HospitalInspections.org

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with smoke detection in corridors with spaces that are open to the corridor. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect an undetermined number of staff and visitors.

FINDINGS INCLUDE:

1. On 3/14/2016 at 2:41 pm, observation revealed on the 1st floor in the employee entrance hallway by the tables, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that are open to the corridor. The corridor in same smoke compartment did not have smoke detection. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director of Maintenance) staff H (Maintenance) and staff F (Maintenance).


2. On 03/14/2016 at 5:05 pm, observation revealed on the 1st floor in the main entrance lobby, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that are open to the corridor. The corridor in same smoke compartment did not have complete smoke detection. The end pockets (east and west) of the ceiling did not have smoke detectors. Every pocket of slanting ceiling is to have a smoke detector per NPFA 72, 2-3.4.6.1 This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.1 . This condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director of Maintenance).

Based on observation and interview, the facility did not enclose hazardous rooms with sealed wall penetrations. This deficiency occurred in 2 of the 8 smoke compartments, and had the potential to affect 5 of the 35 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

1. On 3/14/2016 at 1:30 pm, observation revealed on the 1st floor in the A 104, that penetrations were not sealed according to an approved method. The deficiency included 2 pipes that were not fire caulked and 1 conduit that had an open end. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.

2. On 3/14/2016 at 2:00 pm, observation revealed on the 1st floor in the soiled room of OBGYN, that penetrations were not sealed according to an approved method. The deficiency included all conduits were not fire caulked. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.

3. On 3/14/2016 at 2:24 pm, observation revealed on the 1st floor in the soiled (decontamination room), that penetrations were not sealed according to an approved method. The deficiency included several pipes did not have fire caulk sealing it to the rated wall. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.

4. On 3/14/2016 at 2:33 pm, observation revealed on the 1st floor in the clean room G 1016, that the hazardous room door was prevented from self-closing by 2 wedges at the bottom of the door. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.8.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (Maintenance) and staff F (Maintenance).

Based on observation and interview, the facility did not protect the facility from the contents of the hazardous gift shop by using construction methods required by the code, with rated walls in a hazardous room. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect an undetermined number of staff and visitors.

FINDINGS INCLUDE:

On 03/14/2016 at 3:56 pm, observation revealed on the 1st floor in the gift shop, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall had non rated glass. The gift shop contained a quantity of stored combustible product that was considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director of Maintenance), staff H (Maintenance) and staff F (Maintenance).

Based on observation and interview, the facility did not provide egress paths at all times with no obstructions in the path of egress. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect an undetermined number of staff and visitors.

FINDINGS INCLUDE:

On 3/15/2016 at 9:10 am, observation revealed on the 1st floor in the sterile hold , that the exit path was not readily accessible because carts blocked the exit. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.5.1.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (Maintenance) and staff F (Maintenance).

Based on observation and interview, the facility did not provide and maintain emergency illumination of the interior means of egress for at least 90 minutes after a power failure. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect 5 of the 35 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

On 03/14/2016 at 7:00 pm, observation revealed on the 1st floor in the corridor by the radiology waiting area, that there was a switch installed on the lights in the corridor so when turned off were was no illumination along the path of egress at this location. The lights were turned off. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.8.1.2.

This condition was confirmed on March 15, 2016 at 9 am by a concurrent observation and interview with staff C, (Maintenance Director), staff H (Maintenance) and staff F (Maintenance).

Based on observation and interview, the facility did not maintain a written evacuation plan that contained all the elements with staff trained on the extinguishment of fires. This deficiency occurred in all of the 8 smoke compartments and had the potential to affect all of the 35 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

On 3/14/2016 at 3:20 pm, observation revealed on the 1st floor in the kitchen, that staff were not familiar with what class of fire extinguisher to use on cooking media fires, such as a kitchen grease fire. During an interview, staff HH (cook), could not identify the type of portable extinguisher, either the red Class ABC or stainless Class K type, to use on cooking media fires. In addition, staff HH (cook) did not know 'RACE', which is the hospital policy. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.7.2.2(8). This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Dietary Manager).

Based on record review and interview, the facility did not conduct fire drills as required by the code to ensure that staff are familiar with fire response procedures with fire drills that fully test the staff's ability to respond to fire emergencies. This deficiency occurred in of the 8 smoke compartments, and had the potential to affect of the 35 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

On 03/14/2016 at 6:00 pm, record review revealed that the facility's fire drills for the past 12 months were not conducted at varied times. Three out of four night shift fire drills for the year 2015 were conducted at 11 pm. This situation was not compliant with NFPA 101 (2000 ed.), 18.7.1.2. This condition was confirmed on March 15, 2015 by a concurrent record review and interview with staff C (Director of Maintenance) and staff J (Maintenance).

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with non-sprinkled rooms that meet permitted exceptions . This deficiency occurred in 1 of the 8 smoke compartments and had the potential to affect all of the 35 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

On 3/15/2016 at 10:43 am, observation revealed on the 1st floor in the utilities electrical room, that the room was not sprinkler protected, although the entire facility was required to be sprinkled. The facility did not meet all the requirements of the code to avoid sprinkling the space. The room was enclosed with 2-hour rated construction, but the following was not provided: The electrical room contained more than only electrical equipment. It had storage in the room. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.5.1 (exception). This condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Maintenance)

Based on observation and interview, the facility did not maintain the sprinkler system in a reliable operating condition that included appropriate storage of spare sprinklers. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 03/15/2016 at 11:30 am, observation revealed on the 1st floor in the Fire Pump room, that spare sprinklers were not stored in a safe manner that would protect them from damage. Three spare sprinkler heads were laying out and were not kept in the designed slots inside the spare sprinkler cabinet. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-4.1.4.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director of Maintenance).

Based on observation and interview, the facility did not provide and maintain portable fire extinguishers as required by the codes with fully visible extinguishers. This deficiency occurred in 8 of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 03/15/2016 at 11:45 am, observation revealed that fire extinguishers were obstructed from view because all the fire extinguishers were kept in opaque metal cabinets without any see thru window and the locations of fire extinguishers were not marked. Only two fire extinguisher locations located inside the laboratory were identified with arrow signs. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.5.6, 9.7.4.1 and NFPA 10 (1998 ed.), 1-6.6 & 1-6.12.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director of Maintenance).

Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A and neutral airflow between the corridor and rooms. This deficiency occurred in 2 of the 8 smoke compartments and had the potential to affect 5 of the 35 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

1. On 3/14/2016 at 5:00 pm, observation revealed on the 1st floor in the dining room, that airflow between the corridor and the room was not neutral. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.5.2.1 9.2 and NFPA 90A, 2-3.11.1.

2. On 03/14/2016 at 5:10 pm, observation revealed on the 1st floor in the main entrance lobby, that airflow between the main entrance lobby (corridor) and the Medical Office Building was not neutral. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.5.2.1 9.2 and NFPA 90A, 2-3.11.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (Maintenance) and staff F (Maintenance).

Based on observation and interview, the facility did not maintain an egress path that was free of highly flammable furnishings/decoration, as with non-combustible decorations. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect 5 of the 35 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

On 3/14/2016 at 2:10 pm, observation revealed on the 1st floor in the OB side corridor, that decorations made with combustible materials were used. The items could not be confirmed as being flame-retardant. The decorations included wall boards, papers and other flammable material lining both sides of the corridor. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.7.5.2 thru 18.7.5.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director of Maintenance), staff H (Maintenance) and staff F (Maintenance).

Based on observation and interview, the facility did not provide and maintain linen/trash collection receptacles in compliance with the codes by having properly sized storage containers for soiled/trash. This deficiency occurred in 1 of the 8 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/15/2016 at 10:00 am, observation revealed on the 1st floor in the Nuclear Medicine waiting area, that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. One 24 gallon and one 13 gallon size trash receptacles were kept together inside the room. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.7.5.6.

2. On 03/15/2016 at 10:15 am, observation revealed on the 1st floor in the Nuclear Medicine room, that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. One more than 32 gallon size trash receptacles was kept inside the room. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.7.5.6.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director of Maintenance).

Based on observation and interview, the facility did not provide medical gas piping as required by NFPA 99 with compliant medical gas piping, maintaining combustibles at least 50 feet away from a 1000 gallon or greater liquid oxygen tank, and having staff properly instructed when to turn off the oxygen at the zone valves. These deficiencies could affect 8 of the 8 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

1. On March 15, 2016 at 10:30 am, surveyor observed that the bulk oxygen tank in the parking lot area had combustibles, such as pallets, located within 50 feet of the Oxygen Tank, greater than 1000 gallons. This observed situation was not compliant with NFPA 50 (1998 edition) section 2.2.7 and NFPA 99 section 4-3.1.1.2(a). This condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Maintenance).

2. On March 14, 2016 at 1:15 PM and at 1:50 PM interview revealed in the Med/surge nurse station and OBGYN nurse station respectfully, that staff FF, (CNA) and staff GG, (RN) did not know when to shut off the oxygen supply valve when there was a fire. This condition was confirmed at the time of discovery by interview with staff FF (CNA) and GG (RN).

3. On March 15, 2016 at 9:40 am, surveyor observed that the WAGD discharge from the anesthetic gas machine was into the vacuum connection instead of the WAGD connection. WAGD inlets shall not be interchangeable with other system, including medical-surgical vacuum per NFPA 99, 1999 edition 4-3.3.2.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Maintenance), staff G (Maintenance), staff L (Director of Anesth.) and staff S (Surgery Director).

Based on observation and interview, the facility did not provide interior walls and partitions made of noncombustible or limited-combustible materials with non-combustible wall materials. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect an undetermined number of staff and visitors.

FINDINGS INCLUDE:

On 3/15/2016 at 9:50 am, observation revealed on the 1st floor in the central storage, that a wall was made with combustible materials which is not permitted in non-combustible types of building construction. The wall was constructed with clear plastic This observed situation was not compliant with NFPA 101 (2000 ed.), 18.1.6.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (Maintenance) and staff F (Maintenance).

K 56

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with no wall obstructions and properly labeling of the sprinkler pipes and hydraulic calculations. This deficiency occurred in the Lodi Medical office building and had the potential to affect all outpatients, staff and visitors.

FINDINGS INCLUDE:

1) On March 15, 2016 at 1:30 pm, observation revealed on the 1st floor in the two nurse workstations, that a wall obstructed the discharge of sprinkler water from reaching an unprotected area on the other side of the wall. The obstruction included the wing walls between the nurse writing stations. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Maintenance) and staff G (Maintenance).

2) On March 15, 2016 at 1:40 pm, observation revealed on the 1st floor in the mechanical room, that the sprinkler installation was not compliant. In the sprinkler room, the two service areas were not identified as to which area they served and the hydraulic information for those areas was not on the sprinkler pipes. This observed situation was not compliant with NFPA 101 (2000 ed.) and NFPA 13. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Maintenance) and staff G (Maintenance).

K22
Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage with "no-exit" signs that may be confused as exits. This deficiency had the potential to affect all outpatients, staff and visitors within this building.

FINDINGS INCLUDE:

On 03/15/2016 at 2:45 pm, observation revealed on the 1st floor in the main stairwell, that the path of travel was likely to be mistaken as an exit and a "NO Exit" sign was not provided. Traveling down the stairs, the double door out of the stairs into the first floor requires the "No Exit" sign. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.10.1.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff G (maintenance).

K 38
Based on observation and interview, the facility did not provide egress paths at all times with no obstructions in the path of egress, and doors that were unlockable in the egress path. This deficiency had the potential to affect all outpatients, staff and visitors within this building.

FINDINGS INCLUDE:

1. On 03/15/2016 at 2:50 pm, observation revealed on the 1st floor in stairwell
#2, that the exit path was not readily accessible because a container of salt was in the stairs blocking the exit path. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.5.1.1.

2. On 03/15/2016 at 2:47 pm, observation revealed on the roof floor in stairwell
#2, that the door was locked from the egress side. The exit from the roof into the stairs was always locked. This observed situation was not compliant with NFPA 101 (2000 ed.), 38.2.2.2. and 7.2.1.5.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with with staff G.

K56
Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with sprinkler coverage throughout the building, and no wall obstructions. This deficiency had the potential to affect all outpatients, staff and visitors within this building.

FINDINGS INCLUDE:

1. On 03/15/2016 at 2:53 pm, observation revealed on the basement floor in the pool equipment room, that the room was not sprinkled. This building is required to be fully sprinklered, since the corridor walls are not 1 hour fire rated. This observed situation was not compliant with NFPA 101 (2000 ed.), 38.3.6.1.

2. On 03/15/2016 at 2:57 pm, observation revealed on the floor in the men's and women's locker room, that a wall obstructed the discharge of sprinkler water from reaching an unprotected area on the other side of the wall. The obstruction included the wing walls of the shower and shower curtains to the ceiling. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff G (maintenance).

Based on interview and a review of documents, the facility did not test the emergency electrical generator in accordance with the codes with full testing of the automatic transfer switches. This deficiency occurred in 1 of the 8 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 03/15/2016 at 2:00 pm, during a review of facility documents it was discovered that the facility did not exercise the automatic transfer switch for the fire pump on a monthly basis. This situation was not compliant with NFPA 13 (1999 ed.) 9-2.2; NFPA 20 (1999 ed.) 6-6.2; NFPA 110 (1999 ed.) 6-4.5.

This condition was confirmed at the time of discovery by a concurrent record review and interview with staff C (Director of Maintenance).

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with smoke detection in corridors with spaces that are open to the corridor. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect an undetermined number of staff and visitors.

FINDINGS INCLUDE:

1. On 3/14/2016 at 2:41 pm, observation revealed on the 1st floor in the employee entrance hallway by the tables, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that are open to the corridor. The corridor in same smoke compartment did not have smoke detection. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director of Maintenance) staff H (Maintenance) and staff F (Maintenance).


2. On 03/14/2016 at 5:05 pm, observation revealed on the 1st floor in the main entrance lobby, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that are open to the corridor. The corridor in same smoke compartment did not have complete smoke detection. The end pockets (east and west) of the ceiling did not have smoke detectors. Every pocket of slanting ceiling is to have a smoke detector per NPFA 72, 2-3.4.6.1 This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.1 . This condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director of Maintenance).

Based on observation and interview, the facility did not enclose hazardous rooms with sealed wall penetrations. This deficiency occurred in 2 of the 8 smoke compartments, and had the potential to affect 5 of the 35 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

1. On 3/14/2016 at 1:30 pm, observation revealed on the 1st floor in the A 104, that penetrations were not sealed according to an approved method. The deficiency included 2 pipes that were not fire caulked and 1 conduit that had an open end. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.

2. On 3/14/2016 at 2:00 pm, observation revealed on the 1st floor in the soiled room of OBGYN, that penetrations were not sealed according to an approved method. The deficiency included all conduits were not fire caulked. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.

3. On 3/14/2016 at 2:24 pm, observation revealed on the 1st floor in the soiled (decontamination room), that penetrations were not sealed according to an approved method. The deficiency included several pipes did not have fire caulk sealing it to the rated wall. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.

4. On 3/14/2016 at 2:33 pm, observation revealed on the 1st floor in the clean room G 1016, that the hazardous room door was prevented from self-closing by 2 wedges at the bottom of the door. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.8.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (Maintenance) and staff F (Maintenance).

Based on observation and interview, the facility did not protect the facility from the contents of the hazardous gift shop by using construction methods required by the code, with rated walls in a hazardous room. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect an undetermined number of staff and visitors.

FINDINGS INCLUDE:

On 03/14/2016 at 3:56 pm, observation revealed on the 1st floor in the gift shop, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall had non rated glass. The gift shop contained a quantity of stored combustible product that was considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director of Maintenance), staff H (Maintenance) and staff F (Maintenance).

Based on observation and interview, the facility did not provide egress paths at all times with no obstructions in the path of egress. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect an undetermined number of staff and visitors.

FINDINGS INCLUDE:

On 3/15/2016 at 9:10 am, observation revealed on the 1st floor in the sterile hold , that the exit path was not readily accessible because carts blocked the exit. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.5.1.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (Maintenance) and staff F (Maintenance).

Based on observation and interview, the facility did not provide and maintain emergency illumination of the interior means of egress for at least 90 minutes after a power failure. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect 5 of the 35 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

On 03/14/2016 at 7:00 pm, observation revealed on the 1st floor in the corridor by the radiology waiting area, that there was a switch installed on the lights in the corridor so when turned off were was no illumination along the path of egress at this location. The lights were turned off. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.8.1.2.

This condition was confirmed on March 15, 2016 at 9 am by a concurrent observation and interview with staff C, (Maintenance Director), staff H (Maintenance) and staff F (Maintenance).

Based on observation and interview, the facility did not maintain a written evacuation plan that contained all the elements with staff trained on the extinguishment of fires. This deficiency occurred in all of the 8 smoke compartments and had the potential to affect all of the 35 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

On 3/14/2016 at 3:20 pm, observation revealed on the 1st floor in the kitchen, that staff were not familiar with what class of fire extinguisher to use on cooking media fires, such as a kitchen grease fire. During an interview, staff HH (cook), could not identify the type of portable extinguisher, either the red Class ABC or stainless Class K type, to use on cooking media fires. In addition, staff HH (cook) did not know 'RACE', which is the hospital policy. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.7.2.2(8). This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Dietary Manager).

Based on record review and interview, the facility did not conduct fire drills as required by the code to ensure that staff are familiar with fire response procedures with fire drills that fully test the staff's ability to respond to fire emergencies. This deficiency occurred in of the 8 smoke compartments, and had the potential to affect of the 35 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

On 03/14/2016 at 6:00 pm, record review revealed that the facility's fire drills for the past 12 months were not conducted at varied times. Three out of four night shift fire drills for the year 2015 were conducted at 11 pm. This situation was not compliant with NFPA 101 (2000 ed.), 18.7.1.2. This condition was confirmed on March 15, 2015 by a concurrent record review and interview with staff C (Director of Maintenance) and staff J (Maintenance).

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with non-sprinkled rooms that meet permitted exceptions . This deficiency occurred in 1 of the 8 smoke compartments and had the potential to affect all of the 35 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

On 3/15/2016 at 10:43 am, observation revealed on the 1st floor in the utilities electrical room, that the room was not sprinkler protected, although the entire facility was required to be sprinkled. The facility did not meet all the requirements of the code to avoid sprinkling the space. The room was enclosed with 2-hour rated construction, but the following was not provided: The electrical room contained more than only electrical equipment. It had storage in the room. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.5.1 (exception). This condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Maintenance)

Based on observation and interview, the facility did not maintain the sprinkler system in a reliable operating condition that included appropriate storage of spare sprinklers. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 03/15/2016 at 11:30 am, observation revealed on the 1st floor in the Fire Pump room, that spare sprinklers were not stored in a safe manner that would protect them from damage. Three spare sprinkler heads were laying out and were not kept in the designed slots inside the spare sprinkler cabinet. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-4.1.4.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director of Maintenance).

Based on observation and interview, the facility did not provide and maintain portable fire extinguishers as required by the codes with fully visible extinguishers. This deficiency occurred in 8 of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 03/15/2016 at 11:45 am, observation revealed that fire extinguishers were obstructed from view because all the fire extinguishers were kept in opaque metal cabinets without any see thru window and the locations of fire extinguishers were not marked. Only two fire extinguisher locations located inside the laboratory were identified with arrow signs. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.5.6, 9.7.4.1 and NFPA 10 (1998 ed.), 1-6.6 & 1-6.12.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director of Maintenance).

Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A and neutral airflow between the corridor and rooms. This deficiency occurred in 2 of the 8 smoke compartments and had the potential to affect 5 of the 35 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

1. On 3/14/2016 at 5:00 pm, observation revealed on the 1st floor in the dining room, that airflow between the corridor and the room was not neutral. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.5.2.1 9.2 and NFPA 90A, 2-3.11.1.

2. On 03/14/2016 at 5:10 pm, observation revealed on the 1st floor in the main entrance lobby, that airflow between the main entrance lobby (corridor) and the Medical Office Building was not neutral. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.5.2.1 9.2 and NFPA 90A, 2-3.11.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (Maintenance) and staff F (Maintenance).

Based on observation and interview, the facility did not maintain an egress path that was free of highly flammable furnishings/decoration, as with non-combustible decorations. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect 5 of the 35 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

On 3/14/2016 at 2:10 pm, observation revealed on the 1st floor in the OB side corridor, that decorations made with combustible materials were used. The items could not be confirmed as being flame-retardant. The decorations included wall boards, papers and other flammable material lining both sides of the corridor. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.7.5.2 thru 18.7.5.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director of Maintenance), staff H (Maintenance) and staff F (Maintenance).

Based on observation and interview, the facility did not provide and maintain linen/trash collection receptacles in compliance with the codes by having properly sized storage containers for soiled/trash. This deficiency occurred in 1 of the 8 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/15/2016 at 10:00 am, observation revealed on the 1st floor in the Nuclear Medicine waiting area, that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. One 24 gallon and one 13 gallon size trash receptacles were kept together inside the room. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.7.5.6.

2. On 03/15/2016 at 10:15 am, observation revealed on the 1st floor in the Nuclear Medicine room, that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. One more than 32 gallon size trash receptacles was kept inside the room. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.7.5.6.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director of Maintenance).

Based on observation and interview, the facility did not provide medical gas piping as required by NFPA 99 with compliant medical gas piping, maintaining combustibles at least 50 feet away from a 1000 gallon or greater liquid oxygen tank, and having staff properly instructed when to turn off the oxygen at the zone valves. These deficiencies could affect 8 of the 8 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

1. On March 15, 2016 at 10:30 am, surveyor observed that the bulk oxygen tank in the parking lot area had combustibles, such as pallets, located within 50 feet of the Oxygen Tank, greater than 1000 gallons. This observed situation was not compliant with NFPA 50 (1998 edition) section 2.2.7 and NFPA 99 section 4-3.1.1.2(a). This condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Maintenance).

2. On March 14, 2016 at 1:15 PM and at 1:50 PM interview revealed in the Med/surge nurse station and OBGYN nurse station respectfully, that staff FF, (CNA) and staff GG, (RN) did not know when to shut off the oxygen supply valve when there was a fire. This condition was confirmed at the time of discovery by interview with staff FF (CNA) and GG (RN).

3. On March 15, 2016 at 9:40 am, surveyor observed that the WAGD discharge from the anesthetic gas machine was into the vacuum connection instead of the WAGD connection. WAGD inlets shall not be interchangeable with other system, including medical-surgical vacuum per NFPA 99, 1999 edition 4-3.3.2.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Maintenance), staff G (Maintenance), staff L (Director of Anesth.) and staff S (Surgery Director).

Based on observation and interview, the facility did not provide interior walls and partitions made of noncombustible or limited-combustible materials with non-combustible wall materials. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect an undetermined number of staff and visitors.

FINDINGS INCLUDE:

On 3/15/2016 at 9:50 am, observation revealed on the 1st floor in the central storage, that a wall was made with combustible materials which is not permitted in non-combustible types of building construction. The wall was constructed with clear plastic This observed situation was not compliant with NFPA 101 (2000 ed.), 18.1.6.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (Maintenance) and staff F (Maintenance).

K 56

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with no wall obstructions and properly labeling of the sprinkler pipes and hydraulic calculations. This deficiency occurred in the Lodi Medical office building and had the potential to affect all outpatients, staff and visitors.

FINDINGS INCLUDE:

1) On March 15, 2016 at 1:30 pm, observation revealed on the 1st floor in the two nurse workstations, that a wall obstructed the discharge of sprinkler water from reaching an unprotected area on the other side of the wall. The obstruction included the wing walls between the nurse writing stations. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Maintenance) and staff G (Maintenance).

2) On March 15, 2016 at 1:40 pm, observation revealed on the 1st floor in the mechanical room, that the sprinkler installation was not compliant. In the sprinkler room, the two service areas were not identified as to which area they served and the hydraulic information for those areas was not on the sprinkler pipes. This observed situation was not compliant with NFPA 101 (2000 ed.) and NFPA 13. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Maintenance) and staff G (Maintenance).

K22
Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage with "no-exit" signs that may be confused as exits. This deficiency had the potential to affect all outpatients, staff and visitors within this building.

FINDINGS INCLUDE:

On 03/15/2016 at 2:45 pm, observation revealed on the 1st floor in the main stairwell, that the path of travel was likely to be mistaken as an exit and a "NO Exit" sign was not provided. Traveling down the stairs, the double door out of the stairs into the first floor requires the "No Exit" sign. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.10.1.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff G (maintenance).

K 38
Based on observation and interview, the facility did not provide egress paths at all times with no obstructions in the path of egress, and doors that were unlockable in the egress path. This deficiency had the potential to affect all outpatients, staff and visitors within this building.

FINDINGS INCLUDE:

1. On 03/15/2016 at 2:50 pm, observation revealed on the 1st floor in stairwell
#2, that the exit path was not readily accessible because a container of salt was in the stairs blocking the exit path. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.5.1.1.

2. On 03/15/2016 at 2:47 pm, observation revealed on the roof floor in stairwell
#2, that the door was locked from the egress side. The exit from the roof into the stairs was always locked. This observed situation was not compliant with NFPA 101 (2000 ed.), 38.2.2.2. and 7.2.1.5.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with with staff G.

K56
Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with sprinkler coverage throughout the building, and no wall obstructions. This deficiency had the potential to affect all outpatients, staff and visitors within this building.

FINDINGS INCLUDE:

1. On 03/15/2016 at 2:53 pm, observation revealed on the basement floor in the pool equipment room, that the room was not sprinkled. This building is required to be fully sprinklered, since the corridor walls are not 1 hour fire rated. This observed situation was not compliant with NFPA 101 (2000 ed.), 38.3.6.1.

2. On 03/15/2016 at 2:57 pm, observation revealed on the floor in the men's and women's locker room, that a wall obstructed the discharge of sprinkler water from reaching an unprotected area on the other side of the wall. The obstruction included the wing walls of the shower and shower curtains to the ceiling. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff G (maintenance).

Based on interview and a review of documents, the facility did not test the emergency electrical generator in accordance with the codes with full testing of the automatic transfer switches. This deficiency occurred in 1 of the 8 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 03/15/2016 at 2:00 pm, during a review of facility documents it was discovered that the facility did not exercise the automatic transfer switch for the fire pump on a monthly basis. This situation was not compliant with NFPA 13 (1999 ed.) 9-2.2; NFPA 20 (1999 ed.) 6-6.2; NFPA 110 (1999 ed.) 6-4.5.

This condition was confirmed at the time of discovery by a concurrent record review and interview with staff C (Director of Maintenance).