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Based on observation and interview, it was determined the facility failed to ensure valves located in the facility sprinkler system were supervised by a tamper switch. A tamper switch ensures valves controlling the water supply for the sprinkler system cannot be shut off without the facility knowing. The deficiency had the potential to affect the Phase II part of the facility. The facility is certified for four hundred sixty three (463) beds.

The findings include:

Observation on 11/09/12, at 10:03 AM, with the Safety and Security Manager, and the Facilities Supervisor revealed the sprinkler riser located and serving the Phase II building was not electronically supervised. The valve was not equipped with a tamper switch, but was secured with a chain

Interview on 11/09/12, at 10:03 AM, with the Safety and Security Manager, and the Facilities Supervisor they were not aware the valve was unsupervised.

Reference: NFPA 101 (2000 Edition).

9.7.2.1* Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves.
Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

Based on observation and interview it was determined the facility failed to ensure, portable space heaters used in the facility were in accordance with NFPA standards. The deficiency had the potential to affect one (1) of forty seven (47) smoke compartments, residents, staff and visitors. The facility is certified for four hundred sixty three (463) beds.
The findings include:

Observation, on 11/08/12 at 5:54 PM, with the Safety and Security Manager, and the Facilities Supervisor revealed portable space heaters located in Medical Records Room.

Interview, on 11/08/12 at 5:54 PM, with the Safety and Security Manager, and the Facilities Supervisor revealed they were not aware the heaters could not exceed 212°F in non-sleeping, staff, and employee areas.


Reference: NFPA 101 (2000 edition)
19.7.8 Portable Space-Heating Devices. Portable space-heating
devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used
in non-sleeping staff and employee areas where the heating elements of
such devices do not exceed 212°F (100°C).

Based on observation and interview, it was determined the facility failed to maintain exit access in accordance with NFPA standards. The deficiency had the potential to affect four () of forty seven (47) smoke compartments, residents, staff and visitors. The facility is certified for four hundred sixty three (463) beds.

The findings include:

Observation, on 11/08/12 between 2:00 PM and 6:00 PM, with the Safety and Security Manager and the Facilities Supervisor revealed the storage of Computers on wheels (COWS) and med carts stored in the egress path located in unit 5-5, the forth (4th) floor Rehab, and Unit 3-5.Further observation revealed the storage of wood pallets, and cardboard boxes located outside the Cath Lab.

Interview, on 11/08/12 between 2:00 PM and 6:00 PM, with the Safety and Security Manager and the Facilities Supervisor revealed these items were routinely stored in the egress corridors.

Reference: NFPA 101 (2000 Edition)
Means of Egress Reliability 7.1.10.1
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on observation and interview, it was determined the facility failed to ensure trash collection receptacles with capacities greater than 32 gallon were stored in accordance with NFPA standards. The deficiency had the potential to affect one (1) of forty seven (47) smoke compartments, residents, staff and visitors. The facility is certified for four hundred sixty three (463) beds.

The findings include:

Observation, on 11/09/12 at 8:12 AM, with the Safety and Security Manager, and the Facilities Supervisor revealed an unattended trash cart in the corridor outside the Cath Lab that was full of cardboard boxes.

Interview, on 11/09/12 at 8:12 AM, with the Safety and Security Manager, and the Facilities Supervisor revealed they were unaware the Staff would leave the trash cart in the corridor unattended.



19.7.5.5
Soiled linen or trash collection receptacles shall not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gal/ft2 (20.4 L/m2). A capacity of 32 gal (121 L) shall not be exceeded within any 64-ft2 (5.9-m2) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) shall be located in a room protected as a hazardous area when not attended.
Exception: Container size and density shall not be limited in hazardous areas.

Based on observation and interview, it was determined the facility failed to ensure oxygen storage areas were protected in accordance with NFPA standards. The deficiency had the potential to affect one (1) of forty seven (47) smoke compartments, residents, staff and visitors. The facility is certified for four hundred sixty three (463) beds. The facility failed to ensure oxygen was stored in a room rated for hazardous storage.


The findings include:

Observation, on 11/08/12 at 2:29 PM, with the Safety and Security Manager, and the Facilities Supervisor revealed fifteen (15) size " E " oxygen cylinders were being stored in the fifth (5th) floor Acute Therapy Room. The cylinders were not located in a room rated for oxygen storage.

Interview, on 11/08/12 at 2:29 PM, with the Safety and Security Manger, and the Facilities Supervisor revealed they were aware fifteen (15) oxygen tanks could not be stored without being in a protected room.





Reference: NFPA 101 (2000 edition)
8-3.1.11.2
Storage for nonflammable gases greater than 8.5 m3 (300 ft3) but less than 85 m3 (3000 ft3)
(A) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
(B) Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor.
(C) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following:
(1) A minimum distance of 6.1 m (20 ft)
(2) A minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems
(3) An enclosed cabinet of noncombustible construction having a minimum fire protection rating of ½ hour. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.

Based on observation and interview, it was determined the facility failed to ensure electrical wiring was maintained in accordance with NFPA standards. The deficiency had the potential to affect three (3) of forty seven (47) smoke compartments, residents, staff, and visitors. The facility is certified for four hundred sixty three (463) beds. The facility failed to ensure the proper use of power strips, extension cords, and ground fault protected outlets.

The findings include:

Observation, on 11/08/12 between 2:00 PM and 6:00 PM, with the Safety and Security Manager, and the Facilities Supervisor revealed medical equipment plugged into a power strip located in the fifth (5th) floor sleep lab. Further observation revealed a Hydrocollator was not plugged into a ground fault protected outlet (GFCI) located in the fifth (5th) floor Acute Therapy, and the forth (4th) floor Therapy Office. Further observation revealed an extension cord plugged into a power strip located in the 5-3 Case Management Office. Further observation revealed a refrigerator was plugged into a power strip located at the forth (4th) floor Nurses ' Station. Further observation revealed a power strip was plugged into another power strip located in Medical Records.


Interview, on 11/08/12 between 2:00 PM and 6:00 PM, with the Safety and Security Manager and the Facilities Supervisor revealed they were aware of the proper use of power strips and extension cords, but not aware of who plugged the power strips into each other or who plugged the medical equipment into the power strips.





Reference: NFPA 70 400-8
( Extensions Cords) Uses Not Permitted.
Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces


Reference: NFPA 99 (1999 edition)

3-3.2.1.2 D

Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.