HospitalInspections.org

Based on document review and interview, Nursing Administration failed to ensure nursing followed their policy/procedure for transfer and transport of a patient to another facility in 2 of 2 transfer medical records (MR) reviewed (patients 5 and 6).


Findings:

1. Policy/procedure SOC #7.2.0, Transfer and Transport of a patient to another facility, revised 01/2017 and reviewed 04/2017 indicated: "1. Transports obtain physician order for transport, including method and type of personnel to accompany, 2. Prior to transport, and upon returning, the Registered Nurse (RN) will document a patient assessment, condition, on a supplemental note. 3. The Transfer/Transport Consent/Order forms are required to be completed when transporting the patient."

2. Review of MR's for patients 5 and 6 indicated both were transferred and lacked documentation of order for transport including method and type of personnel to accompany, supplemental note per RN with patient assessment and condition prior to transport and when returned to unit and Transfer/Transport Consent/Order form.

3. On 5/18/21 at approximately 1600 hours, staff S6 (RN, Director of Nursing [DON]) was interviewed and confirmed patients 5 and 6 MR's lacked documentation of order for transport including method and type of personnel to accompany, supplemental note per RN with patient assessment and condition prior to transport and when returned to unit and Transfer/Transport Consent/Order form.

Based on observation, record review, and interview; the facility failed to maintain the fire-rating of 3 of 4 stairway enclosures as required by Section 19.2.2.3, 7.2, and 8.6, NFPA 101 (see tag K225), failed to provide 1 of 5 means of egress compliant with the construction requirements of a ramp used as a component of the means of egress (see tag K227), failed to ensure the means of egress for 1 of 6 egress paths was compliant by having a dead-end in the corridor with a length greater than 30 feet (see tag K251), failed to ensure 1 of 6 exit discharge from the second floor was constructed of a hard packed all-weather travel surface in accordance with CMS Survey and Certification Letter 05-38(see tag K271), failed to ensure 1 of 6 exit discharges from the second floor was constructed with a walking surface on both sides of a door in the means of egress not varying more than 1/2 inch (see tag K271), failed to ensure 1 of 1 fire department connection was in accordance with NFPA 25, 2011 Edition, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (see tag K353), failed to ensure 1 of 1 sprinkler system was maintained with the proper number of spare sprinklers on the premises (see tag K353), failed to provide written documentation or other evidence the sprinkler system components had been inspected and tested for 1 of 4 quarters (see tag K353), failed to ensure the construction of a corridor system to resist the transfer of smoke to the deck above by having corridor walls that extend through the suspended acoustical ceiling system approximately four inches (see tag K362), failed to maintain 6 of 6 corridors walls that were constructed of 1/2-hour fire rated construction as able to resist the transfer of smoke with the installation of the automatic sprinkler system (see tag K362), failed to ensure 3 of 16 consumer bedroom doors to the corridor would resist the passage of smoke (see tag K363), failed to ensure 1 of over 50 corridor doors was equipped with positive latching hardware (see tag K363), failed to maintain the fire resistance rating for 1 of 4 smoke barrier walls that were constructed of 1/2-hour fire rated construction with the installation of the automatic sprinkler system (see tag K372), failed to ensure all fire dampers in the facility were inspected and provided necessary maintenance at least every six years in accordance with NFPA 90A (see tag K521), failed to maintain testing of 1 of 1 elevator firefighter recall in accordance with 9.4.6, Elevator Testing (see tag K531), failed to provide quarterly fire drill documentation for 2 of 3 shifts during 3 of 4 quarters (see tag K712), failed to provide complete fire drill documentation for 10 of 10 fire drills performed during the past 12 month period (see tag K712), failed to ensure fire drills were held at varied times for 1 of 3 employee shifts during 4 of 4 (see tag K712), failed to ensure annual inspection and testing of all fire door assemblies were completed in accordance of LSC 19.1.1.4.1.1 (see tag K761), and failed to ensure all nonhospital-grade electrical receptacles in 12 of 16 consumer bedroom locations were tested at least annually (see tag K914).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure a safe environment was maintained to provide quality health care for patients.

1. Based on observation and interview, the facility failed to maintain the fire-rating of 3 of 4 stairway enclosures as required by Section 19.2.2.3, 7.2, and 8.6, NFPA 101. Penetrations of the two-hour fire-rated fire barrier enclosing the stairs has not been properly firestopped to maintain the fire-resistance rating of the enclosure. This deficient practice could affect all consumers and all other occupants in the facility.

Findings include:

Based on observations on 05/19/21 between 12:00 p.m. and 2:15 p.m. during a tour of the facility with the Director of Operations and Housekeeping Supervisor, several penetrations of the stairway enclosure were observed as noted:
a) Southwest stairwell, second floor - from inside the stairwell enclosure, north wall - one yellow data cable
b) Southwest stairwell, second floor- from the corridor side, north wall - one sprinkler pipe and one fire alarm wire
c) North stairwell, first floor - from inside the stairwell enclosure, south wall - one conduit
d) South stairwell, first floor - from inside the stairwell enclosure, north wall - one conduit and one wire
Based on interview at the time of each observation, the Director of Operations acknowledged the penetrations were there and that firestopping appeared to be missing leaving a breach in the fire-rated wall assembly.

This finding was reviewed with the Director of Operations and C.O.O. during the exit conference.

2. Based on observation, record review, and interview; the facility failed to ensure the construction of a corridor system to resist the transfer of smoke to the deck above by having corridor walls that extend through the suspended acoustical ceiling system approximately four inches. This deficient practice could affect all consumers and all other occupants in the facility.

Findings include:

Based on observation on 05/19/2021 between 12:00 p.m. and 2:15 p.m. during a tour of the facility with the Director of Operations and Housekeeping Supervisor, the walls of the Elevator Corridor and Office Corridor were not constructed to the roof deck above. The healthcare occupancy is not separated from other portions of the second floor using 2-hour fire rated fire barriers. Using a ladder provided by the facility, we were able to determine that the corridor partitions of the Office Corridor were incomplete. The above ceiling interstitial space was open and the suspended acoustical ceiling is not classified as a smoke-resistant barrier. Based on interview at the time of the observation, the Director of Operations acknowledged the walls were not continuous to the deck above, that the walls were not new construction and the configuration of the space had not changed since his arrival at the facility. Based on record review, no Life Safety Drawings illustrating the location of fire barriers and smoke-resistant corridor construction were available.

This finding was reviewed with the Director of Operations and C.O.O. at the exit conference.

3. Based on observation, record review, and interview; the facility failed to maintain 6 of 6 corridors walls that were constructed of 1/2-hour fire rated construction as able to resist the transfer of smoke with the installation of the automatic sprinkler system. This deficient practice could affect all consumers and all other occupants in the facility.

Findings include:

Based on observations on 05/19/2021 between 12:0 p.m. and 2:15 p.m. with the Director of Operations and Housekeeping Supervisor, the corridor walls of the facility were 1/2-hour fire-resistant construction. With the installation of an approved automatic sprinkler system, the corridor walls may be classified as partition capable of resisting the transfer of smoke. Several locations were observed were the new sprinkler pipe penetrated the corridor partition and the penetration was not sealed to resist the transfer of smoke. Other penetrations of low voltage wiring and cable television cabling were observed through the corridor membrane of the former 1/2-hour fire-resistance rated wall/partition constructed to resist the transfer of smoke throughout the building tour. Based on interview with the Director of Operations at the time of observations, the sprinkler piping was installed approximately 14 months ago and the CATV cable was installed in the last week. Based upon record review, no Life Safety Drawings illustrating the location of fire barriers and smoke-resistant corridor construction were available.

This finding was reviewed with the Director of Operations and C.O.O. during the exit conference.

4. Based on observation and interview, the facility failed to ensure 3 of 16 consumer bedroom doors to the corridor would resist the passage of smoke. This deficient practice could affect all consumers in the facility.

Findings include:

Based on observations on 05/19/21 between 12:00 p.m. and 2:15 p.m. during a tour of the facility with the Director of Operations and Housekeeping Supervisor, the following was noted:
a. Consumer bedroom doors 278 and 280 each had a 12 inch by 12 inch frame with steel mesh on both sides of the door in the middle of the top half of the door with no glass between the steel mesh. With no glass between the steel mesh, both doors would not resist the passage of smoke in the event of a fire in either room. Based on interview at the time of observations, the Director of Operations and Housekeeping Supervisor acknowledged the lack of glass between the steel mesh and agreed these doors would not resist the passage of smoke in the event of a fire.
b. The corridor -door to bedroom 224 had a one-half inch hole above and below the door handle. Based on interview at the time of observation, the Director of Operations stated that room was having work completed inside; so the usual handle that would cover the holes had been temporarily replaced with a locking door knob. This room was out of service and not being used by consumers at the time of this survey.

This finding was reviewed with the Director of Operations and C.O.O. at the exit conference.

5. Based on observation, record review, and interview; the facility failed to ensure 1 of over 50 corridor doors was equipped with positive latching hardware. This deficient practice could affect all consumers.

Findings include:

Based on observations on 05/19/21 between 12:00 p.m. and 2:15 p.m. during a tour of the facility with the Director of Operations and Housekeeping Supervisor, the corridor door to the "Relaxation" room used to seclude aggressive consumers was only equipped with a key-operated dead-bolt. There was no positive latching hardware on the door to secure the door closed in the event of a fire emergency. There was no smoke detector in the room. Based on interview at the time of observation, the Director of Operations stated that the door and the use of the room had not changed since his arrival at the facility. The Director of Operations did not know if the room had been classified as an area open to the corridor or not. The Director of Operations acknowledged that the door was not equipped with positive latching hardware. Based on record review, no Life Safety Drawings illustrating the location of smoke-resistant corridor construction were available.

This finding was reviewed with the Director of Operations and C.O.O. during the exit conference.

6. Based on observation record review, and interview; the facility failed to maintain the fire resistance rating for 1 of 4 smoke barrier walls that were constructed of 1/2-hour fire rated construction with the installation of the automatic sprinkler system. This deficient practice could affect all of consumers and other occupants in the event of the fire emergency.

Findings include:

Based on observations on 05/19/2021 between 12:00 p.m. and 2:15 p.m. with the Director of Operations and Housekeeping Supervisor, the smoke barrier wall south of consumer rooms 224 and 225 were 1/2-hour fire-resistant construction. Several locations were observed were the new sprinkler pipe penetrated the smoke barrier and the penetration was not firestopped to maintain the fire-resistance rating of the barrier. Based on interview with the Director of Operations at the time of observation, the sprinkler piping was installed approximately 14 months ago. Based on record review, no Life Safety Drawings illustrating the location of smoke barriers was available for review. The Director of Operations acknowledged that the installation of sprinkler pipe created penetrations in the smoke barrier that were not firestopped.

This finding was reviewed with the Director of Operations during the exit conference.

1. Based on record review and interview, the facility failed to provide quarterly fire drill documentation for 2 of 3 shifts during 3 of 4 quarters. This deficient practice could affect all consumers in the facility.

Findings include:

Based on review of the facility's fire drill reports on 05/19/21 between 9:20 a.m. and 12:00 p.m. with the Director of Operations present and again between 2:15 p.m. and 5:45 p.m. with the Director of Operations and C.O.O. present, the facility lacked fire drill documentation for the following shifts and quarters:
a. Second shift (evening) of the fourth quarter (October, November, and December) of 2020.
b. First shift (day) of the first quarter (January, February, and March) of 2021.
c. Second shift (evening) of the second quarter (April, May, and June) of 2020 and so far in 2021.
Based on interview at the time of record review, the Director of Operations said there was no other documentation available for missing fire drills during the previously mentioned shifts and quarters of 2020 and 2021.

This finding was reviewed with the Director of Operations and the C.O.O. during the exit conference.

2. Based on record review and interview, the facility failed to provide complete fire drill documentation for 10 of 10 fire drills performed during the past 12 month period. This deficient practice could affect all consumers in the facility.

Findings include:

Based on review of the facility's fire drill reports on 05/19/21 between 9:20 a.m. and 12:00 p.m. with the Director of Operations present and again between 2:15 p.m. and 5:45 p.m. with the Director of Operations and C.O.O. present, all 10 documented fire drills performed during the past 12 month period did not include the names and signatures of staff that participated in the fire drills. Based on interview at the time of record review, the Director of Operations said there was no other documentation available to show the names of staff who participated in each fire drill during the past 12 month period.

This finding was reviewed with the Director of Operations and the C.O.O. during the exit conference.

3. Based on record review and interview, the facility failed to ensure fire drills were held at varied times for 1 of 3 employee shifts during 4 of 4 quarters. This deficient practice could affect all consumers in the facility.

Findings include:

Based on review of the facility's fire drill reports on 05/19/21 between 9:20 a.m. and 12:00 p.m. with the Director of Operations present and again between 2:15 p.m. and 5:45 p.m. with the Director of Operations and C.O.O. present, four of five, third shift (night) fire drills were performed between 5:40 a.m. and 5:55 a.m. Based on interview at the time of record review, the Director of Operations acknowledged the times of the third shift fire drills were performed and agreed the times were not varied enough.

This finding was reviewed with the Director of Operations and the C.O.O. during the exit conference.

1. Based on observation and interview, the facility failed to provide 1 of 5 means of egress compliant with the construction requirements of a ramp used as a component of the means of egress. Section 19.2.2.6.1 states that ramps complying with 7.2.5 may be used as a component of the means of egress. Section 7.2.5.3.2 (1) & (4) states, ramp landings shall be as follows: Ramps shall have landings located at the top, at the bottom, and at door leaves opening onto the ramp. Every landing, for ramps in the means of egress, shall be not less than 60 in. (1525 mm) long in the direction of travel, unless the landing is an approved existing landing. This deficient practice could affect all consumers and other occupants if having to traverse the ramp to exit from the dining room and connecting east corridor.

Findings include:

Based on observation on 05/19/2021 between 12:00 p.m. and 2:15 p.m. during a tour of the facility with the Director of Operations and Housekeeping Supervisor, the exit signage and manual pull stations indicate that the corridor in which the ramp is located is designated as part of the means of egress. There were no Life Safety Drawings to indicate otherwise. There is no landing at the bottom of the ramp. The slope of the ramp extends to the double doors and aluminum storefront window system on the first level. Based on interview at the time of observation, the Director of Operations indicated that the ramp has been there longer than he has served as Director of Operations. The plans of the original construction did not include the corridor and ramp.

This finding was reviewed with the Director of Operations and C.O.O. during the exit conference.

2. Based on observation, record review, and interview; the facility failed to ensure the means of egress for 1 of 6 egress paths was compliant by having a dead-end in the corridor with a length greater than 30 feet. This deficient practice could affect all consumers and other occupants in the facility.

Findings include:

Based on observations on 05/19/21 between 12:00 p.m. and 2:15 p.m. during a tour of the facility with the Director of Operations and Housekeeping Supervisor, the set of cross-corridor doors between the elevator corridor and the office corridor was found to be locked. The cross-corridor doors and frame are a 90-minute fire-rated assembly, however, the partition in which they are located extends only through the suspended ceiling. The distance to the doors from the point where a person would have to return upon finding the doors locked is approximately 44 feet. Based on interview at the time of observation, the Director of Operations stated that the doors and partition were not new construction. Based on record review, no Life Safety Drawings illustrating the location of fire barriers and smoke-resistant corridor construction were available for review. No documentation of a risk assessment indicating that correction of this issue was impractical or unfeasible was provided for review. The Director of Operations acknowledged the doors in the cross-corridor opening were always locked and the distance to the doors was more than 30 feet from outside of the housekeeping room.

This finding was reviewed with the Director of Operations and C.O.O. during the exit conference.

3. Based on record review and interview, the facility failed to ensure all fire dampers in the facility were inspected and provided necessary maintenance at least every six years in accordance with NFPA 90A. LSC 9.2.1 requires heating, ventilating and air conditioning (HVAC) ductwork and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. NFPA 90A, 2012 Edition, Section 5.4.8.1 states fire dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. NFPA 80, 2010 Edition, Section 19.4.1 states each damper shall be tested and inspected 1 year after installation. Section 19.4.1.1 states the test and inspection frequency shall then be every 4 years except for hospitals where the frequency is every 6 years. If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in-place if so equipped. The damper shall not be blocked from closure in any way. All inspections and testing shall be documented, indicating the location of the fire damper, date of inspection, name of inspector and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected. This deficient practice could affect all consumers and all other occupants in the facility.

Findings include:

Based on record review on 05/19/2021 between 9:20 a.m. and 12:00 p.m. with the Director of Operations present and again between 2:15 p.m. and 5:45 p.m. with the Director of Operations and C.O.O. present, the Fire/Smoke Damper Maintenance Records were not available for review. The lack of six year maintenance and inspection documentation was verified by the Director of Operations at the time of record review. Furthermore, the Director of Operations said he was not aware of the smoke/fire dampers having ever been inspected.

This finding was reviewed with the Director of Operations and C.O.O. during the exit conference.

4. Based on observation, record review and interview; the facility failed to ensure all nonhospital-grade electrical receptacles in 12 of 16 consumer bedroom locations were tested at least annually. NFPA 99, Health Care Facilities Code 2012 Edition, Section 6.3.4.1.3 states receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months. Additionally, Section 6.3.3.2, Receptacle Testing in Patient Care Rooms requires the physical integrity of each receptacle shall be confirmed by visual inspection. The continuity of the grounding circuit in each electrical receptacle shall be verified. Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed; and retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 grams (4 ounces). This deficient practice could affect all consumers.

Findings include:

Based on record review on 05/19/21 between 9:20 a.m. and 12:00 p.m. and again between 2:15 p.m. and 5:45 p.m. with the Director of Operations present, there was no record of an annual test for each consumer bedroom electrical receptacle that was not a hospital-grade receptacle. Based on interview at the time of record review, the Director of Operations said all of the electrical receptacles in resident rooms were not hospital-grade receptacles as far as he knew. The Director of Operations said there was no record or documentation to show that annual testing per NFPA 99, Receptacle Testing requirements was met, because the receptacles have never been tested/inspected as far as he knew. Based on observations between 12:00 p.m. and 2:15 p.m. during a tour of the facility with the Director of Operations and Housekeeping Supervisor, there were one or two electrical receptacles in each consumer bedroom except rooms 278, 280, 282, and 284. Those four rooms had no electrical receptacles.

This finding was reviewed with the Director of Operations and C.O.O. during the exit conference.

1. Based on observation and interview, the facility failed to ensure 1 of 6 exit discharge from the second floor was constructed of a hard packed all-weather travel surface in accordance with CMS Survey and Certification Letter 05-38. This deficient practice could affect all consumers and other occupants on the second floor that would egress through the Dining Room exit access door.

Findings include:

Based on observations on 05/19/21 between 12:00 p.m. and 2:15 p.m. during a tour of the facility with the Director of Operations and Housekeeping Supervisor, the exterior door from the office corridor was marked with an exit sign. There is a manual fire pull station beside the door. The exit discharged onto a concrete stoop, however, there was approximately 100 feet of grass turf leading to a gate in the perimeter fence and hill to reach the public way. Based on interview at the time of observation, the Director of Operations indicated that the path, use of the door as an exit, location of the gate were not new and provided the approximate distance and confirmed the lack of a hard clearable surface that led to a public way.

This finding was reviewed with the Director of Operations and C.O.O. during the exit conference.

2. Based on observation and interview, the facility failed to ensure 1 of 6 exit discharges from the second floor was constructed with a walking surface on both sides of a door in the means of egress not varying more than 1/2 inch. Section 7.2.1.3.1 of the Life Safety Code requires the elevation of the floor surfaces on both sides of a door opening shall not vary by more than 1/2 in., unless otherwise permitted. This deficient practice could affect all consumers and all other occupants on the second floor that would egress through the Dining Room exit access door.

Findings include:

Based on observations on 05/19/21 between 12:00 p.m. and 2:15 p.m. during a tour of the facility with the Director of Operations and Housekeeping Supervisor, the surface of the exterior concrete stoop at the exterior door was more than 1/2" below the interior floor elevation (approximately seven inches). Based on interview at the time of observation, the Director of Operations stated that the existing condition was not new and that it is unchanged since his arrival at the facility and confirmed the difference in elevation through the door was more than 1/2 inch.

This finding was reviewed with the Director of Operations and C.O.O. during the exit conference.

3. Based on observation and interview, the facility failed to ensure 1 of 1 fire department connection was in accordance with NFPA 25, 2011 Edition, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Section 13.7.1 requires fire department connections to be inspected quarterly to verify the following:
(1) The fire department connections are visible and accessible.
(2) Couplings or swivels are not damaged and rotate smoothly.
(3) Plugs or caps are in place and undamaged.
(4) Gaskets are in place and in good condition.
(5) Identification signs are in place.
(6) The check valve is not leaking.
(7) The automatic drain valve is in place and operating properly.
(8) The fire department connection clapper(s) is in place and operating properly.
This deficient practice could affect all consumers in the facility.

Findings include:

Based on observation on 05/19/21 at 2:00 p.m. during a tour of the facility with the Director of Operations and Housekeeping Supervisor, the facility's fire department connection (FDC) was located on the wall outside the northwest stairwell. There was no signage provided over the FDC connection or at the front of the building for the responding fire department to lead them to the FDC for easy identification. Based on interview at the time of observation, this was acknowledged by the Director of Operations.

This finding was reviewed with the Director of Operations and C.O.O. during the exit conference.

4. Based on record review, observation and interview; the facility failed to ensure 1 of 1 sprinkler system was maintained with the proper number of spare sprinklers on the premises. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 5.4.1.4 states a supply of spare sprinklers (never fewer than six) shall be maintained on the premises so that any sprinklers that have been operated or damaged in any way can be promptly replaced. The sprinklers shall correspond to the types and temperature ratings of the sprinklers on the property. The sprinklers shall be kept in a cabinet located where the temperature in which they are subjected will at no time exceed 100 degrees Fahrenheit. A special sprinkler wrench shall be provided and kept in the cabinet to be used in the removal and installation of sprinklers. This deficient practice could affect all consumers and other occupants in the facility.

Findings include:

Based on record review on 05/19/21 between 9:20 a.m. and 12:00 p.m. with the Director of Operations present and again between 2:15 p.m. and 5:45 p.m. with the Director of Operations and C.O.O. present, the quarterly sprinkler system inspections dated 09/24/20 and 12/28/20 both said in the comments section of each report: "The spare head cabinet should contain upright and pendent sprinkler heads and applicable wrenches". Based on observation of the spare sprinkler cabinet at 4:30 p.m. with the C.O.O. there were only four tamper resistant type spare sprinkler heads and an applicable wrench in the spare sprinkler head cabinet. There were no side wall, pendent, or upright type sprinkler heads or applicable wrenches in the spare sprinkler head cabinet. All three type sprinkler heads plus tamper resistant type sprinkler heads were observed in different sections of the facility. Based on interview at the time of the observation of the spare sprinkler cabinet, the C.O.O. acknowledged the spare sprinkler cabinet was provided with only four tamper resistant spare sprinkler heads, and said there were no additional spare sprinkler heads in the facility.

This finding was reviewed with the Director of Operations and C.O.O. during the exit conference.

5. Based on record review, observation, 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. 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 consumers and other occupants in the facility.

Findings include:

Based on review of the quarterly sprinkler system inspection records on 05/19/21 between 9:20 a.m. and 12:00 p.m. with the Director of Operations present and again between 2:15 p.m. and 5:45 p.m. with the Director of Operations and C.O.O. present, there was no quarterly sprinkler system inspection report available for the first quarter (January, February, and March) of 2021. Based on observation of the sprinkler riser at 4:30 p.m. with the C.O.O., there was an inspection tag attached to the riser from the sprinkler system vendor that had a recorded inspection date of 03/24/21. Based on interview at the time of record review, the Director of Operations said he has called the sprinkler system vendor several times but has been unsuccessful in getting a copy of the 03/24/21 quarterly sprinkler system inspection report.

This finding was reviewed with the Director of Operations and C.O.O. during the exit conference.

6. Based on record review, observation, and interview; the facility failed to maintain testing of 1 of 1 elevator firefighter recall in accordance with 9.4.6, Elevator Testing. LSC 9.4.6.2 states that all elevators with fire fighters' emergency operations in accordance with 9.4.3 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASME A17.1/CSA B44, Safety Code for Elevators and Escalators. This deficient practice could affect all consumers and all other occupants in the facility.

Findings include:

Based on record review on 05/19/21 between 9:20 a.m. and 12:00 p.m. with the Director of Operations present and again from 2:15 p.m. and 5:45 p.m. with the Director of Operations and C.O.O. present, there was no documentation available for the monthly firefighter recall for the elevator for the past twelve months. Based on interview at the time of record review, the Director of Operations said there was no documentation available for the monthly firefighter recall for the elevator for the past twelve months. Based on observations between 12:00 p.m. and 2:15 p.m. during a tour of the facility with the Director of Operations and Housekeeping Supervisor, the elevator was equipped with a firefighter recall key operation.

This finding was reviewed with the Director of Operations and C.O.O. during the exit conference.

7. Based on observation, records review, and interview; the facility failed to ensure annual inspection and testing of all fire door assemblies were completed in accordance of LSC 19.1.1.4.1.1. Communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire door assemblies. (See also Section 8.3.) LSC 8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code. NFPA 80 5.2.1 states fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ. NFPA 80, 5.2.3.1 states functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing. NFPA 80, 5.2.4.1 states fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly.

NFPA 80, 5.2.4.2 states as a minimum, the following items shall be verified:
(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.
This deficient practice could affect all consumers and all other occupants in the facility.

Findings include:

Based on record review on 05/19/21 between 9:20 a.m. and 12:00 p.m. with the Director of Operations present and again from 2:15 p.m. and 5:45 p.m. with the Director of Operations and C.O.O. present, no annual inspection of the fire door assemblies were available for review. Based on observations during the tour of the facility between 12:00 p.m. and 2:15 p.m., there were labeled fire door assemblies noted throughout the building that were fire-rated and non-fire rated wall assemblies. Based on record review, no Life Safety Drawings illustrating the location of fire barriers and smoke-resistant corridor construction were available. Based on interview at the time of records review, the Director of Operations stated an annual inspection was not conducted for the fire door assemblies during the past 12 month period or at any time as far as he knew, and confirmed the doors in the facility were labeled 90-minute and 45-minute assemblies.

This finding was reviewed with the Director of Operations and C.O.O. during the exit conference.

Based on document review, observation and interview, the facility failed to provide a clean and sanitary environment in 5 of 5 bathrooms (Rooms 266, 273, 275, 264 and 274) and 2 of 2 washers and dryers observed on the Unit.

Findings Include:

1. Review of Housekeeping cleaning process indicated on the Daily Schedule "Clean Client's Room".

2. Review of Housekeeping cleaning process indicated on the Discharge Procedure All inpatient bathrooms/bedrooms must be cleaned completely upon discharge.

3. Review of policy titled: Laundry Care (EC.06.01.00.00) last reviewed 06/20, indicated C.1.e. 'Staff will log nightly sanitation and log sanitation between each client use of washer and dryer".

4. Review of washer/dryer Cleaning Log indicated "Place a machine is sanitized sign on washerand / or dryer when sanitizing is complete".

5. Tour of facility on 05/18/21 at 11:00 am with S1 (Deputy Chief/Corporate Compliance Officer), S6 (Director of Nursing), S13 (Supervisor of Housekeeping) and S4 (ED Operations), this surveyor found green/blue hard and crusty material on shower knob, shower head and shower pan in rooms 266, 273, 275, 264 and 274. Also found wipeable, chalky dust on shower pan. Room 266 had black, soft debris under the shower knob. Each plastic tear away shower curtain had dark red/orange stains on the bottom as the curtain lays in the shower pan. Observed 2 washer and dryers in Laundry Room; unable to verify if sanitized.

6. Interview on 05/18/21 at approximately 11:30 am with S13 (Supervisor of Housekeeping) confirmed findings in #3 "due to build-up of calcium from the hard water". Also confirmed that the showers are cleaned weekly and at patient discharge.

7. Interview on 05/18/21 with S6 (Director of Nursing) confirmed there was no sign on the washer/dryer indicating the equipment had been sanitized; confirmed there is no log of nightly sanitizing of washer/dryer.