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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 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 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On June 24, and 25, 2014 the surveyor, accompanied by the Chief Nursing Officer, two Directors of Plant Services and staff, observed the following corridor doors would not tightly close when tested.

1. Staff Lounge, door closing device disconnected.
2. Forth floor, auto clave area, door with a closing device wedged open with a case cart.
3. Pre Op coordinator office, one of two door closing devices disconnected.

During the Exit conference on June 25, 2014 the above findings were again acknowledged by the Chief Nursing Officer, two Directors of Plant Services and the Executive Secretary.

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

Based on observation, it was determined, the facility failed to protect a vertical opening for a service 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 June 24, and 25, 2014 the surveyor, accompanied by the Chief Nursing Officer, two Directors of Plant Services and staff, observed the South Elevator doors by OR will not close and latch secure when tested three of three times.

During the Exit conference on June 25, 2014 the above findings were again acknowledged by the Chief Nursing Officer, two Directors of Plant Services and the Executive Secretary.

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

Based on observation, it was determined, the facility did not maintain the integrity and smoke resistance of doors in hazardous areas; and failed to maintain the smoke resistance of walls, ceilings or pipe chases 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 June 24, and 25, 2014 the surveyor, accompanied by the Chief Nursing Officer, two Directors of Plant Services and staff, observed doors, walls, ceilings, and pipe chases in the following locations that are not smoke resistance:

1. Fifth floor, Medical records, two of two doors no door closing devices.
2. Forth floor, IT, penetrations in the walls, and no door closing device.
3. Forth floor, Nurses environmental services storage room, no door closing device, room contains flammables and combustibles/Environmental services storage room, no door closing device, chemicals.
4. Cath Lab, double rated doors, missing the astragal, not smoke tight.
5. Instrument room, double doors, not smoke tight.
6. Back room of autoclave, penetrations in the walls.
7. Second floor, soiled utility room, door tested three of three times, will not positively latch.
8. First floor, E-3 Penetrations through wall.
9. Riser room, 1,2,and 3, holes in the walls, approximately 12 X 12 inches.
10. Ultra sound door, will not close, held open by a cart.
11. CT Scan room, door wedged open, door has a broken hold open device.
12. Third floor, Data room, two hour wall with penetrations.
13. Nursing North, Double rated doors not smoke tight, penetrations in the wall.

During the Exit conference on June 25, 2014 the above findings were again acknowledged by the Chief Nursing Officer, two Directors of Plant Services and the Executive Secretary.

Failing to fill pipe chases or holes could allow heat and smoke to spread into walls, attics, or exit corridors which will cause harm to the patients.

Based on record review and observation, it was determined, the facility failed to document the monthly and annual testing of battery back up emergency lighting.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.2.9.1, "Emergency lighting shall be provided in accordance with Section 7.9". Section 7.9.3 " Periodic Testing of Emergency Lighting Equipment" " A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction."
Section 7.9."Section 7.9.2.4 "Battery-operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition."

Findings include:

On June 24, and 25, 2014 the surveyor, accompanied by the Chief Nursing Officer, two Directors of Plant Services and staff, requested the documentation for all Emergency lighting, the facility has no documentation of monthly or annual testing.
The following emergency lights failed when tested; room 407 and the Antie room.

During the Exit conference on June 25, 2014 the above findings were again acknowledged by the Chief Nursing Officer, two Directors of Plant Services and the Executive Secretary.

Failure to maintain emergency lighting units in proper operating condition will cause harm to the patients during a power outage.

Based on document review, and staff interview, it was determined, the facility failed to train the staff on life safety procedures and devices.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.7.1.2 Fire exit drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions." When drills are conducted between 9:00 p.m. and 6:00 a.m., a coded announcement shall be permitted to be used instead of a audible alarms.

Findings include:

On June 24, and 25, 2014 the surveyor, accompanied by the Chief Nursing Officer, two Directors of Plant Services and staff, reviewed the Fire Prevention Management Plan, Fire Response Plan and the Fire Drill documents. Staff members were interviewed about their participation during the facilities Fire Drill training.

The facility does not practice the elements required by there Management Plans and CMS for all facility personnel on a quarterly requirement. A five year employee stated they have never participated in a Fire Drill. A Nursing staff supervisor stated she has had one Fire Drill in the last twelve months.

The facility has no Fire Drill training documentation for the third and fourth quarter of 2013.

During the Exit conference on June 25, 2014 the above findings were again acknowledged by the Chief Nursing Officer, two Directors of Plant Services and the Executive Secretary.

Failure to train and drill the staff on fire procedures could result in harm to the patients.

Based on document review, and staff interview, it was determined, the facility failed to complete the repairs after the annual fire alarm system test and maintenance.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.4.1, "Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6." Section 9.6.1.4 "A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code...,
NFPA 72, Chapter 7 "Inspection Testing, and Maintenance" Section 7-3.2 "Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by authority having jurisdiction. Table 7-3.2 requires monthly and annual fire alarm inspections, testing and maintenance.

Findings include:

On June 24, and 25, 2014 the surveyor, accompanied by the Chief Nursing Officer, two Directors of Plant Services and staff, reviewed the April 2014 annual fire alarm system maintenance report. The report indicated numerous items in need of repair with no documentation indicating repairs have been made. The Fire Alarm panel is in trouble and cannot be cleared until repairs are made.

During the Exit conference on June 25, 2014 the above findings were again acknowledged by the Chief Nursing Officer, two Directors of Plant Services and the Executive Secretary.

Failure to test and maintain the fire alarm system will result in harm to the patients.

Based on document review, and staff interview, it was determined, the facility failed to inspect, test and maintain the automatic sprinkler system in accordance with the requirements of the Life Safety Code.
The facility failed to maintain the exterior fire department connection.

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.


NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.1.5, "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.1.1 "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 3, Section 3-2.7.2, "Escutcheon Plates used with a recessed or flushed sprinkler shall be part of a listed sprinkler assembly."
NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.3.5.1 or 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 9.7.1.1. "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 2, Section 3-9 Fire Department Connections, Section 3-9.2 " Fire department connections shall be equipped with listed plugs or caps, properly secured and arranged for easy removal by fire departments."

Finding include:

On June 24, and 25, 2014 the surveyor, accompanied by the Chief Nursing Officer, t6wo Directors of Plant Services and staff, reviewed the records which indicated the automatic sprinkler system is not maintained as required. Components of the system have not been replaced and inspected or tested as required by the above standards.
A staff member stated when the quarterly flow test is done there is no time of the water flow checked by any timing device.
Escutcheon plates are missing from the sprinkler assembly in the following area, Sweet Shop missing two of eight escutcheon plates.
The outside free standing fire department connection was missing one of two caps at the south west FDC.

During the Exit conference on June 25, 2014 the above findings were again acknowledged by the Chief Nursing Officer, two Directors of Plant Services and the Executive Secretary.

Failure to inspect, test, and maintain the sprinkler system could result in harm to the patients through the spread of smoke and fire.
Failing to maintain sprinkler heads, missing escutcheon plates, which are part of the UL Listing of the sprinkler assembly, will allow heat and smoke to effect other areas of the building. This will cause harm to the patients.
Failure to provide plugs or caps for the fire department connection could allow a person to insert material which will block the ability for the fire department to pump into the automatic sprinkler system. This will cause harm to the patients.

Based on observation it was determined the facility failed to wall mount a fire extinguisher.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.5.6 "Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1" Section 9.7.4.1 "Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for portable Fire Extinguishers." NFPA 10, Chapter 1, Section 1-6.7 "Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer's instructions...."

Findings include:

On June 24, and 25, 2014 the surveyor, accompanied by the Chief Nursing Officer, two Directors of Plant Services and staff, observed the fire extinguisher located in the E 3 electrical room was resting on the floor and not mounted to the wall.

During the Exit conference on June 25, 2014 the above findings were again acknowledged by the Chief Nursing Officer, two Directors of Plant Services and the Executive Secretary.

Failing to properly secure a charged fire extinguisher could result in harm to the residents and staff.

Based on Observation it was determined the facility failed to separate empty and full medical gas cylinders and provide a sign for medical gas cylinder and keep the oxygen bottles free of combustible materials.

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.

NFPA 101 Life Safety Code 2000, or 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 "Storage Requirements" Section 8-3.1.11.2 "Storage of nonflammable gases less than 3000 cubic. feet.." (a) "Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. (c) "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by: (c) (2) A minimum distance of 5 ft. if the entire storage location is protected by an automatic sprinkler system..."

Findings Include:

On June 24, and 25, 2014 the surveyor, accompanied by the Chief Nursing Officer, two Directors of Plant Services and staff, observed the storage of oxygen in the following locations:

1. Forth floor, C section, one E O2 bottle not secured in a rack.

2. Labor and Delivery, seven E O2 within five feet of combustibles and electrical, one E O 2 not secure, not segregated or marked full/empty. The room has an approved oxygen storage cabinet that is not being used to capacity,

3. Med Surg. 1, four E O2 bottles stored outside of an approved oxygen storage cabinet by combustibles.

During the Exit conference on June 25, 2014 the above findings were again acknowledged by the Chief Nursing Officer, two Directors of Plant Services and the Executive Secretary.

Leaking oxygen could penetrate combustible materials and create an extreme fire hazard, which could cause harm to the patients. In an emergency, patients could be harmed if an empty medical gas cylinder was mistakenly taken from the storage area.

Based on observation, record review and Staff interview, it was determined the facility failed to document the required testing of the emergency generator, and test the alarm for the generator annunciator panel at the the Nurses station.

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."

NFPA 99 "Standard for Health Care Facilities."Chapter #3 Electrical Systems, Section 3-4.1.1.14 Requirements for Safety Devices. Section 3-4.1.1.15 Alarm Annunciator."A remote annunciator storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station.(see NFPA 70,National Electrical code, 700-12). The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows,

(a) Individual visual signals shall indicate the following:
(1) When the emergency or auxiliary power source is operating to supply power to load.
(2) When the battery charger is malfunctioning
(b) Individual signals plus a common audible signal to warn of an engine-generator alarm condition shall
indicate the following:
(1) Low lubricating oil pressure
(2) Low water temperature(below those required in (3-4.1.1.9)
(3) Excessive water temperature
(4) Low fuel-when the main fuel storage tank contains less than a 3 hour operating supply.
(5) Overcrank (failed to start)
(6) Overspeed

Findings include:

On June 24, and 25, 2014 the surveyor, accompanied by the Chief Nursing Officer, two Directors of Plant Services and staff, reviewed the four emergency generator weekly and monthly documents for the required testing of the emergency generators, and testing of the alarm for the generator annunciator panel at the the Nurses station. The following are the findings:

1. Generator number one (Kohler)
No documented monthly load test for; November; October; August and July of 2013.
No documented monthly load test for; January and May 2014. Septembers transfer time was 13 seconds.

2. Generator number two (Spectrum)
No documented monthly load test for; November; October; September of 2013 transfer time was 13 seconds.

3. Generator number three (Spectrum)
No documented monthly load test for; November; October; August and July of 2013 September transfer time was 13 seconds.
No weekly documentation for the weeks of November 19, 2013 and January 4 and April 16, 2014.

4. Generator number four (Spectrum)
No documented monthly load test for; June; July; and august 2013.
No weekly documentation for the weeks February 11 and 25, 2013.

The Alarm Annunciator panel for generator number three was not working when tested by the surveyor.

During the Exit conference on June 25, 2014 the above findings were again acknowledged by the Chief Nursing Officer, two Directors of Plant Services and the Executive Secretary.

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 emergency system failures.
Failure of the alarm annunciator panel or failure to provide a remote annunciator panel in a readily observed location may result in harm to the patients in time of a fire or emergency.

Based on observation, record review and Staff interview, it was determined the facility failed to document the monthly testing of the Line Isolation Monitor tests/Isolated Electrical Panels.
The facility failed to provide a guard on the light bulb.


NFPA 101, Life Safety Code, 2000 Edition, Maintenance and Testing (See 4.6.12) "Maintenance and Testing "Section 4.6.12.1, "Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction."

"NFPA 99 1999 Edition, Health Care Facilities Section 3-3.3.4.2 The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following: (b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch (see 3-3.2.2.3(f)) For a LIM circuit with automated self-test and self calibration capabilities this test shall be performed at intervals of not more that 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators."

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 June 24, and 25, 2014 the surveyor, accompanied by the Chief Nursing Officer, two Directors of Plant Services and staff, requested the documentation of the testing of the Line Isolation monitors in the operating rooms. The facility has no documentation.

The following areas have no light bulb protection:

1. South mechanical room, sixteen lighting units, no cover.

2. Third floor, data room one of one light no cover.

3. Second Floor, Maintenance/storage, one of two lights, no cover

During the Exit conference on June 25, 2014 the above findings were again acknowledged by the Chief Nursing Officer, two Directors of Plant Services and the Executive Secretary.

Failing to test and maintain documentation on the Line Isolation Tests/Isolated Electrical Panels could cause harm to the patients in an emergency or power outage.

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 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 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On June 24, and 25, 2014 the surveyor, accompanied by the Chief Nursing Officer, two Directors of Plant Services and staff, observed the following corridor doors would not tightly close when tested.

1. Staff Lounge, door closing device disconnected.
2. Forth floor, auto clave area, door with a closing device wedged open with a case cart.
3. Pre Op coordinator office, one of two door closing devices disconnected.

During the Exit conference on June 25, 2014 the above findings were again acknowledged by the Chief Nursing Officer, two Directors of Plant Services and the Executive Secretary.

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

Based on observation, it was determined, the facility failed to protect a vertical opening for a service 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 June 24, and 25, 2014 the surveyor, accompanied by the Chief Nursing Officer, two Directors of Plant Services and staff, observed the South Elevator doors by OR will not close and latch secure when tested three of three times.

During the Exit conference on June 25, 2014 the above findings were again acknowledged by the Chief Nursing Officer, two Directors of Plant Services and the Executive Secretary.

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

Based on observation, it was determined, the facility did not maintain the integrity and smoke resistance of doors in hazardous areas; and failed to maintain the smoke resistance of walls, ceilings or pipe chases 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 June 24, and 25, 2014 the surveyor, accompanied by the Chief Nursing Officer, two Directors of Plant Services and staff, observed doors, walls, ceilings, and pipe chases in the following locations that are not smoke resistance:

1. Fifth floor, Medical records, two of two doors no door closing devices.
2. Forth floor, IT, penetrations in the walls, and no door closing device.
3. Forth floor, Nurses environmental services storage room, no door closing device, room contains flammables and combustibles/Environmental services storage room, no door closing device, chemicals.
4. Cath Lab, double rated doors, missing the astragal, not smoke tight.
5. Instrument room, double doors, not smoke tight.
6. Back room of autoclave, penetrations in the walls.
7. Second floor, soiled utility room, door tested three of three times, will not positively latch.
8. First floor, E-3 Penetrations through wall.
9. Riser room, 1,2,and 3, holes in the walls, approximately 12 X 12 inches.
10. Ultra sound door, will not close, held open by a cart.
11. CT Scan room, door wedged open, door has a broken hold open device.
12. Third floor, Data room, two hour wall with penetrations.
13. Nursing North, Double rated doors not smoke tight, penetrations in the wall.

During the Exit conference on June 25, 2014 the above findings were again acknowledged by the Chief Nursing Officer, two Directors of Plant Services and the Executive Secretary.

Failing to fill pipe chases or holes could allow heat and smoke to spread into walls, attics, or exit corridors which will cause harm to the patients.

Based on record review and observation, it was determined, the facility failed to document the monthly and annual testing of battery back up emergency lighting.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.2.9.1, "Emergency lighting shall be provided in accordance with Section 7.9". Section 7.9.3 " Periodic Testing of Emergency Lighting Equipment" " A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction."
Section 7.9."Section 7.9.2.4 "Battery-operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition."

Findings include:

On June 24, and 25, 2014 the surveyor, accompanied by the Chief Nursing Officer, two Directors of Plant Services and staff, requested the documentation for all Emergency lighting, the facility has no documentation of monthly or annual testing.
The following emergency lights failed when tested; room 407 and the Antie room.

During the Exit conference on June 25, 2014 the above findings were again acknowledged by the Chief Nursing Officer, two Directors of Plant Services and the Executive Secretary.

Failure to maintain emergency lighting units in proper operating condition will cause harm to the patients during a power outage.

Based on document review, and staff interview, it was determined, the facility failed to train the staff on life safety procedures and devices.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.7.1.2 Fire exit drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions." When drills are conducted between 9:00 p.m. and 6:00 a.m., a coded announcement shall be permitted to be used instead of a audible alarms.

Findings include:

On June 24, and 25, 2014 the surveyor, accompanied by the Chief Nursing Officer, two Directors of Plant Services and staff, reviewed the Fire Prevention Management Plan, Fire Response Plan and the Fire Drill documents. Staff members were interviewed about their participation during the facilities Fire Drill training.

The facility does not practice the elements required by there Management Plans and CMS for all facility personnel on a quarterly requirement. A five year employee stated they have never participated in a Fire Drill. A Nursing staff supervisor stated she has had one Fire Drill in the last twelve months.

The facility has no Fire Drill training documentation for the third and fourth quarter of 2013.

During the Exit conference on June 25, 2014 the above findings were again acknowledged by the Chief Nursing Officer, two Directors of Plant Services and the Executive Secretary.

Failure to train and drill the staff on fire procedures could result in harm to the patients.

Based on document review, and staff interview, it was determined, the facility failed to complete the repairs after the annual fire alarm system test and maintenance.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.4.1, "Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6." Section 9.6.1.4 "A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code...,
NFPA 72, Chapter 7 "Inspection Testing, and Maintenance" Section 7-3.2 "Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by authority having jurisdiction. Table 7-3.2 requires monthly and annual fire alarm inspections, testing and maintenance.

Findings include:

On June 24, and 25, 2014 the surveyor, accompanied by the Chief Nursing Officer, two Directors of Plant Services and staff, reviewed the April 2014 annual fire alarm system maintenance report. The report indicated numerous items in need of repair with no documentation indicating repairs have been made. The Fire Alarm panel is in trouble and cannot be cleared until repairs are made.

During the Exit conference on June 25, 2014 the above findings were again acknowledged by the Chief Nursing Officer, two Directors of Plant Services and the Executive Secretary.

Failure to test and maintain the fire alarm system will result in harm to the patients.

Based on document review, and staff interview, it was determined, the facility failed to inspect, test and maintain the automatic sprinkler system in accordance with the requirements of the Life Safety Code.
The facility failed to maintain the exterior fire department connection.

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.


NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.1.5, "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.1.1 "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 3, Section 3-2.7.2, "Escutcheon Plates used with a recessed or flushed sprinkler shall be part of a listed sprinkler assembly."
NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.3.5.1 or 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 9.7.1.1. "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 2, Section 3-9 Fire Department Connections, Section 3-9.2 " Fire department connections shall be equipped with listed plugs or caps, properly secured and arranged for easy removal by fire departments."

Finding include:

On June 24, and 25, 2014 the surveyor, accompanied by the Chief Nursing Officer, t6wo Directors of Plant Services and staff, reviewed the records which indicated the automatic sprinkler system is not maintained as required. Components of the system have not been replaced and inspected or tested as required by the above standards.
A staff member stated when the quarterly flow test is done there is no time of the water flow checked by any timing device.
Escutcheon plates are missing from the sprinkler assembly in the following area, Sweet Shop missing two of eight escutcheon plates.
The outside free standing fire department connection was missing one of two caps at the south west FDC.

During the Exit conference on June 25, 2014 the above findings were again acknowledged by the Chief Nursing Officer, two Directors of Plant Services and the Executive Secretary.

Failure to inspect, test, and maintain the sprinkler system could result in harm to the patients through the spread of smoke and fire.
Failing to maintain sprinkler heads, missing escutcheon plates, which are part of the UL Listing of the sprinkler assembly, will allow heat and smoke to effect other areas of the building. This will cause harm to the patients.
Failure to provide plugs or caps for the fire department connection could allow a person to insert material which will block the ability for the fire department to pump into the automatic sprinkler system. This will cause harm to the patients.

Based on observation it was determined the facility failed to wall mount a fire extinguisher.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.5.6 "Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1" Section 9.7.4.1 "Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for portable Fire Extinguishers." NFPA 10, Chapter 1, Section 1-6.7 "Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer's instructions...."

Findings include:

On June 24, and 25, 2014 the surveyor, accompanied by the Chief Nursing Officer, two Directors of Plant Services and staff, observed the fire extinguisher located in the E 3 electrical room was resting on the floor and not mounted to the wall.

During the Exit conference on June 25, 2014 the above findings were again acknowledged by the Chief Nursing Officer, two Directors of Plant Services and the Executive Secretary.

Failing to properly secure a charged fire extinguisher could result in harm to the residents and staff.

Based on Observation it was determined the facility failed to separate empty and full medical gas cylinders and provide a sign for medical gas cylinder and keep the oxygen bottles free of combustible materials.

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.

NFPA 101 Life Safety Code 2000, or 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 "Storage Requirements" Section 8-3.1.11.2 "Storage of nonflammable gases less than 3000 cubic. feet.." (a) "Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. (c) "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by: (c) (2) A minimum distance of 5 ft. if the entire storage location is protected by an automatic sprinkler system..."

Findings Include:

On June 24, and 25, 2014 the surveyor, accompanied by the Chief Nursing Officer, two Directors of Plant Services and staff, observed the storage of oxygen in the following locations:

1. Forth floor, C section, one E O2 bottle not secured in a rack.

2. Labor and Delivery, seven E O2 within five feet of combustibles and electrical, one E O 2 not secure, not segregated or marked full/empty. The room has an approved oxygen storage cabinet that is not being used to capacity,

3. Med Surg. 1, four E O2 bottles stored outside of an approved oxygen storage cabinet by combustibles.

During the Exit conference on June 25, 2014 the above findings were again acknowledged by the Chief Nursing Officer, two Directors of Plant Services and the Executive Secretary.

Leaking oxygen could penetrate combustible materials and create an extreme fire hazard, which could cause harm to the patients. In an emergency, patients could be harmed if an empty medical gas cylinder was mistakenly taken from the storage area.

Based on observation, record review and Staff interview, it was determined the facility failed to document the required testing of the emergency generator, and test the alarm for the generator annunciator panel at the the Nurses station.

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."

NFPA 99 "Standard for Health Care Facilities."Chapter #3 Electrical Systems, Section 3-4.1.1.14 Requirements for Safety Devices. Section 3-4.1.1.15 Alarm Annunciator."A remote annunciator storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station.(see NFPA 70,National Electrical code, 700-12). The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows,

(a) Individual visual signals shall indicate the following:
(1) When the emergency or auxiliary power source is operating to supply power to load.
(2) When the battery charger is malfunctioning
(b) Individual signals plus a common audible signal to warn of an engine-generator alarm condition shall
indicate the following:
(1) Low lubricating oil pressure
(2) Low water temperature(below those required in (3-4.1.1.9)
(3) Excessive water temperature
(4) Low fuel-when the main fuel storage tank contains less than a 3 hour operating supply.
(5) Overcrank (failed to start)
(6) Overspeed

Findings include:

On June 24, and 25, 2014 the surveyor, accompanied by the Chief Nursing Officer, two Directors of Plant Services and staff, reviewed the four emergency generator weekly and monthly documents for the required testing of the emergency generators, and testing of the alarm for the generator annunciator panel at the the Nurses station. The following are the findings:

1. Generator number one (Kohler)
No documented monthly load test for; November; October; August and July of 2013.
No documented monthly load test for; January and May 2014. Septembers transfer time was 13 seconds.

2. Generator number two (Spectrum)
No documented monthly load test for; November; October; September of 2013 transfer time was 13 seconds.

3. Generator number three (Spectrum)
No documented monthly load test for; November; October; August and July of 2013 September transfer time was 13 seconds.
No weekly documentation for the weeks of November 19, 2013 and January 4 and April 16, 2014.

4. Generator number four (Spectrum)
No documented monthly load test for; June; July; and august 2013.
No weekly documentation for the weeks February 11 and 25, 2013.

The Alarm Annunciator panel for generator number three was not working when tested by the surveyor.

During the Exit conference on June 25, 2014 the above findings were again acknowledged by the Chief Nursing Officer, two Directors of Plant Services and the Executive Secretary.

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 emergency system failures.
Failure of the alarm annunciator panel or failure to provide a remote annunciator panel in a readily observed location may result in harm to the patients in time of a fire or emergency.

Based on observation, record review and Staff interview, it was determined the facility failed to document the monthly testing of the Line Isolation Monitor tests/Isolated Electrical Panels.
The facility failed to provide a guard on the light bulb.


NFPA 101, Life Safety Code, 2000 Edition, Maintenance and Testing (See 4.6.12) "Maintenance and Testing "Section 4.6.12.1, "Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction."

"NFPA 99 1999 Edition, Health Care Facilities Section 3-3.3.4.2 The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following: (b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch (see 3-3.2.2.3(f)) For a LIM circuit with automated self-test and self calibration capabilities this test shall be performed at intervals of not more that 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators."

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 June 24, and 25, 2014 the surveyor, accompanied by the Chief Nursing Officer, two Directors of Plant Services and staff, requested the documentation of the testing of the Line Isolation monitors in the operating rooms. The facility has no documentation.

The following areas have no light bulb protection:

1. South mechanical room, sixteen lighting units, no cover.

2. Third floor, data room one of one light no cover.

3. Second Floor, Maintenance/storage, one of two lights, no cover

During the Exit conference on June 25, 2014 the above findings were again acknowledged by the Chief Nursing Officer, two Directors of Plant Services and the Executive Secretary.

Failing to test and maintain documentation on the Line Isolation Tests/Isolated Electrical Panels could cause harm to the patients in an emergency or power outage.