HospitalInspections.org

Based on observation and staff interview, the facility failed to ensure safety to residents due to corridor wall not being smoke-tight in two locations in accordance with the requirement of NFPA 101 19.3.6.2.2. This deficient practice affected 2 of 9 smoke compartments. The facility has a capacity of 25 with a census of 7 inpatients at the time of survey.
Findings include
During a tour of the facility with Staff B (RN, director of quality and safety officer), and Staff N (environmental services director) on 7/11/2011, Surveyor 12316 observed that (i) at 4:30 pm, the 3 ' x 3 ' -6 " opening in upper half of corridor wall of the Physical Therapy Main Reception was protected with a wood door, but the ? in gap at the bottom of door (door undercut) did not prevent the passage of smoke in accordance with NFPA 19.3.6.2.2; and (ii) corridor wall of CT Scan Control room had 2 cable and 1 electrical conduit penetrations of 2 in to 2 1/2 in diameter that were not sealed to make the wall smoke-tight.
The above deficiency was acknowledged by the environmental services director, and Staff N (environmental services director) at the time of discovery, and confirmed with Staff Z (administrator/CEO), and Staff A (chief nursing officer) at the exit conference on 7/13/2011 at 4:30 pm.

Based on observation and staff interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to failure to keep doors suitably closed in 2 locations. This affected 2 of 9 smoke compartments in the facility. The facility has a capacity of 25 with a census of 7 inpatients at the time of survey.

Findings include

During a tour of the facility with Staff B (RN, director of quality and safety officer), and Staff N (environmental services director) on 7/12/2011, Surveyor 12316 observed in the following two locations that corridor doors did not suitably close.
(i) On 7/12/2011 at 11:50 am, the corridor double doors of the Intensive Care Unit did not positively latch due to the inactive leaf not kept latched to the top door frame. When Surveyor 12316 closed the active leaf, the door latched onto the inactive leaf, but the doors were observed to swing and bow in, when a push force was applied on the doors. This does not meet the NFPA 101 19.3.6.3.2 requirement; and (ii) On 7/12/2011 at 2:34 pm, the Staff Locker Room corridor door adjacent to the dark room in the Medical Imaging was held open with two wheel chairs, which is an impediment to closing of doors.

The above deficiency was acknowledged by the environmental services director, and director of quality and safety officer at the time of discovery, and confirmed with Staff Z (administrator/CEO), and Staff A (chief nursing officer) at the exit conference on 7/13/2011 at 4:30 pm.

Based on observation and staff interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to two sets of smoke doors not maintained or installed to fully close. This deficient practice affected 2 of 9 smoke compartments in the facility. The facility has a capacity of 25 with a census of 7 inpatients at the time of survey.

Findings Include

During a tour of the facility with Staff B (RN, director of quality and safety officer), and Staff N (environmental services director), Surveyor 12316 observed that (i) on 7/11/2011 at 4:16 pm, the cross-corridor smoke doors located adjacent to the Therapy in the Lower Level (ground floor) did not fully close and left a gap more than necessary for proper operation at the meeting edge; and (ii) on 7/12/2011 at 2:33 pm, the cross-corridor smoke doors located near the Ultrasound Room on the 1st Floor did not fully close when manually tested; the doors left a ? in gap at the meeting edge, which is more than necessary for proper operation.

The above deficiency was acknowledged by the environmental services director, and director of quality and safety officer at the time of discovery, and confirmed with Staff Z (administrator/CEO), and Staff A (chief nursing officer) at the exit conference on 7/13/2011 at 4:30 pm.

Based on observation and staff interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to two fire-rated doors of hazardous areas not properly maintained. This deficient practice affected 2 of 9 smoke compartments in the facility. The facility has a capacity of 25 with a census of 7 inpatients at the time of survey.
Findings Include

During a tour of the facility with Staff B (RN, director of quality and safety officer), and Staff N (environmental services director) on 7/12/2011, Surveyor 12316 observed that (i) at 10:19 pm, the 45 minute fire-rated corridor door of the hospital Central Supply Room adjacent to the Kitchen on the Lower Level closed but did not latch, when tested; and (ii) at 3:20 pm, the fire-rated door of the Gift Shop Storage on the 1st Floor was propped open with a wood wedge, which is an impediment to closing of doors. This did not meet the requirement of NFPA 101 19.3.2.1.

The above deficiency was acknowledged by the environmental services director at the time of discovery, and confirmed with Staff Z (administrator/CEO), Staff B (RN, director of quality and safety officer, and Staff A (chief nursing officer) at the exit conference on 7/13/2011 at 4:30 pm.

Based on observation and staff interview, the facility failed to ensure safety to residents due to lack of handrails on ramp in one means of egress, which is required to provide a safe access to a public way in accordance with the requirement of NFPA 101 7.1.7.2. This deficient practice affected all patients in 2 of 9 smoke compartments in resident sleeping areas. The facility has a capacity of 25 with a census of 7 inpatients at the time of survey.
Findings include
During a tour of the facility with Staff B (RN, director of quality and safety officer), and Staff N (environmental services director) on 7/11/2011, Surveyor 12316 observed at 4:06 pm that there was no handrails in one exit discharge ramp from the West Exit Stair B in accordance with NFPA 101.7.1.7.2, 7.2.2.4.2.
The above deficiency was acknowledged by the environmental services director, and director of quality and safety officer at the time of discovery, and confirmed with Staff Z (administrator/CEO), and Staff A (chief nursing officer) at the exit conference on 7/13/2011 at 4:30 pm.

NFPA 101 7.1.7.2
"Changes in level in means of egress not in excess of 21 in. (53.3 cm) shall be achieved either by a ramp or by a stair complying with the requirements of 7.2.2. "
NFPA 101 7.2.2.4.2
"Stairs and ramps shall have handrails on both sides .... "

Based on record review and staff interview, the facility failed to maintain the fire drill records. This affected the entire facility. The facility has a capacity of 25 with a census of 7 inpatients at the time of survey.

Findings include

During the review of fire drill records on 7/13/2011 between 11:40 am and 3:30 pm, it was revealed that fire drill reports for the following quarters were not documented.

1st Shift drill of 3rd and 4th Quarters of 2010;
2nd Shift drill of 2nd, 3rd and 4th Quarters of 2010, and 1st and 2nd Quarters of 2011;
3rd Shift drill of all 4 Quarters of 2010, and 1st and 2nd Quarters of 2011.

When interviewed on 7/13/2011 at 4:15 pm, Staff N (environmental services director) stated that the fire drills were conducted, but not documented. Due to lack of fire drill reports, Surveyor 12316 could not verify that procedures in case of fire were observed during the fire drills in accordance with NFPA 101 19.7.2.1, and whether the fire drills were conducted under varied conditions as stated in NFPA 101 19.7.1.2.

The above deficiency was confirmed with the environmental services director, Staff B (director of quality and safety officer), Staff Z (administrator/CEO) and Staff A (chief nursing officer) at the exit conference on 7/13/2011 at 4:30 pm.

Based on observation and staff interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to failure to install sprinkler heads at proper spacing in accordance with NFPA 13 (1999) 5-6.3.4. This deficient practice affected 3 of 9 smoke compartments in the facility. The facility has a capacity of 25 with a census of 7 inpatients at the time of survey.

Findings include

During a tour of the facility with Staff B (RN, director of quality and safety officer), and Staff N (environmental services director) between 7/11 - 7/13/2011, Surveyor 12316 observed in the following 4 locations that the sprinkler heads were spaced less than 6 ft apart. This did not meet the requirement of NFPA 13 5-6.3.4.
(i) On 7/11/2011 at 3:06 pm, the Storage Room 131 in the West Wing had two sprinkler heads installed 2'-9" apart;
(ii) On 7/11/2011 at 4:24 pm, the Speech Therapy Room, and Physical Therapy Office Room had two sprinklers spaced sprinkler heads spaced 2'-6" apart; and
(iii) On 7/12/2011 at 2:32 pm, the Change Room in Medical Imaging had two sprinklers spaced sprinkler heads spaced 4'-4" apart.

The above deficiency was acknowledged by the environmental services director and director of quality and safety officer at the time of discovery, and confirmed with Staff Z (administrator/CEO), and Staff A (chief nursing officer) at the exit conference on 7/13/2011 at 4:30 pm.

Based on observation, staff interview, and review of records the facility failed to ensure safety to patients, staff and visitors of the facility due to failure to maintain the automatic, supervised sprinkler system in accordance with the requirements of NFPA 13 (1999) and 25 Standards 1998 edition. This deficient practice affected the entire facility. The facility has a capacity of 25 with a census of 7 inpatients at the time of survey.

Findings include

1. During a tour of the facility with Staff B (RN, director of quality and safety officer), and Staff N (environmental services director) between 7/11 - 7/12/2011, Surveyor 12316 observed in the following 8 locations that there was either less than 18 in. vertical clearance between the sprinkler deflectors and the top of storage in accordance with the requirement of NFPA 13 5-5.6, or dirty sprinkler heads.

(i) On 7/11/2011 at 4:20 pm, the Physical Therapy (PT) Storage adjacent to smoke doors on the Lower Level did not have the 18 in. clearance;
(ii) On 7/11/2011 at 4:32 pm, the PT Storage Closet located in the Therapy Room on the Lower Level did not have the 18 in. clearance;
(iii) On 7/12/2011 at 10:05 am, the top of storage in aisle adjacent to the dietary manager's office in the Kitchen did not have the 18 in. clearance;
(iv) On 7/12/2011 at 1:30 pm, one sprinkler head in Pre-Op Room 2 was dirty;
(v) On 7/12/2011 at 2:16 pm, the escutcheon plate of one sprinkler head was missing in the Lab Room;
(vi) On 7/12/2011 at 2:22 pm, the Lab Supply Room on the 1st Floor (upper level) did not have the 18 in. clearance above the top of storage. The sprinkler head was almost completely surrounded by stored objects on the top shelf.
(vii) On 7/12/2011 at 2:28 pm, one sprinkler head in the Medical Imaging Area was dirty. The sprinkler was located in the corridor adjacent to the control room of CT Scan; and
(viii) On 7/12/2011 at 3:20 pm, the Gift Shop Storage did not have the 18 in. clearance between the top of storage and sprinkler deflector;

2. During the review of sprinkler system maintenance records on 7/12/2011 between 3:30 and 4:45 pm, Surveyor 12316 found that there were no records (i) of quarterly and monthly inspections of the sprinkler system; and (ii) of the five-yearly inspection of gauges and check valves. Surveyor 12316 could not verify that inspection, testing and maintenance were performed in accordance with the requirements of NFPA 25 2-1 and 9-1.

When interviewed on 7/13/2011 at 4:15 pm, Staff N (environmental services director) stated that the quarterly and monthly inspections were performed, but not documented. This did not meet the requirement of NFPA 25 2-1.3.

3. During the review of sprinkler system maintenance records 7/12/2011 between 3:30 and 4:45 pm, Surveyor 12316 found that the supervisory switch of control valves of the sprinkler system was tested annually, but not semi-annually in accordance with the requirement of NFPA 25 9-3.4.3. The annual testes were performed on 3/29/2011 and 3/30/2010 by Van's Fire and Safety.

The above deficiency was acknowledged by the environmental services director and by the director of quality and safety officer either at the time of discovery, or confirmed with them and with Staff Z (administrator/CEO) and Staff A (chief nursing officer) at the exit conference on 7/13/2011 at 4:30 pm.


NFPA 25 2-1.3
" Records: Records shall be maintained in accordance with Section 1-8. "

NFPA 25 1-9.1
" System components shall be inspected at intervals specified in the appropriate chapters. "

NFPA 25 1-8
" Records. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request ... "

Based on observation and staff interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to objects placed in two locations of means of egress causing obstruction to access the exit stair. This deficient practice affected 2 of 9 smoke compartments in the facility. The facility has a capacity of 25 with a census of 7 inpatients at the time of survey.

Findings include

During a tour of the facility with Staff B (RN, director of quality and safety officer), and Staff N (environmental services director) on 7/11/2011, Surveyor 12316 observed that (i) at 3:10 pm, one Hoyer lift was stored in corridor adjacent to Stair B on the Upper Level of 1972 building causing obstruction to access the exit stair; and (ii) at 4 pm, one Northern Lights Clinic poster stand was stored/placed in corridor in front of Stair B causing obstruction to access the Stairwell Exit. This did not meet the requirement of NFPA 101 7.1.10.1 which requires the means of egress to be maintained free of obstructions or impediments.

The above deficiency was acknowledged by the environmental services director, and director of quality and safety officer at the time of discovery, and confirmed with Staff Z (administrator/CEO), and Staff A (chief nursing officer) at the exit conference on 7/13/2011 at 4:30 pm.

Based on observation and staff interview, the facility failed to ensure safety to patients due to failure to perform station inlet performance test of the vacuum system in accordance with NFPA 99 4-3.5.6.1(c). This deficient practice affected all patients in the facility. The facility has a capacity of 25 with a census of 7 inpatients at the time of survey.

Findings include

During the review of medical gas and vacuum system maintenance records on 7/13/2011 between 11:40 am and 3 pm, Surveyor 12316, based on the information available at the time of survey, determined that the station inlet performance test for the vacuum system was not performed on a regular preventive maintenance schedule. This did not meet the requirement of NFPA 99 4-3.5.6.1(c).

The above deficiency was verified with Staff N (environmental services director), and confirmed with Staff Z (administrator/CEO), Staff B (director of quality and safety officer) and Staff A (chief nursing officer) at the exit conference on 7/13/2011 at 4:30 pm.

Based on observation and staff interview, the facility failed to ensure safety to residents due to wrong branch of essential electrical power system (EPSS) to supply power to task illumination in the emergency Generator Room in accordance with the requirement of NFPA 99 3-4.2.2.2(b)5. This deficient practice affected the entire facility. The facility has a capacity of 25 with a census of 7 inpatients at the time of survey.
Findings include
During a tour of the facility with Staff B (RN, director of quality and safety officer), Staff N (environmental services director) on 7/12/2011, Surveyor 12316 observed at 10:35 am that the emergency battery powered lighting unit used for task illumination and emergency lighting was supplied from the Equipment Branch automatic transfer switch (ATS) Q1 Circuit Breaker #3 of the essential power system and not from the life safety branch ATS in accordance with NFPA 99 3-4.2.2.2(b)5.
The above deficiency was acknowledged by the environmental services director, and director of quality and safety officer at the time of discovery, and confirmed with Staff Z (administrator/CEO), and Staff A (chief nursing officer) at the exit conference on 7/13/2011 at 4:30 pm.

Based on observation and staff interview, the facility failed to protect an opening into one hazardous area with a fire-rated door, or protect the hazardous room with an automatic extinguishing system and a self-closing door in accordance with the requirement of NFPA 101 38.3.2.1, 8.4.1. This could affect all patients and staff of the facility.

Findings include

During a tour of the Suring Primary Care facility with Staff N (environmental services director), and Staff J (clinic director) on 7/13/2011, Surveyor 12316 observed at 9:40 am that the Medical Records Storage behind the reception area had a solid bonded wood core door, but the door was not 3/4 hr fire-rated and self-closing; nor was the storage room protected with a automatic extinguishing system in lieu of the fire-rated enclosure and a door with a self-closing device.
The above deficiency was acknowledged by the environmental services director, and clinic director at the time of discovery, and confirmed with Staff Z (administrator/CEO), Staff A (chief nursing officer), and Staff B (director of quality) at the exit conference on 7/13/2011 at 4:30 pm.


NFPA 101 38.3.2.1
" Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4. "

NFPA 101 8.4.1.1
" Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42. "

NFPA 101 8.4.1.2
" In new construction, where protection is provided with automatic extinguishing systems without fire-resistive separation, the space protected shall be enclosed with smoke partitions in accordance with 8.2.4. "

Based on observation and record review, the facility failed to label the critical branch electrical outlets of the essential electrical power system in 2 operation rooms in accordance with NFPA 99 3-3.2.1.2(a)1, NFPA 70 517-19(a). This affected 1 of 9 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff B (RN, director of quality and safety officer), Staff N (environmental services director), and Staff V (RN, Surgery Manager) on 7/12/2011, Surveyor 12316 observed at 1:20 pm that the red-colored, critical branch electrical ceiling outlets in 2 of 3 Operation Rooms - ORs 1 and 2 - were not identified as to which electrical panel and branch circuit the power is supplied from as required by NFPA 70. The 1st Floor Surgery Suite containing ORs 1 and 2 was renovated to add a new operation room (OR #3) in 2003.

The above deficiency was acknowledged by the environmental services director, director of quality and safety officer, and surgery manager at the time of discovery, and confirmed with Staff Z (administrator/CEO), and Staff A (chief nursing officer) at the exit conference on 7/13/2011 at 4:30 pm.

Based on observation and staff interview, the facility failed to ensure safety to residents due to corridor wall not being smoke-tight in two locations in accordance with the requirement of NFPA 101 19.3.6.2.2. This deficient practice affected 2 of 9 smoke compartments. The facility has a capacity of 25 with a census of 7 inpatients at the time of survey.
Findings include
During a tour of the facility with Staff B (RN, director of quality and safety officer), and Staff N (environmental services director) on 7/11/2011, Surveyor 12316 observed that (i) at 4:30 pm, the 3 ' x 3 ' -6 " opening in upper half of corridor wall of the Physical Therapy Main Reception was protected with a wood door, but the ? in gap at the bottom of door (door undercut) did not prevent the passage of smoke in accordance with NFPA 19.3.6.2.2; and (ii) corridor wall of CT Scan Control room had 2 cable and 1 electrical conduit penetrations of 2 in to 2 1/2 in diameter that were not sealed to make the wall smoke-tight.
The above deficiency was acknowledged by the environmental services director, and Staff N (environmental services director) at the time of discovery, and confirmed with Staff Z (administrator/CEO), and Staff A (chief nursing officer) at the exit conference on 7/13/2011 at 4:30 pm.

Based on observation and staff interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to failure to keep doors suitably closed in 2 locations. This affected 2 of 9 smoke compartments in the facility. The facility has a capacity of 25 with a census of 7 inpatients at the time of survey.

Findings include

During a tour of the facility with Staff B (RN, director of quality and safety officer), and Staff N (environmental services director) on 7/12/2011, Surveyor 12316 observed in the following two locations that corridor doors did not suitably close.
(i) On 7/12/2011 at 11:50 am, the corridor double doors of the Intensive Care Unit did not positively latch due to the inactive leaf not kept latched to the top door frame. When Surveyor 12316 closed the active leaf, the door latched onto the inactive leaf, but the doors were observed to swing and bow in, when a push force was applied on the doors. This does not meet the NFPA 101 19.3.6.3.2 requirement; and (ii) On 7/12/2011 at 2:34 pm, the Staff Locker Room corridor door adjacent to the dark room in the Medical Imaging was held open with two wheel chairs, which is an impediment to closing of doors.

The above deficiency was acknowledged by the environmental services director, and director of quality and safety officer at the time of discovery, and confirmed with Staff Z (administrator/CEO), and Staff A (chief nursing officer) at the exit conference on 7/13/2011 at 4:30 pm.

Based on observation and staff interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to two sets of smoke doors not maintained or installed to fully close. This deficient practice affected 2 of 9 smoke compartments in the facility. The facility has a capacity of 25 with a census of 7 inpatients at the time of survey.

Findings Include

During a tour of the facility with Staff B (RN, director of quality and safety officer), and Staff N (environmental services director), Surveyor 12316 observed that (i) on 7/11/2011 at 4:16 pm, the cross-corridor smoke doors located adjacent to the Therapy in the Lower Level (ground floor) did not fully close and left a gap more than necessary for proper operation at the meeting edge; and (ii) on 7/12/2011 at 2:33 pm, the cross-corridor smoke doors located near the Ultrasound Room on the 1st Floor did not fully close when manually tested; the doors left a ? in gap at the meeting edge, which is more than necessary for proper operation.

The above deficiency was acknowledged by the environmental services director, and director of quality and safety officer at the time of discovery, and confirmed with Staff Z (administrator/CEO), and Staff A (chief nursing officer) at the exit conference on 7/13/2011 at 4:30 pm.

Based on observation and staff interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to two fire-rated doors of hazardous areas not properly maintained. This deficient practice affected 2 of 9 smoke compartments in the facility. The facility has a capacity of 25 with a census of 7 inpatients at the time of survey.
Findings Include

During a tour of the facility with Staff B (RN, director of quality and safety officer), and Staff N (environmental services director) on 7/12/2011, Surveyor 12316 observed that (i) at 10:19 pm, the 45 minute fire-rated corridor door of the hospital Central Supply Room adjacent to the Kitchen on the Lower Level closed but did not latch, when tested; and (ii) at 3:20 pm, the fire-rated door of the Gift Shop Storage on the 1st Floor was propped open with a wood wedge, which is an impediment to closing of doors. This did not meet the requirement of NFPA 101 19.3.2.1.

The above deficiency was acknowledged by the environmental services director at the time of discovery, and confirmed with Staff Z (administrator/CEO), Staff B (RN, director of quality and safety officer, and Staff A (chief nursing officer) at the exit conference on 7/13/2011 at 4:30 pm.

Based on observation and staff interview, the facility failed to ensure safety to residents due to lack of handrails on ramp in one means of egress, which is required to provide a safe access to a public way in accordance with the requirement of NFPA 101 7.1.7.2. This deficient practice affected all patients in 2 of 9 smoke compartments in resident sleeping areas. The facility has a capacity of 25 with a census of 7 inpatients at the time of survey.
Findings include
During a tour of the facility with Staff B (RN, director of quality and safety officer), and Staff N (environmental services director) on 7/11/2011, Surveyor 12316 observed at 4:06 pm that there was no handrails in one exit discharge ramp from the West Exit Stair B in accordance with NFPA 101.7.1.7.2, 7.2.2.4.2.
The above deficiency was acknowledged by the environmental services director, and director of quality and safety officer at the time of discovery, and confirmed with Staff Z (administrator/CEO), and Staff A (chief nursing officer) at the exit conference on 7/13/2011 at 4:30 pm.

NFPA 101 7.1.7.2
"Changes in level in means of egress not in excess of 21 in. (53.3 cm) shall be achieved either by a ramp or by a stair complying with the requirements of 7.2.2. "
NFPA 101 7.2.2.4.2
"Stairs and ramps shall have handrails on both sides .... "

Based on record review and staff interview, the facility failed to maintain the fire drill records. This affected the entire facility. The facility has a capacity of 25 with a census of 7 inpatients at the time of survey.

Findings include

During the review of fire drill records on 7/13/2011 between 11:40 am and 3:30 pm, it was revealed that fire drill reports for the following quarters were not documented.

1st Shift drill of 3rd and 4th Quarters of 2010;
2nd Shift drill of 2nd, 3rd and 4th Quarters of 2010, and 1st and 2nd Quarters of 2011;
3rd Shift drill of all 4 Quarters of 2010, and 1st and 2nd Quarters of 2011.

When interviewed on 7/13/2011 at 4:15 pm, Staff N (environmental services director) stated that the fire drills were conducted, but not documented. Due to lack of fire drill reports, Surveyor 12316 could not verify that procedures in case of fire were observed during the fire drills in accordance with NFPA 101 19.7.2.1, and whether the fire drills were conducted under varied conditions as stated in NFPA 101 19.7.1.2.

The above deficiency was confirmed with the environmental services director, Staff B (director of quality and safety officer), Staff Z (administrator/CEO) and Staff A (chief nursing officer) at the exit conference on 7/13/2011 at 4:30 pm.

Based on observation and staff interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to failure to install sprinkler heads at proper spacing in accordance with NFPA 13 (1999) 5-6.3.4. This deficient practice affected 3 of 9 smoke compartments in the facility. The facility has a capacity of 25 with a census of 7 inpatients at the time of survey.

Findings include

During a tour of the facility with Staff B (RN, director of quality and safety officer), and Staff N (environmental services director) between 7/11 - 7/13/2011, Surveyor 12316 observed in the following 4 locations that the sprinkler heads were spaced less than 6 ft apart. This did not meet the requirement of NFPA 13 5-6.3.4.
(i) On 7/11/2011 at 3:06 pm, the Storage Room 131 in the West Wing had two sprinkler heads installed 2'-9" apart;
(ii) On 7/11/2011 at 4:24 pm, the Speech Therapy Room, and Physical Therapy Office Room had two sprinklers spaced sprinkler heads spaced 2'-6" apart; and
(iii) On 7/12/2011 at 2:32 pm, the Change Room in Medical Imaging had two sprinklers spaced sprinkler heads spaced 4'-4" apart.

The above deficiency was acknowledged by the environmental services director and director of quality and safety officer at the time of discovery, and confirmed with Staff Z (administrator/CEO), and Staff A (chief nursing officer) at the exit conference on 7/13/2011 at 4:30 pm.

Based on observation, staff interview, and review of records the facility failed to ensure safety to patients, staff and visitors of the facility due to failure to maintain the automatic, supervised sprinkler system in accordance with the requirements of NFPA 13 (1999) and 25 Standards 1998 edition. This deficient practice affected the entire facility. The facility has a capacity of 25 with a census of 7 inpatients at the time of survey.

Findings include

1. During a tour of the facility with Staff B (RN, director of quality and safety officer), and Staff N (environmental services director) between 7/11 - 7/12/2011, Surveyor 12316 observed in the following 8 locations that there was either less than 18 in. vertical clearance between the sprinkler deflectors and the top of storage in accordance with the requirement of NFPA 13 5-5.6, or dirty sprinkler heads.

(i) On 7/11/2011 at 4:20 pm, the Physical Therapy (PT) Storage adjacent to smoke doors on the Lower Level did not have the 18 in. clearance;
(ii) On 7/11/2011 at 4:32 pm, the PT Storage Closet located in the Therapy Room on the Lower Level did not have the 18 in. clearance;
(iii) On 7/12/2011 at 10:05 am, the top of storage in aisle adjacent to the dietary manager's office in the Kitchen did not have the 18 in. clearance;
(iv) On 7/12/2011 at 1:30 pm, one sprinkler head in Pre-Op Room 2 was dirty;
(v) On 7/12/2011 at 2:16 pm, the escutcheon plate of one sprinkler head was missing in the Lab Room;
(vi) On 7/12/2011 at 2:22 pm, the Lab Supply Room on the 1st Floor (upper level) did not have the 18 in. clearance above the top of storage. The sprinkler head was almost completely surrounded by stored objects on the top shelf.
(vii) On 7/12/2011 at 2:28 pm, one sprinkler head in the Medical Imaging Area was dirty. The sprinkler was located in the corridor adjacent to the control room of CT Scan; and
(viii) On 7/12/2011 at 3:20 pm, the Gift Shop Storage did not have the 18 in. clearance between the top of storage and sprinkler deflector;

2. During the review of sprinkler system maintenance records on 7/12/2011 between 3:30 and 4:45 pm, Surveyor 12316 found that there were no records (i) of quarterly and monthly inspections of the sprinkler system; and (ii) of the five-yearly inspection of gauges and check valves. Surveyor 12316 could not verify that inspection, testing and maintenance were performed in accordance with the requirements of NFPA 25 2-1 and 9-1.

When interviewed on 7/13/2011 at 4:15 pm, Staff N (environmental services director) stated that the quarterly and monthly inspections were performed, but not documented. This did not meet the requirement of NFPA 25 2-1.3.

3. During the review of sprinkler system maintenance records 7/12/2011 between 3:30 and 4:45 pm, Surveyor 12316 found that the supervisory switch of control valves of the sprinkler system was tested annually, but not semi-annually in accordance with the requirement of NFPA 25 9-3.4.3. The annual testes were performed on 3/29/2011 and 3/30/2010 by Van's Fire and Safety.

The above deficiency was acknowledged by the environmental services director and by the director of quality and safety officer either at the time of discovery, or confirmed with them and with Staff Z (administrator/CEO) and Staff A (chief nursing officer) at the exit conference on 7/13/2011 at 4:30 pm.


NFPA 25 2-1.3
" Records: Records shall be maintained in accordance with Section 1-8. "

NFPA 25 1-9.1
" System components shall be inspected at intervals specified in the appropriate chapters. "

NFPA 25 1-8
" Records. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request ... "

Based on observation and staff interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to objects placed in two locations of means of egress causing obstruction to access the exit stair. This deficient practice affected 2 of 9 smoke compartments in the facility. The facility has a capacity of 25 with a census of 7 inpatients at the time of survey.

Findings include

During a tour of the facility with Staff B (RN, director of quality and safety officer), and Staff N (environmental services director) on 7/11/2011, Surveyor 12316 observed that (i) at 3:10 pm, one Hoyer lift was stored in corridor adjacent to Stair B on the Upper Level of 1972 building causing obstruction to access the exit stair; and (ii) at 4 pm, one Northern Lights Clinic poster stand was stored/placed in corridor in front of Stair B causing obstruction to access the Stairwell Exit. This did not meet the requirement of NFPA 101 7.1.10.1 which requires the means of egress to be maintained free of obstructions or impediments.

The above deficiency was acknowledged by the environmental services director, and director of quality and safety officer at the time of discovery, and confirmed with Staff Z (administrator/CEO), and Staff A (chief nursing officer) at the exit conference on 7/13/2011 at 4:30 pm.

Based on observation and staff interview, the facility failed to ensure safety to patients due to failure to perform station inlet performance test of the vacuum system in accordance with NFPA 99 4-3.5.6.1(c). This deficient practice affected all patients in the facility. The facility has a capacity of 25 with a census of 7 inpatients at the time of survey.

Findings include

During the review of medical gas and vacuum system maintenance records on 7/13/2011 between 11:40 am and 3 pm, Surveyor 12316, based on the information available at the time of survey, determined that the station inlet performance test for the vacuum system was not performed on a regular preventive maintenance schedule. This did not meet the requirement of NFPA 99 4-3.5.6.1(c).

The above deficiency was verified with Staff N (environmental services director), and confirmed with Staff Z (administrator/CEO), Staff B (director of quality and safety officer) and Staff A (chief nursing officer) at the exit conference on 7/13/2011 at 4:30 pm.

Based on observation and staff interview, the facility failed to ensure safety to residents due to wrong branch of essential electrical power system (EPSS) to supply power to task illumination in the emergency Generator Room in accordance with the requirement of NFPA 99 3-4.2.2.2(b)5. This deficient practice affected the entire facility. The facility has a capacity of 25 with a census of 7 inpatients at the time of survey.
Findings include
During a tour of the facility with Staff B (RN, director of quality and safety officer), Staff N (environmental services director) on 7/12/2011, Surveyor 12316 observed at 10:35 am that the emergency battery powered lighting unit used for task illumination and emergency lighting was supplied from the Equipment Branch automatic transfer switch (ATS) Q1 Circuit Breaker #3 of the essential power system and not from the life safety branch ATS in accordance with NFPA 99 3-4.2.2.2(b)5.
The above deficiency was acknowledged by the environmental services director, and director of quality and safety officer at the time of discovery, and confirmed with Staff Z (administrator/CEO), and Staff A (chief nursing officer) at the exit conference on 7/13/2011 at 4:30 pm.

Based on observation and staff interview, the facility failed to protect an opening into one hazardous area with a fire-rated door, or protect the hazardous room with an automatic extinguishing system and a self-closing door in accordance with the requirement of NFPA 101 38.3.2.1, 8.4.1. This could affect all patients and staff of the facility.

Findings include

During a tour of the Suring Primary Care facility with Staff N (environmental services director), and Staff J (clinic director) on 7/13/2011, Surveyor 12316 observed at 9:40 am that the Medical Records Storage behind the reception area had a solid bonded wood core door, but the door was not 3/4 hr fire-rated and self-closing; nor was the storage room protected with a automatic extinguishing system in lieu of the fire-rated enclosure and a door with a self-closing device.
The above deficiency was acknowledged by the environmental services director, and clinic director at the time of discovery, and confirmed with Staff Z (administrator/CEO), Staff A (chief nursing officer), and Staff B (director of quality) at the exit conference on 7/13/2011 at 4:30 pm.


NFPA 101 38.3.2.1
" Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4. "

NFPA 101 8.4.1.1
" Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42. "

NFPA 101 8.4.1.2
" In new construction, where protection is provided with automatic extinguishing systems without fire-resistive separation, the space protected shall be enclosed with smoke partitions in accordance with 8.2.4. "

Based on observation and record review, the facility failed to label the critical branch electrical outlets of the essential electrical power system in 2 operation rooms in accordance with NFPA 99 3-3.2.1.2(a)1, NFPA 70 517-19(a). This affected 1 of 9 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff B (RN, director of quality and safety officer), Staff N (environmental services director), and Staff V (RN, Surgery Manager) on 7/12/2011, Surveyor 12316 observed at 1:20 pm that the red-colored, critical branch electrical ceiling outlets in 2 of 3 Operation Rooms - ORs 1 and 2 - were not identified as to which electrical panel and branch circuit the power is supplied from as required by NFPA 70. The 1st Floor Surgery Suite containing ORs 1 and 2 was renovated to add a new operation room (OR #3) in 2003.

The above deficiency was acknowledged by the environmental services director, director of quality and safety officer, and surgery manager at the time of discovery, and confirmed with Staff Z (administrator/CEO), and Staff A (chief nursing officer) at the exit conference on 7/13/2011 at 4:30 pm.