HospitalInspections.org

A. Kindred Hospital Northwest Phoenix
Surveyed on June 7, 2012

Based on observation the facility failed to maintain the smoke/fire resistive rating of corridor walls.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.1, "Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5 (See also 19.2.5.9) (See all Exceptions) Section 19.3.6.2 "Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour." (See all Exceptions}.

Findings Include:

On June 7, 2012 the surveyor, accompanied by the Director of Maintenance, and Staff observed penetrations in the corridor wall located by door number six smoke barrier of the facility.

During the exit conference on June 7, 2012, the above findings were again acknowledged by the Four CEO's, Two CCO's, Vice President Clinical Operations, Regional Director of Clinical Operations,and the Director of Plant Operations.


Corridor walls must remain smoke tight/fire resistive to prevent smoke and heat from entering resident rooms. Smoke/heat will cause harm to the patients.

A. Kindred Hospital Phoenix
Survey on June 6, 2012

Based on observation the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 18. 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On June 6, 2012 the surveyor, accompanied by the Director of Maintenance, and Staff observed that the following corridor doors would not tightly close when tested.

1. Forth floor Nursing Supervisor, door will not positively latch when tested three of three times
2. Forth floor WC Shower room, rated door with a closing device will not positively latch when tested three of three times
3. Third floor Nurse Station EVS closet, will not positively latch when tested three of three times
4. Second floor EVS closet in the utility corridor, penetration and the door will not positively latch when tested three of three times

B. Kindred Hospital Northwest Phoenix
Findings include on Survey June 7, 2012

1. Rehabilitation, rated corridor door does not have a door closing device
2. Staff coordinator door, closing device removed
3. Director of Case Management office, Director of Rehabilitation and Infection Prevention offices, the door closing devices were removed


During the exit conference on June 6 th and 7 th of 2012, the above findings were again acknowledged by the Four CEO's, Two CCO's, Vice President Clinical Operations, Regional Director of Clinical Operations,and the Director of Plant Operations.

In time of a fire failing to protect patients from heat and smoke could cause harm to the patients.

A. Kindred Hospital Northwest Phoenix
Survey on June 7, 2012

Based on observation the facility failed to fill penetrations in the smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of at least ? hour." (1 Hour New) Chapter 8, Section 8.3.6. "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.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
(a) It shall be made on either side of the smoke barrier.
(b) It shall be made by an approved device that is designed for the specific purpose.

Findings include:

On June 7, 2012 the surveyor, accompanied by the Director of Maintenance, and Staff observed the following unsealed penetrations in the smoke barrier/s, located at:

1. North Wing breezeway by the mechanical room, unsealed penetrations to include an approximate 8"by 8" cut out of of the sheet rock in the smoke barrier
2. South wing smoke barrier, penetrations in the smoke barrier

During the exit conference on June 7, 2012, the above findings were again acknowledged by the Four CEO's, Two CCO's, Vice President Clinical Operations, Regional Director of Clinical Operations,and the Director of Plant Operations.


Failing to fill holes in smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility, which will cause harm to patients.

A. Kindred Hospital Phoenix
Survey on June 6, 2012

Based on observation the facility failed to provide a self-closing or an automatic-closing device in a hazardous area.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.2.1, "Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

Findings Include:

On June 6, 2012 the surveyor, accompanied by the Director of Maintenance, and Staff observed that the following hazardous areas have no self closing device

1. Second floor Kitchen dry food storage

B. Kindred Hospital Northwest Phoenix

1. Equipment storage rooms 101 and 102, doors do not have a closing device

During the exit conference on June 6, 2012, the above findings were again acknowledged by the Four CEO's, Two CCO's, Vice President Clinical Operations, Regional Director of Clinical Operations,and the Director of Plant Operations.

Failing to install self-closing hardware on a smoke/fire resistance door could cause harm to residents in time of a fire.

A. Kindred Hospital Phoenix
Survey on June 6, 2012

Based on observation the facility did not keep exits readily accessible at all times.

NFPA 101 Life Safety Code, 2000, Chapter 19 Section 19.2.1, and Section 19.2.3.3. Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 19.2.3.3 "Aisles, corridors and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft (Existing built to 8 feet must be maintained 8 feet clear) in clear and unobstructed width". Chapter 7 Section 7.5.1.1" Exits shall be so located and exit access shall be arranged so that exits are readily accessible at all times." Section 7.5.1.2 "Where exits are not immediately accessible from an open floor area, continuous passageways, aisles, or corridors leading directly to every exit and shall be maintained and shall be arranged to provide access for each occupant to not less than two exits by separate ways of travel."

Findings include:

Third Floor;

On June 6, 2012 the surveyor, accompanied by the Director of Maintenance, observed storage in the following areas:

1. Patient side of ICU, the items reducing exit access when measured from eight feet to six feet are: two bedside tables, and an equipment cart.
2. Nurses station by ICU, a copy machine reducing when measured the exit access from eight feet to six feet

During the exit conference on June 6, 2012, the above findings were again acknowledged by the Four CEO's, Two CCO's, Vice President Clinical Operations, Regional Director of Clinical Operations,and the Director of Plant Operations.


Failure to keep the exit corridors and exit access clear could hinder the evacuation during an emergency and will cause harm to patients.

A. Kindred Hospital Phoenix
Survey on June 6, 2012

Based on observation the facility failed to keep automatic sprinkler heads free of lint, paint and corrosion.

NFPA 101, Life Safety Code, 2000 Edition, Chapter 19, Section 19.3.5.1, "Buildings containing health care facilities shall be protected throughout by an approved supervised automatic sprinkler system in accordance with 9.7." Section 9.7.1.1 "Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13, Standard for the installation of Sprinkler Systems." NFPA 13, Chapter 12, Section 12-1 "General" "A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25....NFPA 25, Chapter 2, Section 2-2.1 "Sprinklers" 2-2.1.1 ...Sprinklers shall be free of corrosion, foreign material, paint, and physical damage and shall be installed in the proper orientation (e.g.,upright, pendant, or sidewall).

Findings Include:

On June 6, 2012 the surveyor, accompanied by the Director of Maintenance, observed that the following sprinkler heads have either lint, paint corrosion, or a foreign material

Forth floor

1. By room 416 and case management, 1 of 9 sprinklers lint
2. High side Shower room, by room 417, 2 of 2 sprinklers lint
3. Room 425, 1 of 2 escutcheon plates missing, bathroom sprinkler foreign material

Third floor

1. ICU staff bathroom, 1 sprinkler foreign substance
2. Room 301, 1 of 2 sprinklers lint
3. Low side EVS paint on sprinkler
4. By room 307, corridor sprinkler lint
5. Low side tub room, by room 310, sprinkler paint

B. Kindred Hospital Scottsdale
Survey on June 7, 2012
Findings include:

First floor

1. Walk in refrigerator, corroded

During the exit conference on June 6 th and 7 th of 2012, the above findings were again acknowledged by the Four CEO's, Two CCO's, Vice President Clinical Operations, Regional Director of Clinical Operations,and the Director of Plant Operations.


Failure to maintain the sprinkler heads could result in a malfunction during a fire. Sprinkler heads are U.L. listed to respond to a calculated ceiling temperature. Grease and lint on the head could slow that response or disable the sprinkler head. This will cause harm to patients and staff.

A. Kindred Hospital Scottsdale
Survey on June 7, 2012

Based on Observation the facility failed to provide noncombustible ashtrays, and failed to provide self-closing metal containers in the designated smoking area.
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NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.7.4 or Chapter 19, Section 19.7.4. "Smoking regulations shall be adopted and shall include not less than the following provisions:
(3) "Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted."
(4) "Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted."

Findings include:

On June 7, 2012 the surveyor, accompanied by the Director of Maintenance, observed the designated smoking area. No ashtrays were provided in the area or self-closing cover devices into which ashtrays can be emptied.

During the exit conference on June 7, 2012, the above findings were again acknowledged by the Four CEO's, Two CCO's, Vice President Clinical Operations, Regional Director of Clinical Operations,and the Director of Plant Operations.


Failure to provide metal containers for the disposal of cigarette butts could result in a fire which could cause harm to patients.

A. Kindred Hospital Phoenix
survey on June 6, 2012

Based on Observations the facility failed to separate empty and full medical gas cylinders, the facility failed to mount an electrical light switch five feet above the floor in the oxygen storage room.


NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.2.4. "Medical gas storage and administration areas shall be protected in Accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99, Chapter 4, Section 4-3.5.2.2 (a) (2) "If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly. " Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 Chapter 8, Storage Requirements, Section 8-3.1.11.2 Storage for nonflammable gases less than 3000 cubic feet. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2 (a) 11d. Section 4-3.1.1.2 (a) 11(d) Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft. (1.5m) above the floor to avoid physical damage.


Findings include:

Second Floor

On June 6, 2012 the surveyor, accompanied by the Director of Maintenance, and staff observed the medical gas storage in the following rooms were not marked or segregated from each other. And the oxygen was within 5 ft of electrical outlets and combustibles.

1. Resp. Therapy, 12 E O2 bottles
2. Material Management, 13 E O2 bottles

B. Kindred Northwest Hospital
Survey on June 7, 2012
Findings include:

1. Material Management, 12 EO 2 bottles, 4 bottles mixed with 2 empty bottles in the empty marked storage rack
2. ICU storage, 5 EO 2 bottles stored next to combustibles

During the exit conference on June 6 th and 7 th of 2012, the above findings were again acknowledged by the Four CEO's, Two CCO's, Vice President Clinical Operations, Regional Director of Clinical Operations,and the Director of Plant Operations.


In an emergency, patients would be harmed if an empty medical gas cylinder was mistakenly taken from the storage area. Failing to mount a light switch five feet above the floor to prevent an accident/or possible fire could cause harm to the patients.

A. Kindred Hospital Northwest Phoenix
Survey on June 7, 2012

Based on record Review the facility failed to document the required testing of the emergency generator.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.7.6 " Maintenance and Testing (See 4.6.12) Section 4.6.12.2 " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 99 "HEALTH CARE FACILITIES". Chapter 3, Section 3-5.4.1.1 (a) and Section 3-4.4.1.1 (b) "Generator sets shall be tested twelve (12) times a year... Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Chapter 6, Section 6-4.1 "Level 1 and Level 2 EPSSs, including all appurtenant components shall be inspected weekly and shall be exercised under load at least monthly. NFPA 110, Chapter 6, Section 6-4.2 "Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes...
Chapter 3, Section 3-4.1.1.8. (Level/Type 1) "The generator sets shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power.
or Section 3-5.3.1 (Level/Type 2) "The emergency system shall be installed and connected to the alternate source of power specified in 3-4.1.1.2 and 3-4.1.1.3 so that all functions specified herein for the emergency system will be automatically restored to operation within 10 seconds after interruption of the normal source."

Findings include:

On June 7, 2012 the surveyor, accompanied by the Director of Maintenance, reviewed the generator test records. No documentation of weekly inspections for the weeks of 2-21-2012, 7-6-2010 or 7-13-2010 were seen. The facility did not document the number of seconds (10 seconds or less) from normal power to emergency power for the last two years.

During the exit conference on June 7, 2012, the above findings were again acknowledged by the Four CEO's, Two CCO's, Vice President Clinical Operations, Regional Director of Clinical Operations,and the Director of Plant Operations.


Failure to test the emergency generator under load, inspect weekly, and document time from normal power to emergency power could result in harm to patients during lighting system failures.

A. Kindred Hospital Phoenix
Survey on June 6, 2012

Based on Observation the facility's allowed the use of a multiple outlet adapter, power strips and did not use the wall outlet receptacles for appliances. And Based on observation the facility failed to provide protection from electrical shock.
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NFPA 101, Life Safety Code, 2000, Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 1999 Edition. NFPA 99, Chapter 3, Section 3-3.2.1.2, "All Patient Care Areas," Section 3-3.2.1.2 (d) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters,. Section 19-5.1 "Utilities shall comply with the provisions of Section 9.1. Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70 "National Electrical Code. NEC, 1999, ARTICLE 110, SECTION 110-12 (a) Unused Openings. "Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment."


Findings include:

On June 6, 2012 the surveyor, accompanied by the Director of Maintenance, and staff observed refrigerators, and microwaves plugged into multi-outlet power strips and not directly plugged in to the wall outlet receptacles in the following rooms, to include a power strip daisy chained into an extension cord:

Forth floor

1. Rehab, power strip daisy chained into an extension cord

Third floor

1. Pharmacy, extension plugged into a refrigerator

Second floor

1. Resp. Therapy, microwave plugged into a power strip

B. Kindred Hospital Scottsdale
Survey on June 7, 2012
Findings include:

On June 7 th. 2012 the surveyor, accompanied by the Director of Maintenance, observed that the electrical panel PNL CRLA had 1 of 37 unused unprotected openings.

C. Kindred Hospital Northwest Phoenix
Survey on June 7, 2012
Findings include:

1. Break room, Administration, two power strips, one with a refrigerator plugged into it and one with a microwave plugged in

During the exit conferences on June 6 th and 7 th of 2012, the above findings were again acknowledged by the Four CEO's, Two CCO's, Vice President Clinical Operations, Regional Director of Clinical Operations,and the Director of Plant Operations.


The use of multiple outlet adapters could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients. Failing to protect energized electrical equipment or wiring can cause a shock or fire. A fire could cause harm to the patient.