air conditioning and ventilation equipment was in accordance with NFPA 90A: Standard for the Installation of Air Conditioning and Ventilation Systems as required by the referenced LSC.

On 06/27/12 at 11:30 AM, the surveyor s were not provided with documentation from the Interim Director of Facilities to indicate that the mechanical fire dampers throughout the Nirenberg Building-Wound Care Center were inspected or maintained as required in NFPA 90A 3-4.7; i.e. no documentation provided of fire damper inspection/maintenance or deficiencies discovered (if any).

The facility did not ensure that the design, installation and use of its commercial cooking equipment was in accordance with NFPA 96: Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations as required by the referenced LSC.


On 06/27/12 at 11:30 AM, The surveyor was not provided with documentation from the Interim Director of Facilities that the Kitchen hood extinguishment system had been inspected within the past six (6) months (last inspection date: 09/28/11).

The facility did not ensure that piped in medical gas systems are in compliance with NFPA 99, 4.1, 4.1.1.

On 06/27/12 at 11:30 AM, the surveyor s were not provided with documentation from the Interim Director of Facilities to indicate that the piped-in, medical gas system at the Nirenberg Building-Wound Care Center was installed in accordance with Chapter 4 of NFPA 99 " Health Care Facility ' s " ; i.e. no documentation provided of the installation (installer) test report or installers state license to perform work.

The facility did not ensure that penetrations of smoke barriers by ducts are protected in accordance with LSC 8.3.5.

On 06/27/12 at 11:30 AM, the surveyor s were not provided with documentation from the Interim Director of Facilities to indicate that the smoke dampers throughout the Nirenberg Building-Wound Care Center and the Main Campus were inspected at least annually, as required by NFPA 72, " National Fire Alarm & Signal Code " , Table # 7-3.2; i.e. no documentation provided of smoke damper inspections or deficiencies discovered (if any).

The facility did not ensure that electrical receptacle outlets in patient areas were maintained as required in NFPA 99 "Health Care Facilities" Section 3-3.3.3 and 3-3.4.2.3, and as part of the facilities preventive maintenance program.

a. On 06/27/12 at 11:30 AM, the surveyor s were not provided with documentation from the Interim Director of Facilities to indicate that electrical receptacle outlets in patient areas are inspected annually as required in NFPA 99, Section 3-3.3.3 and 3-3.4.2.3, and as part of the facilities preventive maintenance program.

The facility did not ensure that Emergency and Standby Power Systems were being inspected and maintained as required in NFPA 110 "Standard for Emergency and Standby Power Systems".

b. On 04/27/06 at 10:00 AM, The surveyor was not provided with documentation from the Interim Director of Facilities to indicate the emergency generators were being maintained as required by NFPA 110 "Standard for Emergency and Standby Power Systems" Chapter 6 section 1.1 i.e. no Level 1 on the 285 KW generator and No Level 2 maintenance conducted on the 750 KW rental Generator.