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Based on observation it was determined 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 January 27, 28, and 29 of 2015, the surveyor, accompanied by the Facilities Director, PXO and staff, observed the following penetrations:

1. Women's and Children's, second floor janitors closet, hole in the wall.
2. Electrical room, door 052597, hole in wall.

During the exit conference on January 29, 2015, the above findings were again acknowledged by the CEO, CNO, Compliance officer, ED Clinical Supervisor, ANE Director, Facilities Director and PXO.

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.

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

NFPA 101 Life Safety Code 2000, Chapter 19, 19.3.6.3.1 " Doors protecting corridor openings in other than required enclosures of vertical openings, exit, or hazardous areas shall be substantial doors, such as those constructed of 1 3/4 in. thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke

Findings Include:

On January 27, 28, and 29 of 2015, the surveyor, accompanied by the Facilities Director, PXO and staff, observed the following corridor doors would not positively latch:

1. Rooms C 211 and 214 tested three of three times and will not positively latch.
2. Room C 208, door tested three of three times, will not positively latch.
3. Door 052905, latch taped, door will not latch.
4. Door 052911, door tested three of three times, will not positively latch.
5. Door 050437, Three West Nurse Director. Door has a closing device, a pull to close, and the door is impeded by a garbage can.
6. Door 053542, impeded by a metal object placed over latch mechanism.
7. Door 050838, will not positively latch.

During the exit conference on January 29, 2015, the above findings were again acknowledged by the CEO, CNO, Compliance officer, ED Clinical Supervisor, ANE Director, Facilities Director and PXO.

The facility failed to protect patients from heat and smoke.

Based on observation it was determined the facility failed to protect a vertical opening for a elevator.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.1.1 "Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating." Section 8.2.5.2 "Openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier.

Findings Include:

On January 27, 28, and 29 of 2015, the surveyor, accompanied by the Facilities Director, PXO and staff, observed the following corridor door would not tightly close when tested.

1. Fifth floor double doors # 053833 will not latch.
2. Third floor double doors # 053745 will not latch.

During the exit conference on January 29, 2015, the above findings were again acknowledged by the CEO, CNO, Compliance officer, ED Clinical Supervisor, ANE Director, Facilities Director and PXO.

Failing to provide enclosures between floors will cause harm to patients and staff.

Based on observation it was determined 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 ½ 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 January 27, 28, and 29 of 2015, the surveyor, accompanied by the Facilities Director, PXO and staff, observed unsealed penetrations in the smoke barrier/s, located at:

1. Women's and Children smoke barrier doors ID # 052925.

During the exit conference on January 29, 2015, the above findings were again acknowledged by the CEO, CNO, Compliance officer, ED Clinical Supervisor, ANE Director, Facilities Director and PXO.

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.

Based on observation it was determined the facility failed to maintain the self closing/automatic-closing doors in the smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Sections, 19.3.7.6 "Doors in smoke barriers shall comply with 8.3.4.1*" Doors in smoke barriers shall close the opening leaving only minimum clearance necessary for proper operation and shall be without undercuts, lovers, or grills."

Findings include:

On January 27, 28, and 29 of 2015, the surveyor, accompanied by the Facilities Director, PXO and staff, observed the following smoke barrier doors out of adjustment, and not smoke tight:

1. Doors 052457, twenty minute rated doors not smoke tight.
2. Doors 50904, rated to stair well, not smoke tight.
3. Tower A and B separation rated 1-1/2 hour doors not smoke tight.
4. Door 050772, missing astragal, not smoke tight.

During the exit conference on January 29, 2015, the above findings were again acknowledged by the CEO, CNO, Compliance officer, ED Clinical Supervisor, ANE Director, Facilities Director and PXO.

Failure to properly adjust or repair the smoke doors could cause harm to residents.
Non closing smoke doors could allow smoke to enter smoke zones not directly effected by the fire, which could cause harm to the patients.

Based on observation it was determined the facility did not maintain the integrity, smoke resistanc of doors in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.2.1 requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls and doors must be able to resist the passage of smoke. NFPA 80 "Fire Doors and Fire Windows" Chapter 2, Section 2-3.1.7 "The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. +/- 1/16 in for steel doors and shall not exceed 1/8 in. for wood doors.

Findings include:

On January 27, 28, and 29 of 2015, the surveyor, accompanied by the Facilities Director, PXO and staff, observed the following hazardous area doors:

1. Women's and Children's, double doors rated ninety minutes, will not close, coordinator out of adjustment.
2. Corner store, storage room with combustibles, no closing device.
3. Second floor, janitors closet, will not latch.
4. Door 052556, office/storage room, door closing device removed.
5. Door 50414, door wedged open, will not close and positively latch.
6. Door 05054, soiled utility, latch impeded, will not positively latch.
7. OR, 2,4,8, 9 and anesthesia, doors will not positively latch.
8. PACU, soiled utility, door impeded and will not positively latch.
9. Endo deacon room, door 050590, will not positively latch.
10. Door 050586, soiled utility, door will not positively latch.
11. Door 050728 to OR core out of adjustment and will not positively latch.

During the exit conference on January 29, 2015, the above findings were again acknowledged by the CEO, CNO, Compliance officer, ED Clinical Supervisor, ANE Director, Facilities Director and PXO.

Failing to prevent heat and smoke from spreading into the exit corridor will cause harm to patients.

K039 Is a CONDITION of PARTICIPATION

Based on observation it was determined 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. "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:

On January 27, 28, and 29 of 2015, the surveyor, accompanied by the Facilities Director, ED Director, PXO and staff, observed the following exits not immediately accessible from an open floor area, continuous passageways, aisles, or corridors leading directly to every exit:

1. NICU exit access has a storage rack approximately 6' X 6' X 2' and a paper shredder stored in the corridor.
2. Woman's Pre and Post Op, two of two exits reduced from eight feet to approximately six feet by two large cabinets with computers.
3. Old Tower B, by rooms B 383 and 384, nine pieces of equipment reducing exit access from eight feet to approximately seven feet.
4. Outside "Speciality", nine foot corridor reduced to seven feet six inches by eight chairs and a table, two of two exits not readily accessible.
5. ED North by morgue, eight chairs in the exit access, reduced from eight feet to six feet.
6. Main ED, four of four exit access reduced from eight feet to less than approximately six feet by seven beds with patients, chairs, medical equipment, linen storage racks, and a fold down work station.
7. MRI Exit blocked by a bed.

During the exit conference on January 29, 2015, the above findings were again acknowledged by the CEO, CNO, Compliance officer, ED Clinical Supervisor, ANE Director, Facilities Director and PXO.

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

Based on document review and observation it was determined the facility did not inspect, test and maintain the automatic sprinkler system in accordance with the requirements of the Life Safety Code.

NFPA 101 Life Safety Code, 2000, 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 Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems." NFPA 25, Water Based Extinguishment Systems, requires monthly, quarterly and annual testing of automatic sprinkler systems.

Findings include:

On January 27, 28, and 29 of 2015, the surveyor, accompanied by the Facilities Director, PXO and staff, reviewed the records which indicated that the automatic sprinkler system was not inspected or tested monthly, quarterly or annually. The quarterly inspection dated September 10, 2014 was one month late.

The following sprinklers were not maintained:
1. Anesthesia, one of one sprinkler lint.
2. Diagnostic imaging multipurpose room, door number 051258, one of five sprinklers missing escutcheon plate, and two covered with lint.
3. By door 050016, sprinkler covered.
4. Room at door 052916, one of on escutcheon plate missing
5. Door/room 50414, combustibles within 18 inches of sprinklers.

During the exit conference on January 29, 2015, the above findings were again acknowledged by the CEO, CNO, Compliance officer, ED Clinical Supervisor, ANE Director, Facilities Director and PXO

Failure to inspect, test, and maintain the sprinkler system could result in harm to the patients through the spread of smoke and fire.

Based on observation it was determined the facility failed to maintain fire doors.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.2.2.5, "Horizontal exits complying with 7.2.4 and the modifications of (18) or 19.2.2.5.1 through (18) or 19.2.2.5.4 shall be permitted. Section 7.2.4.3.7, Doors in horizontal exits or fire barriers shall be designed and installed to minimize air leakage.

Findings include:

On January 27, 28, and 29 of 2015, the surveyor, accompanied by the Facilities Director, PXO and staff, tested the 3 hour U.L. listed fire doors located in Tower B Med West, doors B243 and B 293 will not positively latch when tested three of three times.

During the exit conference on January 29, 2015, the above findings were again acknowledged by the CEO, CNO, Compliance officer, ED Clinical Supervisor, ANE Director, Facilities Director and PXO

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

Based on observation and no documentation it was determined the facility failed to provide the flame spread rating decorations.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.7.5.4, "Combustible decorations shall be prohibited in any health care occupancy unless they are flame-retardant."

Findings include:

On January 27, 28, and 29 of 2015, the surveyor, accompanied by the Facilities Director, PXO and staff, observed combustible decorations in room ID door # 050540, the facilities has no documentation.

During the exit conference on January 29, 2015, the above findings were again acknowledged by the CEO, CNO, Compliance officer, ED Clinical Supervisor, ANE Director, Facilities Director and PXO.

Failing to maintain decorations in exit corridors could contribute to fire spread and cause harm to the patients.

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

NFPA 101 Life Safety Code, 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 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.

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 8, Section 8-3.1.11.2 (3) (h) Cylinder or container restraint shall meet 4-3.5.2.1(b) (27)." Section 4-3.5.2.1(b)(27) "Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart."

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.

Findings include:

On January 27, 28, and 29 of 2015, the surveyor, accompanied by the Facilities Director, PXO and staff, observed the following medical gas storage:

1. Women's and Children electrical work room, seven E-O2 bottles stored within sixty inches of electrical outlets.
2. Oxygen storage cabinet by room B 377, four empty E-O2 bottles not marked and one full E-O2 bottle marked and not separate.
3. Main ED, oxygen storage cabinet not positively latched, eighteen full E-O2 bottles not separated from four E-O2 bottles.
4. Bed Repair, one unsecured E-O2 bottle.

During the exit conference on January 29, 2015, the above findings were again acknowledged by the CEO, CNO, Compliance officer, ED Clinical Supervisor, ANE Director, Facilities Director and PXO.

Failing to separate an electrical fixture five feet to prevent an accident/or possible fire could cause harm to the patients.
Failing to secure compressed gas cylinders, which could be knocked over, will cause harm to residents and staff.
In an emergency, patients could be harmed if an empty medical gas cylinder was mistakenly taken from the storage area.

Based on observation it was determined the facility failed to allow access to the electrical equipment/panel, allowed the use of a multiple outlet adapter/extension cords, and failed to provide a guard on light bulbs located in the supply closets.,

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1., Section 9.1.2 "Electrical wiring and equipment shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, ARTICLE 110, SECTION 110-26 Spaces About Electrical Equipment. "Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons." Table 110-26(a) Working Space Minimum of three (3) feet in all directions.

( NO STORAGE ALLOWED IN THE WORKING SPACE)

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.

NFPA 101 Life Safety Code, 2000, Chapter 19, 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 110-27 (b) Prevent Physical Damage. " In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage.

Findings include:

On January 27, 28, and 29 of 2015, the surveyor, accompanied by the Facilities Director, PXO and staff, observed the following electrical issues:

1. Electrical room door number 052477,
a. No light cover.
b. Electrical panels L2A and CL2A, blocked by ladder.
2. Door 052451 elevator room,
a. Electrical panel H2R and H2A blocked.
b. No light cover.
3. Broken four plex cover room B 393
4. Two B West, door 050548, staff lounge, microwave plugged into power strip.
5. Nursing support services, door 050541, two power strips daisy chained together with a micro wave plugged into them.
6. Tower A and B, vending machines plugged into extension cord.
7. Hybrid OR, medical equipment plugged into a power strip.

During the exit conference on January 29, 2015, the above findings were again acknowledged by the CEO, CNO, Compliance officer, ED Clinical Supervisor, ANE Director, Facilities Director and PXO.

Blocking of access to electrical panels or equipment may delay personnel from controlling an emergency situation. Patients will be harmed if a fire should start because of a delay.
The facility failed to remove a multiple outlet adapter/extension cord from a receptacle. The use of multiple outlet adapters/extension cord will create an overload of the electrical system and will cause a fire or an electrical hazard. A fire will cause harm to the patients.
Failure to keep light guards on the light bulbs could cause accidental damage or possibly a fire, which could cause harm to the patients.

Based on observation it was determined the facility mounted Alcohol Based Hand Rub (ABHR) dispensers directly over an ignition source.

NFPA 101, Life Safety Code, 2000, 19.3.2.7 and CFR 403.744, 418.100, 460.72, 482.41, 483.70, 483.623, and 485.623. 19.3.2.7, Alcohol-based hand-rub dispensers shall be protected in accordance with 8.7.3, unless all of the following conditions are met:
(1) Where dispensers are installed in a corridor, the corridor shall have a minimum width of 6 feet.
(2) The maximum individual dispenser fluid capacity shall be as follows:
(a) 0.32 gal for dispensers in rooms, corridors, and areas open to corridors.
(b) 0.53 gal for dispensers in suites of rooms.
(3) The dispensers shall be separated from each other by horizontal spacing of not less than 48 inches.
(4) Not more than an aggregate 10 gal of alcohol-based hand-rub solution shall be in use outside of a
storage cabinet in a single smoke compartment.
(5) Storage of quantities greater than 5 gal in a single smoke compartment shall meet the requirements of NFPA 30, Flammable and Combustible Liquids Code.
(6) The dispensers shall not be installed over or directly adjacent to an ignition source.
(7) Dispensers installed directly over carpeted floors shall be permitted only in sprinkler smoke compartments.

On January 27, 28, and 29 of 2015, the surveyor, accompanied by the Facilities Director, PXO and staff, observed the following ABHR dispensers were installed over an electrical outlet or less than forty eight inches together:

1. Electrical room door 052477, 63 per cent alcohol hand sanitizer mounted over a 110 electrical outlet.
2. Two ABS dispensers by room 133 less than 48 inches separation.

During the exit conference on January 29, 2015, the above findings were again acknowledged by the CEO, CNO, Compliance officer, ED Clinical Supervisor, ANE Director, Facilities Director and PXO.

Failing to properly mount ABHR dispensers will cause a fire and harm the patients and staff.

Based on observation it was determined 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 January 27, 28, and 29 of 2015, the surveyor, accompanied by the Facilities Director, PXO and staff, observed the following penetrations:

1. Women's and Children's, second floor janitors closet, hole in the wall.
2. Electrical room, door 052597, hole in wall.

During the exit conference on January 29, 2015, the above findings were again acknowledged by the CEO, CNO, Compliance officer, ED Clinical Supervisor, ANE Director, Facilities Director and PXO.

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.

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

NFPA 101 Life Safety Code 2000, Chapter 19, 19.3.6.3.1 " Doors protecting corridor openings in other than required enclosures of vertical openings, exit, or hazardous areas shall be substantial doors, such as those constructed of 1 3/4 in. thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke

Findings Include:

On January 27, 28, and 29 of 2015, the surveyor, accompanied by the Facilities Director, PXO and staff, observed the following corridor doors would not positively latch:

1. Rooms C 211 and 214 tested three of three times and will not positively latch.
2. Room C 208, door tested three of three times, will not positively latch.
3. Door 052905, latch taped, door will not latch.
4. Door 052911, door tested three of three times, will not positively latch.
5. Door 050437, Three West Nurse Director. Door has a closing device, a pull to close, and the door is impeded by a garbage can.
6. Door 053542, impeded by a metal object placed over latch mechanism.
7. Door 050838, will not positively latch.

During the exit conference on January 29, 2015, the above findings were again acknowledged by the CEO, CNO, Compliance officer, ED Clinical Supervisor, ANE Director, Facilities Director and PXO.

The facility failed to protect patients from heat and smoke.

Based on observation it was determined the facility failed to protect a vertical opening for a elevator.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.1.1 "Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating." Section 8.2.5.2 "Openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier.

Findings Include:

On January 27, 28, and 29 of 2015, the surveyor, accompanied by the Facilities Director, PXO and staff, observed the following corridor door would not tightly close when tested.

1. Fifth floor double doors # 053833 will not latch.
2. Third floor double doors # 053745 will not latch.

During the exit conference on January 29, 2015, the above findings were again acknowledged by the CEO, CNO, Compliance officer, ED Clinical Supervisor, ANE Director, Facilities Director and PXO.

Failing to provide enclosures between floors will cause harm to patients and staff.

Based on observation it was determined 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 ½ 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 January 27, 28, and 29 of 2015, the surveyor, accompanied by the Facilities Director, PXO and staff, observed unsealed penetrations in the smoke barrier/s, located at:

1. Women's and Children smoke barrier doors ID # 052925.

During the exit conference on January 29, 2015, the above findings were again acknowledged by the CEO, CNO, Compliance officer, ED Clinical Supervisor, ANE Director, Facilities Director and PXO.

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.

Based on observation it was determined the facility failed to maintain the self closing/automatic-closing doors in the smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Sections, 19.3.7.6 "Doors in smoke barriers shall comply with 8.3.4.1*" Doors in smoke barriers shall close the opening leaving only minimum clearance necessary for proper operation and shall be without undercuts, lovers, or grills."

Findings include:

On January 27, 28, and 29 of 2015, the surveyor, accompanied by the Facilities Director, PXO and staff, observed the following smoke barrier doors out of adjustment, and not smoke tight:

1. Doors 052457, twenty minute rated doors not smoke tight.
2. Doors 50904, rated to stair well, not smoke tight.
3. Tower A and B separation rated 1-1/2 hour doors not smoke tight.
4. Door 050772, missing astragal, not smoke tight.

During the exit conference on January 29, 2015, the above findings were again acknowledged by the CEO, CNO, Compliance officer, ED Clinical Supervisor, ANE Director, Facilities Director and PXO.

Failure to properly adjust or repair the smoke doors could cause harm to residents.
Non closing smoke doors could allow smoke to enter smoke zones not directly effected by the fire, which could cause harm to the patients.

Based on observation it was determined the facility did not maintain the integrity, smoke resistanc of doors in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.2.1 requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls and doors must be able to resist the passage of smoke. NFPA 80 "Fire Doors and Fire Windows" Chapter 2, Section 2-3.1.7 "The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. +/- 1/16 in for steel doors and shall not exceed 1/8 in. for wood doors.

Findings include:

On January 27, 28, and 29 of 2015, the surveyor, accompanied by the Facilities Director, PXO and staff, observed the following hazardous area doors:

1. Women's and Children's, double doors rated ninety minutes, will not close, coordinator out of adjustment.
2. Corner store, storage room with combustibles, no closing device.
3. Second floor, janitors closet, will not latch.
4. Door 052556, office/storage room, door closing device removed.
5. Door 50414, door wedged open, will not close and positively latch.
6. Door 05054, soiled utility, latch impeded, will not positively latch.
7. OR, 2,4,8, 9 and anesthesia, doors will not positively latch.
8. PACU, soiled utility, door impeded and will not positively latch.
9. Endo deacon room, door 050590, will not positively latch.
10. Door 050586, soiled utility, door will not positively latch.
11. Door 050728 to OR core out of adjustment and will not positively latch.

During the exit conference on January 29, 2015, the above findings were again acknowledged by the CEO, CNO, Compliance officer, ED Clinical Supervisor, ANE Director, Facilities Director and PXO.

Failing to prevent heat and smoke from spreading into the exit corridor will cause harm to patients.

K039 Is a CONDITION of PARTICIPATION

Based on observation it was determined 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. "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:

On January 27, 28, and 29 of 2015, the surveyor, accompanied by the Facilities Director, ED Director, PXO and staff, observed the following exits not immediately accessible from an open floor area, continuous passageways, aisles, or corridors leading directly to every exit:

1. NICU exit access has a storage rack approximately 6' X 6' X 2' and a paper shredder stored in the corridor.
2. Woman's Pre and Post Op, two of two exits reduced from eight feet to approximately six feet by two large cabinets with computers.
3. Old Tower B, by rooms B 383 and 384, nine pieces of equipment reducing exit access from eight feet to approximately seven feet.
4. Outside "Speciality", nine foot corridor reduced to seven feet six inches by eight chairs and a table, two of two exits not readily accessible.
5. ED North by morgue, eight chairs in the exit access, reduced from eight feet to six feet.
6. Main ED, four of four exit access reduced from eight feet to less than approximately six feet by seven beds with patients, chairs, medical equipment, linen storage racks, and a fold down work station.
7. MRI Exit blocked by a bed.

During the exit conference on January 29, 2015, the above findings were again acknowledged by the CEO, CNO, Compliance officer, ED Clinical Supervisor, ANE Director, Facilities Director and PXO.

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

Based on document review and observation it was determined the facility did not inspect, test and maintain the automatic sprinkler system in accordance with the requirements of the Life Safety Code.

NFPA 101 Life Safety Code, 2000, 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 Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems." NFPA 25, Water Based Extinguishment Systems, requires monthly, quarterly and annual testing of automatic sprinkler systems.

Findings include:

On January 27, 28, and 29 of 2015, the surveyor, accompanied by the Facilities Director, PXO and staff, reviewed the records which indicated that the automatic sprinkler system was not inspected or tested monthly, quarterly or annually. The quarterly inspection dated September 10, 2014 was one month late.

The following sprinklers were not maintained:
1. Anesthesia, one of one sprinkler lint.
2. Diagnostic imaging multipurpose room, door number 051258, one of five sprinklers missing escutcheon plate, and two covered with lint.
3. By door 050016, sprinkler covered.
4. Room at door 052916, one of on escutcheon plate missing
5. Door/room 50414, combustibles within 18 inches of sprinklers.

During the exit conference on January 29, 2015, the above findings were again acknowledged by the CEO, CNO, Compliance officer, ED Clinical Supervisor, ANE Director, Facilities Director and PXO

Failure to inspect, test, and maintain the sprinkler system could result in harm to the patients through the spread of smoke and fire.

Based on observation it was determined the facility failed to maintain fire doors.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.2.2.5, "Horizontal exits complying with 7.2.4 and the modifications of (18) or 19.2.2.5.1 through (18) or 19.2.2.5.4 shall be permitted. Section 7.2.4.3.7, Doors in horizontal exits or fire barriers shall be designed and installed to minimize air leakage.

Findings include:

On January 27, 28, and 29 of 2015, the surveyor, accompanied by the Facilities Director, PXO and staff, tested the 3 hour U.L. listed fire doors located in Tower B Med West, doors B243 and B 293 will not positively latch when tested three of three times.

During the exit conference on January 29, 2015, the above findings were again acknowledged by the CEO, CNO, Compliance officer, ED Clinical Supervisor, ANE Director, Facilities Director and PXO

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

Based on observation and no documentation it was determined the facility failed to provide the flame spread rating decorations.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.7.5.4, "Combustible decorations shall be prohibited in any health care occupancy unless they are flame-retardant."

Findings include:

On January 27, 28, and 29 of 2015, the surveyor, accompanied by the Facilities Director, PXO and staff, observed combustible decorations in room ID door # 050540, the facilities has no documentation.

During the exit conference on January 29, 2015, the above findings were again acknowledged by the CEO, CNO, Compliance officer, ED Clinical Supervisor, ANE Director, Facilities Director and PXO.

Failing to maintain decorations in exit corridors could contribute to fire spread and cause harm to the patients.

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

NFPA 101 Life Safety Code, 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 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.

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 8, Section 8-3.1.11.2 (3) (h) Cylinder or container restraint shall meet 4-3.5.2.1(b) (27)." Section 4-3.5.2.1(b)(27) "Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart."

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.

Findings include:

On January 27, 28, and 29 of 2015, the surveyor, accompanied by the Facilities Director, PXO and staff, observed the following medical gas storage:

1. Women's and Children electrical work room, seven E-O2 bottles stored within sixty inches of electrical outlets.
2. Oxygen storage cabinet by room B 377, four empty E-O2 bottles not marked and one full E-O2 bottle marked and not separate.
3. Main ED, oxygen storage cabinet not positively latched, eighteen full E-O2 bottles not separated from four E-O2 bottles.
4. Bed Repair, one unsecured E-O2 bottle.

During the exit conference on January 29, 2015, the above findings were again acknowledged by the CEO, CNO, Compliance officer, ED Clinical Supervisor, ANE Director, Facilities Director and PXO.

Failing to separate an electrical fixture five feet to prevent an accident/or possible fire could cause harm to the patients.
Failing to secure compressed gas cylinders, which could be knocked over, will cause harm to residents and staff.
In an emergency, patients could be harmed if an empty medical gas cylinder was mistakenly taken from the storage area.

Based on observation it was determined the facility failed to allow access to the electrical equipment/panel, allowed the use of a multiple outlet adapter/extension cords, and failed to provide a guard on light bulbs located in the supply closets.,

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1., Section 9.1.2 "Electrical wiring and equipment shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, ARTICLE 110, SECTION 110-26 Spaces About Electrical Equipment. "Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons." Table 110-26(a) Working Space Minimum of three (3) feet in all directions.

( NO STORAGE ALLOWED IN THE WORKING SPACE)

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.

NFPA 101 Life Safety Code, 2000, Chapter 19, 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 110-27 (b) Prevent Physical Damage. " In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage.

Findings include:

On January 27, 28, and 29 of 2015, the surveyor, accompanied by the Facilities Director, PXO and staff, observed the following electrical issues:

1. Electrical room door number 052477,
a. No light cover.
b. Electrical panels L2A and CL2A, blocked by ladder.
2. Door 052451 elevator room,
a. Electrical panel H2R and H2A blocked.
b. No light cover.
3. Broken four plex cover room B 393
4. Two B West, door 050548, staff lounge, microwave plugged into power strip.
5. Nursing support services, door 050541, two power strips daisy chained together with a micro wave plugged into them.
6. Tower A and B, vending machines plugged into extension cord.
7. Hybrid OR, medical equipment plugged into a power strip.

During the exit conference on January 29, 2015, the above findings were again acknowledged by the CEO, CNO, Compliance officer, ED Clinical Supervisor, ANE Director, Facilities Director and PXO.

Blocking of access to electrical panels or equipment may delay personnel from controlling an emergency situation. Patients will be harmed if a fire should start because of a delay.
The facility failed to remove a multiple outlet adapter/extension cord from a receptacle. The use of multiple outlet adapters/extension cord will create an overload of the electrical system and will cause a fire or an electrical hazard. A fire will cause harm to the patients.
Failure to keep light guards on the light bulbs could cause accidental damage or possibly a fire, which could cause harm to the patients.