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1. Based on observation and interview, the facility failed to ensure 1 of 1 corridor doors, a pair of doors, to the purchasing supply room were provided with positive latching hardware. This deficient practice could affect up to 15 patients and visitors obtaining services in the basement.

Findings includes:

Based on observation during a tour of the facility with the Director of Operations on 04/25/16 at 11:05 a.m., the purchasing supply room was designed with double corridor doors. One door in the set of double doors was equipped with a manual latching device that would latch into the door frame and the remaining door was designed to latch into the stationary door. Each door could not latch automatically, and independent of the other door, into the door frame. Based on interview, this was acknowledged by the Director of Operations at the time of observation.

2. Based on observation and interview, the facility failed to ensure there were no impediments to the closing of 1 of 1 Pharmacy doors, 3 of 9 Emergency Room patient room doors, and 1 of 1 Endoscopy doors protecting corridor openings. This deficient practice could affect up to 25 patients in the basement and on the first floor.

Findings include:

Based on observation during a tour of the facility with the Director of Operations on 04/25/16 between 10:00 a.m. and 1:30 p.m., the following corridor doors were propped open with door wedge or a kick down prop.
a. Pharmacy entrance
b. Emergency Room patient door 3
c. Emergency Room patient door 4
d. Emergency Room patient door 5
e. Endoscopy entrance
Based on interview at the time of observation, this was acknowledged by Director of Operations.

3. Based on observation and interview, the facility failed to ensure 1 of 20 patient room corridor doors on the third floor would closed and latched into the door frame. This deficient practice could up to 20 patients on the third floor.

Findings include:

Based on observation during a tour of the facility with the Facilities Man #1 on 04/25/16 at 1:25 p.m., the corridor door to patient room 322 failed to latch into the door frame. Based on interview, this was acknowledged by the Facilities Man #1 at the time of observations.

1. Based on observation and interview, the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 9 of 12 smoke barrier walls were protected to maintain the smoke resistance of each smoke barrier. LSC Section 19.3.7.3 requires smoke barriers to be constructed in accordance with LSC Section 8-3. LSC Section 8.3.6.1 requires the passage of building service materials such as pipe, cable or wire to be protected so the space between the penetrating item and the smoke barrier shall be filled with a material capable of maintaining the smoke resistance of the smoke barrier or be protected by an approved device designed for the specific purpose. This deficient practice could affect up to all occupants in basement and on the first and second floors.

Findings include:

Based on observation during a tour of the facility with the Director of Operations and the Facilities Man #1 on 04/25/16 between 11:05 a.m. and 2:00 p.m., the following smoke barrier walls above the ceiling tiles had unsealed penetrations:
a) The 83/63 basement smoke barrier wall had an unsealed three by three inch hole and a six by six inch hole.
b) The smoke barrier wall by the director office has seven unsealed six to four inch penetrations around a wires.
c) The smoke barrier wall by the morgue had an unsealed hole measuring two feet by one foot and seven unsealed two inch penetrations around wires.
d) The smoke barrier wall by pharmacy had five unsealed four inch penetration around wires.
e) The smoke barrier wall by stairwell B had five unsealed one inch penetration around wires and an unsealed half inch gap from the top of the smoke wall to the ceiling.
f) The smoke barrier wall by X-ray had five unsealed one inch penetration around wires and conduits.
g) The smoke barrier wall by the lab had four unsealed two inch penetration around a conduit.
h) The smoke barrier wall by surgery had three unsealed one inch penetration around wires and a six inch hole.
j) The west hall smoke barrier wall on the second floor had an unsealed one inch penetration around a wire.
Based on interview at the time of observation, the Director of Operations and the Facilities Man #1 acknowledged and provided the measurements of the penetrations.


2. Based on observation and interview, the facility failed to ensure 3 of 4 ceiling smoke barriers were maintained to provide a one half hour fire resistance rating. LSC 8.3.2 requires smoke barriers shall be continuous from an outside wall to an outside wall. This deficient practice could affect all occupants in the basement and on the first and third floors.

Findings include:

Based on observation during a tour of the facility with the Director of Operations and the Facilities Man #1 on 04/25/16 between 11:05 a.m. and 2:00 p.m., the following areas had unsealed ceiling penetrations:
a) In the basement IT office closet there were two unsealed five inch penetrations around a wires.
b) In the outpatient recovery electrical panel closet there were 20 unsealed fourth of an inch penetrations around conduit.
c) In janitor closet on the third floor there was an unsealed half of an inch penetration.
Based on interview at the time of observation, the Director of Operations and the Facilities Man #1 acknowledged and provided the measurements of the penetrations.

Based on observation and interview, the facility failed to ensure 1 of 4 sets of smoke barrier doors on the first floor and 1 of 2 sets of smoke barrier doors on the second floor would restrict the movement of smoke for at least 20 minutes. LSC 19.3.7.6 requires doors in smoke barriers shall comply with LSC Section 8.3.4. LSC 8.3.4.1 requires doors in smoke barrier shall close the opening leaving only the minimum clearance necessary for proper operation which is defined as 1/8 inch. This deficient practice could affect up to 30 patients on the first and second floors.

Finding include:

Based on observation during a tour of the facility with the Director of Operations and the Facilities Man #1 on 04/25/16 at 12:30 p.m. and at 2:17 p.m., the smoke barrier doors by the northeast exit on the first floor had a one half inch gap between the doors when closed. Also, the smoke barrier doors in the west hallway on the second floor had a one quarter inch gap between the doors when closed. Based on an interview with at the time of observation, the Director of Operations and Facilities Man #1 acknowledged the gap in the smoke doors.

Based on observation and interview, the facility failed to ensure the corridor door to 1 of 1 soiled utility rooms in oncology were provided with self-closer and would latch into the frame. This deficient practice could affect 6 patients in the oncology office.

Findings include:

Based on observation during a tour of the facility with the Director of Operations on 04/25/16 at 10:30 a.m., there was no self-closer on the soiled utility room door located in the oncology office. Based on an interview at the time of observation, the Director of Operations acknowledged soiled linen and trash are stored in the soiled utility room and the door lacked a self-closer.

Based on observation and interview, the facility failed to ensure 1 of 3 stairway enclosure doors on the third floor were in accordance with 7.2. LSC Section 7.2.1.5.4 requires a latch or other fastening device to be provided. This deficient practice could affect up to 20 patients on the third floor.

Findings include:

Based on observation during a tour of the facility with the Facilities Man #1 on 04/25/16 at 2:25 p.m., the third floor door to stairwell 3E did not latch into the frame. Based on interview at the time of observation, the Facilities Man #1 acknowledged the stairwell door would not latch.

Based on observation and interview, the facility failed to ensure 1 of 2 fire door sets on the first floor were arranged to automatically close and latch. LSC 19.2.2.5 requires horizontal exits to be in accordance with 7.2.4 and 7.2.4.3.8 requires fire doors to be self-closing or automatic closing in accordance with 7.2.1.8. In addition NFPA 80, Standard for Fire Doors and Windows at 2-1.4.1 requires all closing mechanisms shall be adjusted to overcome fire resistance of the latch mechanism so that positive latching is achieved on each door operation. This deficient practice could affect 25 patients on the first floor.

Findings include:

Based on observation during a tour of the facility with the Director of Operations on 04/25/16 at 12:00 p.m., the fire door set on the first floor by the Lab failed to latch into the frame. Based on interview at the time of observation, this was acknowledged and confirmed these were fire doors by the Director of Operations.

Based on record review and interview, the facility failed to provide a written plan that included the activation of a patient room battery operated smoke detector in 1 of 1 written fire plans. LSC 19.7.2.2 requires a written health care occupancy fire safety plan that shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to the fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
This deficient practice could affect all patients.

Findings include:

Based on a record review of the written fire safety plan with Director of Operations on 04/25/16 at 10:05 a.m., the plan did not address response to the activation of the 14 patient room battery operated smoke alarms located on the second floor long term residential care hall. Based on interview, this was acknowledged by the Director of Operations at the time of record review.

1. Based on record review and interview, the facility failed to insure fire drills included the transmission of a fire alarm signal to monitoring company for 8 of 12 fire drills conducted. This deficient practice affects all patients, staff, and visitors.

Findings include:

Based on record review of the "Fire Drill Report" with the Director of Operations on 04/25/16 between 9:13 a.m. and 9:23 a.m., the documentation for all first and second shift fire drills conducted between the hours of 6 a.m. and 9 p.m. lacked the verification of the alarm signal transmission to a monitoring company. Based on interview, this was confirmed by the Director of Operations at the time of record review.

2. Based on record review and interview, the facility failed to conduct quarterly fire drills for second shift at unexpected times for 4 of 4 quarters. This deficient practice affects all patients, staff, and visitors.

Findings include:

Based on record review of the "Fire Drill Report" with the Director of Operations on 04/25/16 between 09:13 a.m. and 09:23 a.m., all second shift fire drills took place between 3:00 p.m. and 4:00 p.m. for the last four quarters. Based on interview, this was confirmed by the Director of Operations at the time of record review.

Based on observation and interview, the facility failed to ensure 3 of 25 smoke detectors on second floor was installed where air flow would not adversely affect their operation. Section 9.6.1.4 requires fire alarm systems comply with NFPA 72, National Fire Alarm Code. NFPA 72, 2-3.5.1 requires in spaces served by air handling systems, detectors shall not be located where air flow prevents operation of the detectors. This deficient practice could up to 24 patients on the second floor.

Findings include:

Based on observation during a tour of the facility with the Facilities Man #1 on 04/25/16 between 2:00 p.m. and 2:15 p.m., three smoke detectors on the second floor located at the OD nurse ' s station, nursery, and OB room 241 were within three feet of an air supply duct. Based on interview, this was acknowledged by the Facilities Man #1 at the time of observation.

1. Based on record review and interview, the facility failed to ensure a battery testing program was provided to ensure 14 of 14 single station battery operated smoke alarms would operate. This deficient practice affects up to 14 patients in the second floor long term residential care.

Findings include:

Based on record review of the with the Director of Operations on 04/25/16 at 10:05 a.m., no documentation was available to show monthly testing for the 14 patient room battery operated smoke alarms on the second floor long term residential care hall. Based on an interview at the time of record review, the Director of Operations state there was no documentation to show testing for the battery operated smoke alarms.


2. Based on record review and interview, the facility failed to adopt a battery replacement program and a maintenance program to ensure 14 of 14 single station battery operated smoke alarms would operate properly. NFPA 70; 10.4.8 states where batteries are used as a source of energy, they shall be replaced in accordance with the alarm equipment manufacturer's publish instruction. 10.5.1 States fire alarm equipment shall be maintained in accordance with the alarm equipment manufacturers published instructions. This deficient practice affects up to 14 patients in the second floor long term residential care.

Findings include:

Based on record review with the Director of Operations on 04/25/16 at 10:05 a.m., no documentation was available to show when the 14 patient room battery operated smoke alarms on the second floor long term residential care hall had the batteries replaced, or when cleaning and maintenance was conducted. Based on an interview during records review, the Director of Operations stated there was no documentation to show when the battery operated smoke alarms were cleaned or had the batteries replaced.

Based on observation and interview, the facility failed to ensure proper sprinkler coverage was provided for 4 of 4 stairwells in accordance with NFPA 13, 1999 Edition Section 5-13.3.2 in noncombustible stair shafts with noncombustible stairs, sprinklers shall be installed at the top of the shaft and under the first landing above the bottom of the shaft. This deficient practice could all occupants of the facility

Findings include:

Based on observation during a tour of the facility with the Facilities Man #1 on 04/25/16 2:00 p.m. and during telephone call with the Director of Operations on 04/28/16 at 10:30 a.m., it was noted that stairwell "C" had a sprinkler at the first floor of the stairwell but not at the top and bottom of the stairwell. Based on interview, this was acknowledged by the Director of Operations at the time of telephone call.

Based on observation and interview, the facility failed to ensure 1 of 2 sprinkler gauges on the main riser and 1 of 1 gauges the riser in stairwell D2 were tested every five years. NFPA 25, Section 2-3.2 states gauges shall be replaced every five years or tested every five years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced. This deficient practice could affect all occupants in the building.

Findings include:

Based on observation during a tour of the facility with the Director of Operations and the Facilities Man #1 on 04/25/16 at 1:00 p.m. and at 1:20 p.m., one sprinkler gauge on the main riser and the sprinkler gauge on the riser in stairwell D2 had a date of 2010. Based on an interview and the time of observation, the Director of Operations or the Facilities Man #1 was unable to verify if the sprinkler gauges had been calibrated within the last five years.

Based on record review, observation, and interview, the facility failed to provide 1 of 1 fire damper inspections to show dampers were inspected and provided necessary maintenance at least every four years in accordance with NFPA 90A. LSC 9.2.1 requires air conditioning, heating, ventilating ductwork (HVAC) and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. NFPA 90A, 1999 Edition, 3.4.7, Maintenance, requires at least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify they fully close; the latch, if provided, shall be checked, and moving parts shall be lubricated as necessary. This deficient practice affects all occupants in the facility.

Findings include:

Based on record review on with the Director of Operations on 04/25/16 at 10:30 a.m., and again at 2:00 p.m., there were no inspection records available for review for any of the facility's fire dampers. Based on interview during records review, the Director of Operations stated the facility had dampers, but did not know when the last inspection was conducted and there were no other records available to show completed maintenance on the facility's fire dampers.

Based on observation and interview, the facility failed to ensure a capacity of 32 gallons for soiled linen or trash collection receptacles was not exceeded within any 64 square feet area for 1 of 2 corridors on the second floor. This deficient practice could affect 24 patients on the second floor.

Findings include:


Based on observation during a tour of the facility with the Facilities Man #1 on 04/25/16 between 2:00 p.m. and 2:30 p.m. a soiled linen container larger than 32 gallons in capacity was unattended and stored in the corridor by room 241 from 2:00 p.m. to 2:30 p.m. Based on an interview at the time of observation, the Facilities Man #1 acknowledged the container and stated the soiled linen container should be stored in the soiled utility room when not in use.

1. Based on observation and interview, the facility failed to ensure materials used as an interior finish on the ceiling in 1 of 1 Lobby and 1 of 1 Court Hallway had a flame spread rating of Class A or Class B. LSC 101 39.3.3.2 states products required to be tested in accordance with NFPA 255, Standard Method of Test of Surface Burning Characteristics of Building Materials, shall be grouped in the following classes in accordance with their flame spread and smoke development.
(a) Class A Interior Wall and Ceiling Finish. Flame spread 0-25; smoke development 0-450. Includes any material classified at 25 or less on the flame spread test scale and 450 or less on the smoke test scale. Any element thereof, when so tested, shall not continue to propagate fire.
(b) Class B Interior Wall and Ceiling Finish. Flame spread 26-75; smoke development 0-450. Includes any material classified at more than 25 but not more than 75 on the flame spread test scale and 450 or less on the smoke test scale.
(c) Class C Interior Wall and Ceiling Finish. Flame spread 76-200; smoke development 0-450. Includes any material classified at more than 75 but not more than 200 on the flame spread test scale and 450 or less on the smoke test scale. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Facilities Man #1 and the Fitness Supervisor on 04/25/16 at 11:38 a.m. and 11:49 a.m., the Lobby contained wood paneling on one of the walls. Then again, the Court Hallway contained carpet on one side of the hallway wall. Based on interview at the time of each observation, the Facilities Man #1 and the Fitness Supervisor was unable to provide documentation for a flame spread classification.

2. Based on observation and interview, the facility failed to ensure 5 of 5 flexible cords were not used as a substitute for fixed wiring to provide power equipment with a high current draw. LSC Chapter 39.5.1 requires utilities to comply with the provisions of Section 9.1. Section 9.1.2 requires electrical wiring and equipment to be in accordance with NFPA 70, National Electrical Code. NFPA 70, National Electrical Code, 1999 Edition, Article 400-8 requires that, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice affects all occupants.

Findings include:

Based on observation with the Facilities Man #1 and the Fitness Supervisor on 04/25/16 between 11:45 a.m. to 12:00 p.m. the following was discovered:
a) an extension cord was powering a surge protector powering two refrigerators in the Lobby
b) an extension cord was powering television equipment in the Lobby
c) an extension cord powering two separate heat tapes. Additionally, a surge protector was powering an air compressor in the Equipment room
Based on interview at the time of each observation, the Facilities Man #1 and the Fitness Supervisor acknowledged each aforementioned condition.

3. Based on observation and interview, the facility failed to ensure exit access was arranged so 3 of 4 exits were readily accessible at all times in accordance with LSC Section 7.1. LSC Section 39.2.1.1 requires the means of egress for existing buildings shall comply with Chapter 7. LSC Section 7.7.1 requires all exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. In addition to providing the required width to allow all occupants safe access to a public way, such access also needs to meet the requirements with respect to maintaining the means of egress free of obstructions that would prevent its use, such as snow and the need for its removal in some climates or soft ground during heavy periods of rain. This deficient practice could affects all occupants.

Findings include:

Based on observation with the Facilities Man #1 and the Fitness Supervisor on 04/25/16 between 11:48 a.m. and 12:13 p.m., the following exits discharged into grass.
a) Free weights exit
b) West exit
c) Cybex exit
Based on interview at the time of each observation, the Facilities Man #1 and the Fitness Supervisor acknowledged each aforementioned condition and confirmed that each path was considered an exit.

4. Based on observation and interview, the facility failed to protect 3 of 3 hazardous rooms were constructed at least 1 hour fire barrier and door openings are at least ¾ hour self-closing door. LSC 39.3.2.1 states hazardous areas, including but not limited to, areas used for general storage, boiler or furnace rooms shall be protected in accordance with LSC Section 8.4. Section 8.4.1.1 states protection from any area having a degree of hazard greater than that normal to the general occupancy of the building shall be provided with 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 This deficient practice could affect staff and all occupants.

Findings include:

Based on observation with the Facilities Man #1 and the Fitness Supervisor on 04/25/16 between 11:54 a.m. and 12:17 p.m., the following non sprinklered hazardous rooms were discovered:
a) the Racquet ball gas powered furnace room contained a louvered unrated door that did not self-close when tested. No documentation was available for the room ' s construction rating.
b) the Equipment room contained gas powered furnaces and chemical storage. There were at least twenty ceiling penetrations ranging from three quarter inch to eight inch unsealed penetrations. Drywall was removed exposing wooden studs for about 120 square feet of one of the walls. The corridor door to the Equipment room did not latch into the frame. No documentation was available for the room ' s construction rating.
c) the Cardio room gas powered furnace room contained a louvered unrated door that did not self-close when tested. No documentation was available for the room ' s construction rating.
Based on interview at the time of each observation, the Facilities Man #1 and the Fitness Supervisor acknowledged each aforementioned condition and provided the measurements.

5. Based on observation and interview, the facility failed to ensure 1 of 1 Free Weights exit discharge paths were readily accessible at all times. LSC Section 39.2.1.1 requires the means of egress for existing buildings shall comply with Chapter 7. LSC 7.5.1.1 requires exits shall be located and exit access shall be arranged so that exits are readily accessible at all times. This deficient practice could affect staff and at least 2 patients.

Findings include:

Based on observation with the Facilities Man #1 and the Fitness Supervisor on 04/25/16 at 11:56 a.m., the Free Weights exit door would not open. Based on an interview at the time of observation, the Facilities Man #1 and the Fitness Supervisor acknowledged the aforementioned condition.

Based on record review and interview, the facility failed to provide the complete documentation for testing 1 of 3 emergency generators providing power to the emergency lighting systems. NFPA 99, Section 3-4.1.1.8 states the generator set 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. This deficient practice affects all occupant.

Findings include:

Based on review of the generator log titled "Monthly Generator Test Log" with the Director of Operations on 04/25/16 at 9:42 a.m., the emergency generator number three was tested monthly under load for at least 30 minutes, however, the monthly load test record did not include the time for the transfer of power from the main source to the generator. Based on interview, this was acknowledged by the Director of Operations at the time of record review.

3.1-19(b)

1. Based on observation and interview, the facility failed to ensure 1 of 1 receptacles near a wet location was provided with ground fault circuit interrupter (GFCI) protection against electric shock. NFPA 70, Article 517, Health Care Facilities, defines wet locations as patient care areas subjected to wet conditions while patients are present. These include standing fluids on the floor or drenching of the work area, either of which condition is intimate to the patient or staff. NFPA 70, 517-20 Wet Locations, requires all receptacles and fixed equipment within the area of the wet location to have GFCI protection. Moisture can reduce the contact resistance of the body, and electrical insulation is more subject to failure. This deficient practice was not in a patient care area could affect staff with access to the PFC room.

Findings include:

Based on observation during a tour of the facility with the Director of Operations on 04/25/16 at 11:50 a.m., there was an electrical receptacle not GFCI protected on the wall less than three feet from a sink in PFC room on the first floor. Based on interview and testing, the Director of Operations acknowledged the receptacle was not provided with GFCI protection and when tested with a GFCI testing device power was not interrupted at the receptacle.

2. Based on observation and interview, the facility failed to ensure 3 of 3 flexible cords were not used as a substitute for fixed wiring to provide power equipment with a high current draw. NFPA 70, National Electrical Code, 1999 Edition, Article 400-8 requires that, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice could affect up to 30 patients in the basement and on the first and third floors.

Findings include:

Based on observation during a tour of the facility with the Director of Operations and the Facilities Man #1 on 04/25/16 between 11:00 a.m. and 2:00p.m., the following areas had refrigerators and/or microwaves plugged into an extension cord power strip:
a. Basement IS room
b. Third floor ICU nurses station
c. Third floor nurse manger office
Based on interview, the Director of Operations and the Facilities Man #1 acknowledged power strips at the time of observations.

3. Based on observation and interview, the facility failed to ensure 2 of 2 flexible cords such as an extension cord was not used as a substitute for fixed wiring. LSC 9.1.2 requires electrical wiring and equipment to comply with NFPA 70, National Electrical Code, 1999 Edition. NFPA 70, Article 400-8 requires unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice could affect 20 patients on the first and third floors.

Findings include:

Based on observation during a tour of the facility with the Director of Operations and the Facilities Man #1 on 04/25/16 between 11:00 a.m. and 2:00p.m., in the third floor nurses ' station a regular light weight extension cord was plugged in and providing power for a fan. Also in the ER staff lounge regular light weight extension cord was plugged in and providing power for a microwave. Based on interview, the Director of Operations and the Facilities Man #1 acknowledged the power strips at the time of observations.

1. Based on observation and interview, the facility failed to ensure 1 of 1 corridor doors, a pair of doors, to the purchasing supply room were provided with positive latching hardware. This deficient practice could affect up to 15 patients and visitors obtaining services in the basement.

Findings includes:

Based on observation during a tour of the facility with the Director of Operations on 04/25/16 at 11:05 a.m., the purchasing supply room was designed with double corridor doors. One door in the set of double doors was equipped with a manual latching device that would latch into the door frame and the remaining door was designed to latch into the stationary door. Each door could not latch automatically, and independent of the other door, into the door frame. Based on interview, this was acknowledged by the Director of Operations at the time of observation.

2. Based on observation and interview, the facility failed to ensure there were no impediments to the closing of 1 of 1 Pharmacy doors, 3 of 9 Emergency Room patient room doors, and 1 of 1 Endoscopy doors protecting corridor openings. This deficient practice could affect up to 25 patients in the basement and on the first floor.

Findings include:

Based on observation during a tour of the facility with the Director of Operations on 04/25/16 between 10:00 a.m. and 1:30 p.m., the following corridor doors were propped open with door wedge or a kick down prop.
a. Pharmacy entrance
b. Emergency Room patient door 3
c. Emergency Room patient door 4
d. Emergency Room patient door 5
e. Endoscopy entrance
Based on interview at the time of observation, this was acknowledged by Director of Operations.

3. Based on observation and interview, the facility failed to ensure 1 of 20 patient room corridor doors on the third floor would closed and latched into the door frame. This deficient practice could up to 20 patients on the third floor.

Findings include:

Based on observation during a tour of the facility with the Facilities Man #1 on 04/25/16 at 1:25 p.m., the corridor door to patient room 322 failed to latch into the door frame. Based on interview, this was acknowledged by the Facilities Man #1 at the time of observations.

1. Based on observation and interview, the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 9 of 12 smoke barrier walls were protected to maintain the smoke resistance of each smoke barrier. LSC Section 19.3.7.3 requires smoke barriers to be constructed in accordance with LSC Section 8-3. LSC Section 8.3.6.1 requires the passage of building service materials such as pipe, cable or wire to be protected so the space between the penetrating item and the smoke barrier shall be filled with a material capable of maintaining the smoke resistance of the smoke barrier or be protected by an approved device designed for the specific purpose. This deficient practice could affect up to all occupants in basement and on the first and second floors.

Findings include:

Based on observation during a tour of the facility with the Director of Operations and the Facilities Man #1 on 04/25/16 between 11:05 a.m. and 2:00 p.m., the following smoke barrier walls above the ceiling tiles had unsealed penetrations:
a) The 83/63 basement smoke barrier wall had an unsealed three by three inch hole and a six by six inch hole.
b) The smoke barrier wall by the director office has seven unsealed six to four inch penetrations around a wires.
c) The smoke barrier wall by the morgue had an unsealed hole measuring two feet by one foot and seven unsealed two inch penetrations around wires.
d) The smoke barrier wall by pharmacy had five unsealed four inch penetration around wires.
e) The smoke barrier wall by stairwell B had five unsealed one inch penetration around wires and an unsealed half inch gap from the top of the smoke wall to the ceiling.
f) The smoke barrier wall by X-ray had five unsealed one inch penetration around wires and conduits.
g) The smoke barrier wall by the lab had four unsealed two inch penetration around a conduit.
h) The smoke barrier wall by surgery had three unsealed one inch penetration around wires and a six inch hole.
j) The west hall smoke barrier wall on the second floor had an unsealed one inch penetration around a wire.
Based on interview at the time of observation, the Director of Operations and the Facilities Man #1 acknowledged and provided the measurements of the penetrations.


2. Based on observation and interview, the facility failed to ensure 3 of 4 ceiling smoke barriers were maintained to provide a one half hour fire resistance rating. LSC 8.3.2 requires smoke barriers shall be continuous from an outside wall to an outside wall. This deficient practice could affect all occupants in the basement and on the first and third floors.

Findings include:

Based on observation during a tour of the facility with the Director of Operations and the Facilities Man #1 on 04/25/16 between 11:05 a.m. and 2:00 p.m., the following areas had unsealed ceiling penetrations:
a) In the basement IT office closet there were two unsealed five inch penetrations around a wires.
b) In the outpatient recovery electrical panel closet there were 20 unsealed fourth of an inch penetrations around conduit.
c) In janitor closet on the third floor there was an unsealed half of an inch penetration.
Based on interview at the time of observation, the Director of Operations and the Facilities Man #1 acknowledged and provided the measurements of the penetrations.

Based on observation and interview, the facility failed to ensure 1 of 4 sets of smoke barrier doors on the first floor and 1 of 2 sets of smoke barrier doors on the second floor would restrict the movement of smoke for at least 20 minutes. LSC 19.3.7.6 requires doors in smoke barriers shall comply with LSC Section 8.3.4. LSC 8.3.4.1 requires doors in smoke barrier shall close the opening leaving only the minimum clearance necessary for proper operation which is defined as 1/8 inch. This deficient practice could affect up to 30 patients on the first and second floors.

Finding include:

Based on observation during a tour of the facility with the Director of Operations and the Facilities Man #1 on 04/25/16 at 12:30 p.m. and at 2:17 p.m., the smoke barrier doors by the northeast exit on the first floor had a one half inch gap between the doors when closed. Also, the smoke barrier doors in the west hallway on the second floor had a one quarter inch gap between the doors when closed. Based on an interview with at the time of observation, the Director of Operations and Facilities Man #1 acknowledged the gap in the smoke doors.

Based on observation and interview, the facility failed to ensure the corridor door to 1 of 1 soiled utility rooms in oncology were provided with self-closer and would latch into the frame. This deficient practice could affect 6 patients in the oncology office.

Findings include:

Based on observation during a tour of the facility with the Director of Operations on 04/25/16 at 10:30 a.m., there was no self-closer on the soiled utility room door located in the oncology office. Based on an interview at the time of observation, the Director of Operations acknowledged soiled linen and trash are stored in the soiled utility room and the door lacked a self-closer.

Based on observation and interview, the facility failed to ensure 1 of 3 stairway enclosure doors on the third floor were in accordance with 7.2. LSC Section 7.2.1.5.4 requires a latch or other fastening device to be provided. This deficient practice could affect up to 20 patients on the third floor.

Findings include:

Based on observation during a tour of the facility with the Facilities Man #1 on 04/25/16 at 2:25 p.m., the third floor door to stairwell 3E did not latch into the frame. Based on interview at the time of observation, the Facilities Man #1 acknowledged the stairwell door would not latch.

Based on observation and interview, the facility failed to ensure 1 of 2 fire door sets on the first floor were arranged to automatically close and latch. LSC 19.2.2.5 requires horizontal exits to be in accordance with 7.2.4 and 7.2.4.3.8 requires fire doors to be self-closing or automatic closing in accordance with 7.2.1.8. In addition NFPA 80, Standard for Fire Doors and Windows at 2-1.4.1 requires all closing mechanisms shall be adjusted to overcome fire resistance of the latch mechanism so that positive latching is achieved on each door operation. This deficient practice could affect 25 patients on the first floor.

Findings include:

Based on observation during a tour of the facility with the Director of Operations on 04/25/16 at 12:00 p.m., the fire door set on the first floor by the Lab failed to latch into the frame. Based on interview at the time of observation, this was acknowledged and confirmed these were fire doors by the Director of Operations.

Based on record review and interview, the facility failed to provide a written plan that included the activation of a patient room battery operated smoke detector in 1 of 1 written fire plans. LSC 19.7.2.2 requires a written health care occupancy fire safety plan that shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to the fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
This deficient practice could affect all patients.

Findings include:

Based on a record review of the written fire safety plan with Director of Operations on 04/25/16 at 10:05 a.m., the plan did not address response to the activation of the 14 patient room battery operated smoke alarms located on the second floor long term residential care hall. Based on interview, this was acknowledged by the Director of Operations at the time of record review.

1. Based on record review and interview, the facility failed to insure fire drills included the transmission of a fire alarm signal to monitoring company for 8 of 12 fire drills conducted. This deficient practice affects all patients, staff, and visitors.

Findings include:

Based on record review of the "Fire Drill Report" with the Director of Operations on 04/25/16 between 9:13 a.m. and 9:23 a.m., the documentation for all first and second shift fire drills conducted between the hours of 6 a.m. and 9 p.m. lacked the verification of the alarm signal transmission to a monitoring company. Based on interview, this was confirmed by the Director of Operations at the time of record review.

2. Based on record review and interview, the facility failed to conduct quarterly fire drills for second shift at unexpected times for 4 of 4 quarters. This deficient practice affects all patients, staff, and visitors.

Findings include:

Based on record review of the "Fire Drill Report" with the Director of Operations on 04/25/16 between 09:13 a.m. and 09:23 a.m., all second shift fire drills took place between 3:00 p.m. and 4:00 p.m. for the last four quarters. Based on interview, this was confirmed by the Director of Operations at the time of record review.

Based on observation and interview, the facility failed to ensure 3 of 25 smoke detectors on second floor was installed where air flow would not adversely affect their operation. Section 9.6.1.4 requires fire alarm systems comply with NFPA 72, National Fire Alarm Code. NFPA 72, 2-3.5.1 requires in spaces served by air handling systems, detectors shall not be located where air flow prevents operation of the detectors. This deficient practice could up to 24 patients on the second floor.

Findings include:

Based on observation during a tour of the facility with the Facilities Man #1 on 04/25/16 between 2:00 p.m. and 2:15 p.m., three smoke detectors on the second floor located at the OD nurse ' s station, nursery, and OB room 241 were within three feet of an air supply duct. Based on interview, this was acknowledged by the Facilities Man #1 at the time of observation.

1. Based on record review and interview, the facility failed to ensure a battery testing program was provided to ensure 14 of 14 single station battery operated smoke alarms would operate. This deficient practice affects up to 14 patients in the second floor long term residential care.

Findings include:

Based on record review of the with the Director of Operations on 04/25/16 at 10:05 a.m., no documentation was available to show monthly testing for the 14 patient room battery operated smoke alarms on the second floor long term residential care hall. Based on an interview at the time of record review, the Director of Operations state there was no documentation to show testing for the battery operated smoke alarms.


2. Based on record review and interview, the facility failed to adopt a battery replacement program and a maintenance program to ensure 14 of 14 single station battery operated smoke alarms would operate properly. NFPA 70; 10.4.8 states where batteries are used as a source of energy, they shall be replaced in accordance with the alarm equipment manufacturer's publish instruction. 10.5.1 States fire alarm equipment shall be maintained in accordance with the alarm equipment manufacturers published instructions. This deficient practice affects up to 14 patients in the second floor long term residential care.

Findings include:

Based on record review with the Director of Operations on 04/25/16 at 10:05 a.m., no documentation was available to show when the 14 patient room battery operated smoke alarms on the second floor long term residential care hall had the batteries replaced, or when cleaning and maintenance was conducted. Based on an interview during records review, the Director of Operations stated there was no documentation to show when the battery operated smoke alarms were cleaned or had the batteries replaced.

Based on observation and interview, the facility failed to ensure proper sprinkler coverage was provided for 4 of 4 stairwells in accordance with NFPA 13, 1999 Edition Section 5-13.3.2 in noncombustible stair shafts with noncombustible stairs, sprinklers shall be installed at the top of the shaft and under the first landing above the bottom of the shaft. This deficient practice could all occupants of the facility

Findings include:

Based on observation during a tour of the facility with the Facilities Man #1 on 04/25/16 2:00 p.m. and during telephone call with the Director of Operations on 04/28/16 at 10:30 a.m., it was noted that stairwell "C" had a sprinkler at the first floor of the stairwell but not at the top and bottom of the stairwell. Based on interview, this was acknowledged by the Director of Operations at the time of telephone call.

Based on observation and interview, the facility failed to ensure 1 of 2 sprinkler gauges on the main riser and 1 of 1 gauges the riser in stairwell D2 were tested every five years. NFPA 25, Section 2-3.2 states gauges shall be replaced every five years or tested every five years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced. This deficient practice could affect all occupants in the building.

Findings include:

Based on observation during a tour of the facility with the Director of Operations and the Facilities Man #1 on 04/25/16 at 1:00 p.m. and at 1:20 p.m., one sprinkler gauge on the main riser and the sprinkler gauge on the riser in stairwell D2 had a date of 2010. Based on an interview and the time of observation, the Director of Operations or the Facilities Man #1 was unable to verify if the sprinkler gauges had been calibrated within the last five years.

Based on record review, observation, and interview, the facility failed to provide 1 of 1 fire damper inspections to show dampers were inspected and provided necessary maintenance at least every four years in accordance with NFPA 90A. LSC 9.2.1 requires air conditioning, heating, ventilating ductwork (HVAC) and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. NFPA 90A, 1999 Edition, 3.4.7, Maintenance, requires at least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify they fully close; the latch, if provided, shall be checked, and moving parts shall be lubricated as necessary. This deficient practice affects all occupants in the facility.

Findings include:

Based on record review on with the Director of Operations on 04/25/16 at 10:30 a.m., and again at 2:00 p.m., there were no inspection records available for review for any of the facility's fire dampers. Based on interview during records review, the Director of Operations stated the facility had dampers, but did not know when the last inspection was conducted and there were no other records available to show completed maintenance on the facility's fire dampers.

Based on observation and interview, the facility failed to ensure a capacity of 32 gallons for soiled linen or trash collection receptacles was not exceeded within any 64 square feet area for 1 of 2 corridors on the second floor. This deficient practice could affect 24 patients on the second floor.

Findings include:


Based on observation during a tour of the facility with the Facilities Man #1 on 04/25/16 between 2:00 p.m. and 2:30 p.m. a soiled linen container larger than 32 gallons in capacity was unattended and stored in the corridor by room 241 from 2:00 p.m. to 2:30 p.m. Based on an interview at the time of observation, the Facilities Man #1 acknowledged the container and stated the soiled linen container should be stored in the soiled utility room when not in use.

1. Based on observation and interview, the facility failed to ensure materials used as an interior finish on the ceiling in 1 of 1 Lobby and 1 of 1 Court Hallway had a flame spread rating of Class A or Class B. LSC 101 39.3.3.2 states products required to be tested in accordance with NFPA 255, Standard Method of Test of Surface Burning Characteristics of Building Materials, shall be grouped in the following classes in accordance with their flame spread and smoke development.
(a) Class A Interior Wall and Ceiling Finish. Flame spread 0-25; smoke development 0-450. Includes any material classified at 25 or less on the flame spread test scale and 450 or less on the smoke test scale. Any element thereof, when so tested, shall not continue to propagate fire.
(b) Class B Interior Wall and Ceiling Finish. Flame spread 26-75; smoke development 0-450. Includes any material classified at more than 25 but not more than 75 on the flame spread test scale and 450 or less on the smoke test scale.
(c) Class C Interior Wall and Ceiling Finish. Flame spread 76-200; smoke development 0-450. Includes any material classified at more than 75 but not more than 200 on the flame spread test scale and 450 or less on the smoke test scale. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Facilities Man #1 and the Fitness Supervisor on 04/25/16 at 11:38 a.m. and 11:49 a.m., the Lobby contained wood paneling on one of the walls. Then again, the Court Hallway contained carpet on one side of the hallway wall. Based on interview at the time of each observation, the Facilities Man #1 and the Fitness Supervisor was unable to provide documentation for a flame spread classification.

2. Based on observation and interview, the facility failed to ensure 5 of 5 flexible cords were not used as a substitute for fixed wiring to provide power equipment with a high current draw. LSC Chapter 39.5.1 requires utilities to comply with the provisions of Section 9.1. Section 9.1.2 requires electrical wiring and equipment to be in accordance with NFPA 70, National Electrical Code. NFPA 70, National Electrical Code, 1999 Edition, Article 400-8 requires that, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice affects all occupants.

Findings include:

Based on observation with the Facilities Man #1 and the Fitness Supervisor on 04/25/16 between 11:45 a.m. to 12:00 p.m. the following was discovered:
a) an extension cord was powering a surge protector powering two refrigerators in the Lobby
b) an extension cord was powering television equipment in the Lobby
c) an extension cord powering two separate heat tapes. Additionally, a surge protector was powering an air compressor in the Equipment room
Based on interview at the time of each observation, the Facilities Man #1 and the Fitness Supervisor acknowledged each aforementioned condition.

3. Based on observation and interview, the facility failed to ensure exit access was arranged so 3 of 4 exits were readily accessible at all times in accordance with LSC Section 7.1. LSC Section 39.2.1.1 requires the means of egress for existing buildings shall comply with Chapter 7. LSC Section 7.7.1 requires all exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. In addition to providing the required width to allow all occupants safe access to a public way, such access also needs to meet the requirements with respect to maintaining the means of egress free of obstructions that would prevent its use, such as snow and the need for its removal in some climates or soft ground during heavy periods of rain. This deficient practice could affects all occupants.

Findings include:

Based on observation with the Facilities Man #1 and the Fitness Supervisor on 04/25/16 between 11:48 a.m. and 12:13 p.m., the following exits discharged into grass.
a) Free weights exit
b) West exit
c) Cybex exit
Based on interview at the time of each observation, the Facilities Man #1 and the Fitness Supervisor acknowledged each aforementioned condition and confirmed that each path was considered an exit.

4. Based on observation and interview, the facility failed to protect 3 of 3 hazardous rooms were constructed at least 1 hour fire barrier and door openings are at least ¾ hour self-closing door. LSC 39.3.2.1 states hazardous areas, including but not limited to, areas used for general storage, boiler or furnace rooms shall be protected in accordance with LSC Section 8.4. Section 8.4.1.1 states protection from any area having a degree of hazard greater than that normal to the general occupancy of the building shall be provided with 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 This deficient practice could affect staff and all occupants.

Findings include:

Based on observation with the Facilities Man #1 and the Fitness Supervisor on 04/25/16 between 11:54 a.m. and 12:17 p.m., the following non sprinklered hazardous rooms were discovered:
a) the Racquet ball gas powered furnace room contained a louvered unrated door that did not self-close when tested. No documentation was available for the room ' s construction rating.
b) the Equipment room contained gas powered furnaces and chemical storage. There were at least twenty ceiling penetrations ranging from three quarter inch to eight inch unsealed penetrations. Drywall was removed exposing wooden studs for about 120 square feet of one of the walls. The corridor door to the Equipment room did not latch into the frame. No documentation was available for the room ' s construction rating.
c) the Cardio room gas powered furnace room contained a louvered unrated door that did not self-close when tested. No documentation was available for the room ' s construction rating.
Based on interview at the time of each observation, the Facilities Man #1 and the Fitness Supervisor acknowledged each aforementioned condition and provided the measurements.

5. Based on observation and interview, the facility failed to ensure 1 of 1 Free Weights exit discharge paths were readily accessible at all times. LSC Section 39.2.1.1 requires the means of egress for existing buildings shall comply with Chapter 7. LSC 7.5.1.1 requires exits shall be located and exit access shall be arranged so that exits are readily accessible at all times. This deficient practice could affect staff and at least 2 patients.

Findings include:

Based on observation with the Facilities Man #1 and the Fitness Supervisor on 04/25/16 at 11:56 a.m., the Free Weights exit door would not open. Based on an interview at the time of observation, the Facilities Man #1 and the Fitness Supervisor acknowledged the aforementioned condition.

Based on record review and interview, the facility failed to provide the complete documentation for testing 1 of 3 emergency generators providing power to the emergency lighting systems. NFPA 99, Section 3-4.1.1.8 states the generator set 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. This deficient practice affects all occupant.

Findings include:

Based on review of the generator log titled "Monthly Generator Test Log" with the Director of Operations on 04/25/16 at 9:42 a.m., the emergency generator number three was tested monthly under load for at least 30 minutes, however, the monthly load test record did not include the time for the transfer of power from the main source to the generator. Based on interview, this was acknowledged by the Director of Operations at the time of record review.

3.1-19(b)

1. Based on observation and interview, the facility failed to ensure 1 of 1 receptacles near a wet location was provided with ground fault circuit interrupter (GFCI) protection against electric shock. NFPA 70, Article 517, Health Care Facilities, defines wet locations as patient care areas subjected to wet conditions while patients are present. These include standing fluids on the floor or drenching of the work area, either of which condition is intimate to the patient or staff. NFPA 70, 517-20 Wet Locations, requires all receptacles and fixed equipment within the area of the wet location to have GFCI protection. Moisture can reduce the contact resistance of the body, and electrical insulation is more subject to failure. This deficient practice was not in a patient care area could affect staff with access to the PFC room.

Findings include:

Based on observation during a tour of the facility with the Director of Operations on 04/25/16 at 11:50 a.m., there was an electrical receptacle not GFCI protected on the wall less than three feet from a sink in PFC room on the first floor. Based on interview and testing, the Director of Operations acknowledged the receptacle was not provided with GFCI protection and when tested with a GFCI testing device power was not interrupted at the receptacle.

2. Based on observation and interview, the facility failed to ensure 3 of 3 flexible cords were not used as a substitute for fixed wiring to provide power equipment with a high current draw. NFPA 70, National Electrical Code, 1999 Edition, Article 400-8 requires that, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice could affect up to 30 patients in the basement and on the first and third floors.

Findings include:

Based on observation during a tour of the facility with the Director of Operations and the Facilities Man #1 on 04/25/16 between 11:00 a.m. and 2:00p.m., the following areas had refrigerators and/or microwaves plugged into an extension cord power strip:
a. Basement IS room
b. Third floor ICU nurses station
c. Third floor nurse manger office
Based on interview, the Director of Operations and the Facilities Man #1 acknowledged power strips at the time of observations.

3. Based on observation and interview, the facility failed to ensure 2 of 2 flexible cords such as an extension cord was not used as a substitute for fixed wiring. LSC 9.1.2 requires electrical wiring and equipment to comply with NFPA 70, National Electrical Code, 1999 Edition. NFPA 70, Article 400-8 requires unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice could affect 20 patients on the first and third floors.

Findings include:

Based on observation during a tour of the facility with the Director of Operations and the Facilities Man #1 on 04/25/16 between 11:00 a.m. and 2:00p.m., in the third floor nurses ' station a regular light weight extension cord was plugged in and providing power for a fan. Also in the ER staff lounge regular light weight extension cord was plugged in and providing power for a microwave. Based on interview, the Director of Operations and the Facilities Man #1 acknowledged the power strips at the time of observations.