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Based on observation the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On March 5, and 6, 2013 the surveyor, accompanied by the VP of Support Services, Director of Facilities, Life Safety Associate and the Lead Accreditation Specialist, observed the following corridor doors would not tightly close when tested.

1. Fifth Floor East Therapy Gym, door closing device disconnected
2. Fifth Floor, Chapel, door closure disconnected
3. Third Floor, door 301-50 B Telemetry room door will not close, held open with an impediment
4. Third Floor, staff lounge, door closing device disconnected
5. Third Floor, room 319, Manager clinical, door closing device disconnected
6. Respiratory Care, break room, closing device removed
7. First Floor, Radiology Entrance, UL listed doorframe, door removed
8. ER, Door 101-24 A, one south observation, door not smoke tight
9. Eye Center, Pre Admit, door closing device removed
10. Pavilion, fifth floor, FD 5950, door with a closing device held open with an impediment

During the exit conference on March 6, 2013, the above findings were again acknowledged by the CEO, VP Support Services, Lead Accreditation Specialist, Sr. Director Regulatory Functions, CNO and the Director of Facilities.

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

Based on observation the facility did not maintain the integrity, smoke resistance, of doors in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.2.1 requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls and doors must be able to resist the passage of smoke. NFPA 80 "Fire Doors and Fire Windows" Chapter 2, Section 2-3.1.7 "The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. +/- 1/16 in for steel doors and shall not exceed 1/8 in. for wood doors. "Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. NFPA 30 "Flammable and Combustible Liquids"


Findings include:

On March 5, and 6, 2013 the surveyor, accompanied by the VP of Support Services, Director of Facilities, Life Safety Associate and the Lead Accreditation Specialist, observed the following doors :

1. Central Storage OR, door with a closing device not smoke tight
2. Lab Storage Histology, door has vents, no closing device and a non rated door, approximately thirty gallons of Class 3 liquids stored in five gallon containers
3. Door 160-7211, Electrical closet, door vented
4. Clinical Lab, door does not positively latch, the panic hardware has the latch mechanism disconnected
5. Kitchen, door 002-11 F, Storage Par Stock, door with a closing device held open with an impediment
6. Kitchen Double doors, 112-11 H and 002-11 A, not smoke tight
7. Pavilion fifth floor, Housekeeping Nuro ICU, no closing device, flammables and combustibles storage
8. Pavilion fifth floor, respiratory therapy, storage/office, no closing device
9. SD 3462 Door to soiled holding, closing device removed

During the exit conference on March 6, 2013, the above findings were again acknowledged by the CEO, VP Support Services, Lead Accreditation Specialist, Sr. Director Regulatory Functions, CNO and the Director of Facilities.

Failing to prevent heat and smoke from spreading into the exit corridor will cause harm to patients.

Based on observation the facility did not keep exits readily accessible at all times.

NFPA 101 Life Safety Code, 2000, Chapter 19 Section 19.2.1, and Section 19.2.3.3. Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 19.2.3.3 "Aisles, corridors and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft (Existing built to 8 feet must be maintained 8 feet clear) in clear and unobstructed width". Chapter 7 Section 7.5.1.1" Exits shall be so located and exit access shall be arranged so that exits are readily accessible at all times." Section 7.5.1.2 "Where exits are not immediately accessible from an open floor area, continuous passageways, aisles, or corridors leading directly to every exit and shall be maintained and shall be arranged to provide access for each occupant to not less than two exits by separate ways of travel."

Findings include:

On March 5, and 6, 2013 the surveyor, accompanied by the VP of Support Services, Director of Facilities, Life Safety Associate and the Lead Accreditation Specialist, observed storage of the following built in fixtures and stationary equipment in the following the exit corridors. The storage was blocking the exit access.

1. Third Floor, ASCU, the corridor measured eight feet and was reduced to six feet four inches by built in desks, wall shelving and other stored equipment
2. Second Floor, Cardio Pulmonary Rehab. the corridor measured eight feet reduced to four feet by cabinets, scales and chairs
3. First Floor, Out Pt. Rehab. four exit access reduced by a four foot wall from floor to ceiling built in the corridor, copy machines shredders, potted plants and other equipment

During the exit conference on March 6, 2013, the above findings were again acknowledged by the CEO, VP Support Services, Lead Accreditation Specialist, Sr. Director Regulatory Functions, CNO and the Director of Facilities.

Failure to keep the exit corridors and exit access clear could hinder the evacuation during an emergency and will cause harm to patients.

Based on observation the facility failed to maintain the battery operated emergency lighting.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.2.9.1 " Emergency lighting shall be provided in accordance with Section 7.9."Section 7.9.2.4 "Battery-operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition."

Findings Include:

On March 6, 2013 the surveyor, accompanied by the VP of Support Services, Director of Facilities, Life Safety Associate and the Lead Accreditation Specialist, observed, and tested the emergency lighting unit located in the EPS room. The lighting unit would not light during the test.

During the exit conference on March 6, 2013, the above findings were again acknowledged by the CEO, VP Support Services, Lead Accreditation Specialist, Sr. Director Regulatory Functions, CNO and the Director of Facilities.

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

Based on observation the facility failed to assure that exits from the building were each illuminated by more than a single light source.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.2.8 "Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, Section 7.8.1.4 "Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2 Lux) in any designated area."

Findings Include:

On March 5, 2013 the surveyor, accompanied by the VP of Support Services, Director of Facilities, Life Safety Associate and the Lead Accreditation Specialist, observed the exit discharge lighting from the fifth floor east exterior stairwell. The exit discharge was illuminated by a single-bulb light fixture. All designated exits shall have two bulb fixtures.

During the exit conference on March 6, 2013, the above findings were again acknowledged by the CEO, VP Support Services, Lead Accreditation Specialist, Sr. Director Regulatory Functions, CNO and the Director of Facilities.

In an emergency the failure of the one bulb will result in harm to the patients.

Based on observation the facility failed to maintain the sprinkler heads and assure that all parts of the sprinkler system were in accordance with the UL Listing.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.5.1 "Buildings containing health care facilities shall be protected throughout by and approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection,
Testing, and Maintenance of Water-Based Fire Protection systems. NFPA 25, Section 2-2.1.1 "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign material , paint, and physical damage and shall be installed in the proper orientation..." NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, Chapter 3, Section 3-2.7.2, "Escutcheon Plates used with a recessed or flushed sprinkler shall be part of a listed sprinkler assembly."

Findings Include:

On March 5, and 6, 2013 the surveyor, accompanied by the VP of Support Services, Director of Facilities, Life Safety Associate and the Lead Accreditation Specialist, observed the following sprinkler assemblies:

1. Third Floor staff lounge one of two sprinklers lint
2. Third floor door 340-07 A, storage room wreaths one inch from sprinkler assemblies
3. Third floor door SD 3124, one of two sprinklers lint
4. Third floor, room 319 two of two sprinklers lint
5. Kitchen, five of twenty sprinklers, grease and lint
6. Four South Nurses station, four of five sprinklers lint

During the exit conference on March 6, 2013, the above findings were again acknowledged by the CEO, VP Support Services, Lead Accreditation Specialist, Sr. Director Regulatory Functions, CNO and the Director of Facilities.

Failing to maintain sprinkler heads and keep the fusible link clean could allow a fire to burn longer before the sprinkler head will activate. Failing to maintain sprinkler heads, missing escutcheon plates, which are part of the UL Listing of the sprinkler assembly, could allow heat and smoke to effect other areas of the building. This could cause harm to the patients.

Based on Observation the facility failed to clean the kitchen exhaust hood system, filters and grease drip tray.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.3.2.6 "Cooking facilities shall be protected in accordance with 9-2.3" Section 9-2.3 "Commercial cooking equipment shall be installed in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations." , Chapter 8, Section 8-3.1, " Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge".

Findings include:

On March 5, and 6, 2013 the surveyor, accompanied by the VP of Support Services, Director of Facilities, Life Safety Associate and the Lead Accreditation Specialist, observed the kitchen exhaust system hood, filters and grease drip tray area had an excessive amount of grease buildup, kitchen staff stated filters cleaned once a week.

1. Main Cook line, six of eight filters heavy grease, lint
2. Prep line, five of eight filters heavy grease

During the exit conference on March 6, 2013, the above findings were again acknowledged by the CEO, VP Support Services, Lead Accreditation Specialist, Sr. Director Regulatory Functions, CNO and the Director of Facilities.

Failing to keep the entire kitchen exhaust hood system clean from grease will cause a fire, which could cause damage to the kitchen and will cause harm to the patients.

Based on observation the facility failed to mount an electrical light switch five feet above the floor in the oxygen storage rooms, and failed keep the oxygen bottles free of combustible materials.


NFPA 101 Life Safety Code, Chapter 19, Section 19.3.2.4 " Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 Chapter 8, Storage Requirements, Section 8-3.1.11.2 Storage for nonflammable gases less than 3000 cubic feet. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2 (a) 11d. Section 4-3.1.1.2 (a) 11(d) Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft. (1.5m) above the floor to avoid physical damage. Chapter 4, Section 4-3.5.2.2 (a) (2) "If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly. Chapter 8, Section 8-3.1.11 "Storage Requirements" Section 8-3.1.11.2 "Storage of nonflammable gases less than 3000 cubic. feet.." (a) "Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. (c) "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by: (c) (2) A minimum distance of 5 ft. if the entire storage location is protected by an automatic sprinkler system..."

Findings include:

On March 5, and 6, 2013 the surveyor, accompanied by the VP of Support Services, Director of Facilities, Life Safety Associate and the Lead Accreditation Specialist, observed the oxygen storage in the following areas were less than sixty inches from electrical, combustibles and flammables:

1. Fourth Floor, Therapy storage, one EO2 bottle by combustibles
2. Door 4102, eleven EO2 bottles less than five feet from electrical, combustibles and flammables
3. Door SD 4120, thirteen EO2 bottles less than five feet from electrical and combustibles
4. Pavilion, Nero Med. Surgery, Door FD 5905, one EO2 bottle less than five feet from combustibles
5. First floor Dialysis, eight full, seven empty, EO2. bottles, less than sixty inches from electrical and combustibles
6. Three North Clean utility, five EO2 bottles less than sixty inches from electrical and combustibles
7. Central Storage OR, thirty two E type medical gases bottles, five EO2 bottles, stored less than sixty inches from electrical, combustibles, and flammables O2 not marked FULL/EMPTY

During the exit conference on March 6, 2013, the above findings were again acknowledged by the CEO, VP Support Services, Lead Accreditation Specialist, Sr. Director Regulatory Functions, CNO and the Director of Facilities.

Failing to mount a light switch five feet above the floor to prevent an accident/or possible fire could cause harm to the patients. Leaking oxygen could penetrate combustible materials and create an extreme fire hazard, which could cause harm to the patients. In an emergency, patients could be harmed if an empty medical gas cylinder was mistakenly taken from the storage area.

Based on Observation the facility allowed the use of a multiple outlet adapter, power strips and did not use the wall outlet receptacles for appliances, and the facility failed to provide a guard on the light bulbs.

A. Main Hospital

NFPA 101, Life Safety Code, 2000, Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 1999 Edition. NFPA 99, Chapter 3, Section 3-3.2.1.2, "All Patient Care Areas," Section 3-3.2.1.2 (d) Receptacles (2)" 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, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1, Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, Article 110, Section 110-27 (b) Prevent Physical Damage. " In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage

Findings include:

On March 5, and 6, 2013 the surveyor, accompanied by the VP of Support Services, Director of Facilities, Life Safety Associate and the Lead Accreditation Specialist, observed refrigerators and microwaves plugged into multi-outlet power strips and not directly plugged in to the wall outlet receptacles, and observed that the light bulbs located in the following rooms were not protected from physical damage.

1. Fifth Floor, Room 5-1 mechanical room no light covers
2. Fifth floor break room, hard wired eleven 110 outlet power strip with a refrigerator and microwave plugged in. To include exposed energized electrical
3. Fourth Floor, Therapy storage, two light units no covers
4. Eye Center, Pre-Admit, four way 110 outlet, microwave and refrigerator plugged in

During the exit conference on March 6, 2013, the above findings were again acknowledged by the CEO, VP Support Services, Lead Accreditation Specialist, Sr. Director Regulatory Functions, CNO and the Director of Facilities
.
The use of multiple outlet adapters could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.
Failure to keep light guards on the light could cause accidental damage or possibly a fire, which could cause harm to the patients.

B. O'Rielly Care Center

On March 6, 2013 the surveyor, accompanied by the VP of Support Services, Director of Facilities, Life Safety Associate and the Lead Accreditation Specialist, observed two refrigerators plugged into multi-outlet power strip and not directly plugged in to the wall outlet receptacles in the second floor Nurses station, and observed that the light bulb located in the electrical room did not have a protective cover, to include the door is vented to the corridor.

During the exit conference on March 6, 2013, the above findings were again acknowledged by the CEO, VP Support Services, Lead Accreditation Specialist, Sr. Director Regulatory Functions, CNO and the Director of Facilities.

The use of multiple outlet adapters could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.
Failure to keep light guards on the light could cause accidental damage or possibly a fire, which could cause harm to the patients.

K154 IS A CONDITION OF PARTICIPATION

Based on Policy review the facility failed to provide a written policy, for staff members to follow, when the automatic sprinkler system is out of service and document the Fire Watch.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.3.5.1 "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Chapter 9, Section 9.7.6.1 "Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service."

Chapter 3 DEFINITIONS

3.3.77* FIRE WATCH. A PERSON OR PERSONS ASSIGNED TO AN AREA FOR THE PURPOSE OF PROTECTING THE OCCUPANTS FROM FIRE OR SIMILAR EMERGENCIES.

Findings Include:

On March 5, 2013, the surveyor, accompanied by the Director of Facilities and the Life Safety Associate, reviewed the fire disaster plan for the facility. The surveyor reviewed a written policy for an out of service sprinkler system. The facility did not have Fire Watch documentation at the time of records review for the construction in progress.
The CATH Lab has major construction in progress from January 2013 to Approximately May 2013. All sprinklers were removed from the construction area. The surveyor asked several times if there was a dedicated FIRE WATCH. The surveyor was told "Security has increased there rounds" at the time of survey there was no written documentation of Securities rounds. The surveyor observed Security in the area on three occasions, security did not enter the construction area. In the construction area the temporary lighting had plastic overlapping the lights, evidence of burnt plastic, and combustibles are throughout the area. The facility did not have documentation notifying any Authorities Having Jurisdiction of the Fire Watch..

During the exit conference on March 6, 2013, the above findings were again acknowledged by the CEO, VP Support Services, Lead Accreditation Specialist, Sr. Director Regulatory Functions, CNO and the Director of Facilities.

Failing to provide a written policy for an out of service sprinkler system, will cause staff members to delay protection of the patients and the repair of the sprinkler system.

K155 IS A CONDITION OF PARTICIPATION

Based on Policy review the facility failed to provide a written policy, for staff members to follow, when a fire alarm system is out of service and document the Fire Watch.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.4.1. "Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6." Chapter 9, Section 9.6.1.8, "Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service."

Chapter 3 DEFINITIONS

3.3.77* FIRE WATCH. A PERSON OR PERSONS ASSIGNED TO AN AREA FOR THE PURPOSE OF PROTECTING THE OCCUPANTS FROM FIRE OR SIMILAR EMERGENCIES.

Findings Include:

On March 5, 2013, the surveyor, accompanied by the Director of Facilities and the Life Safety Associate, reviewed the fire disaster plan for the facility. The surveyor reviewed a written policy for an out of service Fire Alarm. system. The facility did not have Fire Watch documentation at the time of records review for the construction in project.
The CATH Lab has major construction in progress from January 2013 to Approximately May 2013. All smoke detectors were removed from the construction area. The surveyor asked several times if there was a dedicated FIRE WATCH. The surveyor was told "Security has increased there rounds" at the time of survey there was no written documentation of Securities rounds. The surveyor observed Security in the area on three occasions, security did not enter the construction area. In the construction area the temporary lighting had plastic overlapping the lights, evidence of burnt plastic, and combustibles are throughout the area. The facility did not have documentation notifying any Authorities Having Jurisdiction.

During the exit conference on March 6, 2013, the above findings were again acknowledged by the CEO, VP Support Services, Lead Accreditation Specialist, Sr. Director Regulatory Functions, CNO and the Director of Facilities.

Failing to provide a written policy for an out of service fire alarm system, will cause staff members to delay protection of the patients and the repair of the fire alarm system.

Based on observation the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On March 5, and 6, 2013 the surveyor, accompanied by the VP of Support Services, Director of Facilities, Life Safety Associate and the Lead Accreditation Specialist, observed the following corridor doors would not tightly close when tested.

1. Fifth Floor East Therapy Gym, door closing device disconnected
2. Fifth Floor, Chapel, door closure disconnected
3. Third Floor, door 301-50 B Telemetry room door will not close, held open with an impediment
4. Third Floor, staff lounge, door closing device disconnected
5. Third Floor, room 319, Manager clinical, door closing device disconnected
6. Respiratory Care, break room, closing device removed
7. First Floor, Radiology Entrance, UL listed doorframe, door removed
8. ER, Door 101-24 A, one south observation, door not smoke tight
9. Eye Center, Pre Admit, door closing device removed
10. Pavilion, fifth floor, FD 5950, door with a closing device held open with an impediment

During the exit conference on March 6, 2013, the above findings were again acknowledged by the CEO, VP Support Services, Lead Accreditation Specialist, Sr. Director Regulatory Functions, CNO and the Director of Facilities.

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

Based on observation the facility did not maintain the integrity, smoke resistance, of doors in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.2.1 requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls and doors must be able to resist the passage of smoke. NFPA 80 "Fire Doors and Fire Windows" Chapter 2, Section 2-3.1.7 "The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. +/- 1/16 in for steel doors and shall not exceed 1/8 in. for wood doors. "Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. NFPA 30 "Flammable and Combustible Liquids"


Findings include:

On March 5, and 6, 2013 the surveyor, accompanied by the VP of Support Services, Director of Facilities, Life Safety Associate and the Lead Accreditation Specialist, observed the following doors :

1. Central Storage OR, door with a closing device not smoke tight
2. Lab Storage Histology, door has vents, no closing device and a non rated door, approximately thirty gallons of Class 3 liquids stored in five gallon containers
3. Door 160-7211, Electrical closet, door vented
4. Clinical Lab, door does not positively latch, the panic hardware has the latch mechanism disconnected
5. Kitchen, door 002-11 F, Storage Par Stock, door with a closing device held open with an impediment
6. Kitchen Double doors, 112-11 H and 002-11 A, not smoke tight
7. Pavilion fifth floor, Housekeeping Nuro ICU, no closing device, flammables and combustibles storage
8. Pavilion fifth floor, respiratory therapy, storage/office, no closing device
9. SD 3462 Door to soiled holding, closing device removed

During the exit conference on March 6, 2013, the above findings were again acknowledged by the CEO, VP Support Services, Lead Accreditation Specialist, Sr. Director Regulatory Functions, CNO and the Director of Facilities.

Failing to prevent heat and smoke from spreading into the exit corridor will cause harm to patients.

Based on observation the facility did not keep exits readily accessible at all times.

NFPA 101 Life Safety Code, 2000, Chapter 19 Section 19.2.1, and Section 19.2.3.3. Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 19.2.3.3 "Aisles, corridors and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft (Existing built to 8 feet must be maintained 8 feet clear) in clear and unobstructed width". Chapter 7 Section 7.5.1.1" Exits shall be so located and exit access shall be arranged so that exits are readily accessible at all times." Section 7.5.1.2 "Where exits are not immediately accessible from an open floor area, continuous passageways, aisles, or corridors leading directly to every exit and shall be maintained and shall be arranged to provide access for each occupant to not less than two exits by separate ways of travel."

Findings include:

On March 5, and 6, 2013 the surveyor, accompanied by the VP of Support Services, Director of Facilities, Life Safety Associate and the Lead Accreditation Specialist, observed storage of the following built in fixtures and stationary equipment in the following the exit corridors. The storage was blocking the exit access.

1. Third Floor, ASCU, the corridor measured eight feet and was reduced to six feet four inches by built in desks, wall shelving and other stored equipment
2. Second Floor, Cardio Pulmonary Rehab. the corridor measured eight feet reduced to four feet by cabinets, scales and chairs
3. First Floor, Out Pt. Rehab. four exit access reduced by a four foot wall from floor to ceiling built in the corridor, copy machines shredders, potted plants and other equipment

During the exit conference on March 6, 2013, the above findings were again acknowledged by the CEO, VP Support Services, Lead Accreditation Specialist, Sr. Director Regulatory Functions, CNO and the Director of Facilities.

Failure to keep the exit corridors and exit access clear could hinder the evacuation during an emergency and will cause harm to patients.

Based on observation the facility failed to maintain the battery operated emergency lighting.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.2.9.1 " Emergency lighting shall be provided in accordance with Section 7.9."Section 7.9.2.4 "Battery-operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition."

Findings Include:

On March 6, 2013 the surveyor, accompanied by the VP of Support Services, Director of Facilities, Life Safety Associate and the Lead Accreditation Specialist, observed, and tested the emergency lighting unit located in the EPS room. The lighting unit would not light during the test.

During the exit conference on March 6, 2013, the above findings were again acknowledged by the CEO, VP Support Services, Lead Accreditation Specialist, Sr. Director Regulatory Functions, CNO and the Director of Facilities.

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

Based on observation the facility failed to assure that exits from the building were each illuminated by more than a single light source.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.2.8 "Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, Section 7.8.1.4 "Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2 Lux) in any designated area."

Findings Include:

On March 5, 2013 the surveyor, accompanied by the VP of Support Services, Director of Facilities, Life Safety Associate and the Lead Accreditation Specialist, observed the exit discharge lighting from the fifth floor east exterior stairwell. The exit discharge was illuminated by a single-bulb light fixture. All designated exits shall have two bulb fixtures.

During the exit conference on March 6, 2013, the above findings were again acknowledged by the CEO, VP Support Services, Lead Accreditation Specialist, Sr. Director Regulatory Functions, CNO and the Director of Facilities.

In an emergency the failure of the one bulb will result in harm to the patients.

Based on observation the facility failed to maintain the sprinkler heads and assure that all parts of the sprinkler system were in accordance with the UL Listing.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.5.1 "Buildings containing health care facilities shall be protected throughout by and approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection,
Testing, and Maintenance of Water-Based Fire Protection systems. NFPA 25, Section 2-2.1.1 "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign material , paint, and physical damage and shall be installed in the proper orientation..." NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, Chapter 3, Section 3-2.7.2, "Escutcheon Plates used with a recessed or flushed sprinkler shall be part of a listed sprinkler assembly."

Findings Include:

On March 5, and 6, 2013 the surveyor, accompanied by the VP of Support Services, Director of Facilities, Life Safety Associate and the Lead Accreditation Specialist, observed the following sprinkler assemblies:

1. Third Floor staff lounge one of two sprinklers lint
2. Third floor door 340-07 A, storage room wreaths one inch from sprinkler assemblies
3. Third floor door SD 3124, one of two sprinklers lint
4. Third floor, room 319 two of two sprinklers lint
5. Kitchen, five of twenty sprinklers, grease and lint
6. Four South Nurses station, four of five sprinklers lint

During the exit conference on March 6, 2013, the above findings were again acknowledged by the CEO, VP Support Services, Lead Accreditation Specialist, Sr. Director Regulatory Functions, CNO and the Director of Facilities.

Failing to maintain sprinkler heads and keep the fusible link clean could allow a fire to burn longer before the sprinkler head will activate. Failing to maintain sprinkler heads, missing escutcheon plates, which are part of the UL Listing of the sprinkler assembly, could allow heat and smoke to effect other areas of the building. This could cause harm to the patients.

Based on Observation the facility failed to clean the kitchen exhaust hood system, filters and grease drip tray.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.3.2.6 "Cooking facilities shall be protected in accordance with 9-2.3" Section 9-2.3 "Commercial cooking equipment shall be installed in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations." , Chapter 8, Section 8-3.1, " Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge".

Findings include:

On March 5, and 6, 2013 the surveyor, accompanied by the VP of Support Services, Director of Facilities, Life Safety Associate and the Lead Accreditation Specialist, observed the kitchen exhaust system hood, filters and grease drip tray area had an excessive amount of grease buildup, kitchen staff stated filters cleaned once a week.

1. Main Cook line, six of eight filters heavy grease, lint
2. Prep line, five of eight filters heavy grease

During the exit conference on March 6, 2013, the above findings were again acknowledged by the CEO, VP Support Services, Lead Accreditation Specialist, Sr. Director Regulatory Functions, CNO and the Director of Facilities.

Failing to keep the entire kitchen exhaust hood system clean from grease will cause a fire, which could cause damage to the kitchen and will cause harm to the patients.

Based on observation the facility failed to mount an electrical light switch five feet above the floor in the oxygen storage rooms, and failed keep the oxygen bottles free of combustible materials.


NFPA 101 Life Safety Code, Chapter 19, Section 19.3.2.4 " Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 Chapter 8, Storage Requirements, Section 8-3.1.11.2 Storage for nonflammable gases less than 3000 cubic feet. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2 (a) 11d. Section 4-3.1.1.2 (a) 11(d) Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft. (1.5m) above the floor to avoid physical damage. Chapter 4, Section 4-3.5.2.2 (a) (2) "If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly. Chapter 8, Section 8-3.1.11 "Storage Requirements" Section 8-3.1.11.2 "Storage of nonflammable gases less than 3000 cubic. feet.." (a) "Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. (c) "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by: (c) (2) A minimum distance of 5 ft. if the entire storage location is protected by an automatic sprinkler system..."

Findings include:

On March 5, and 6, 2013 the surveyor, accompanied by the VP of Support Services, Director of Facilities, Life Safety Associate and the Lead Accreditation Specialist, observed the oxygen storage in the following areas were less than sixty inches from electrical, combustibles and flammables:

1. Fourth Floor, Therapy storage, one EO2 bottle by combustibles
2. Door 4102, eleven EO2 bottles less than five feet from electrical, combustibles and flammables
3. Door SD 4120, thirteen EO2 bottles less than five feet from electrical and combustibles
4. Pavilion, Nero Med. Surgery, Door FD 5905, one EO2 bottle less than five feet from combustibles
5. First floor Dialysis, eight full, seven empty, EO2. bottles, less than sixty inches from electrical and combustibles
6. Three North Clean utility, five EO2 bottles less than sixty inches from electrical and combustibles
7. Central Storage OR, thirty two E type medical gases bottles, five EO2 bottles, stored less than sixty inches from electrical, combustibles, and flammables O2 not marked FULL/EMPTY

During the exit conference on March 6, 2013, the above findings were again acknowledged by the CEO, VP Support Services, Lead Accreditation Specialist, Sr. Director Regulatory Functions, CNO and the Director of Facilities.

Failing to mount a light switch five feet above the floor to prevent an accident/or possible fire could cause harm to the patients. Leaking oxygen could penetrate combustible materials and create an extreme fire hazard, which could cause harm to the patients. In an emergency, patients could be harmed if an empty medical gas cylinder was mistakenly taken from the storage area.

Based on Observation the facility allowed the use of a multiple outlet adapter, power strips and did not use the wall outlet receptacles for appliances, and the facility failed to provide a guard on the light bulbs.

A. Main Hospital

NFPA 101, Life Safety Code, 2000, Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 1999 Edition. NFPA 99, Chapter 3, Section 3-3.2.1.2, "All Patient Care Areas," Section 3-3.2.1.2 (d) Receptacles (2)" 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, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1, Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, Article 110, Section 110-27 (b) Prevent Physical Damage. " In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage

Findings include:

On March 5, and 6, 2013 the surveyor, accompanied by the VP of Support Services, Director of Facilities, Life Safety Associate and the Lead Accreditation Specialist, observed refrigerators and microwaves plugged into multi-outlet power strips and not directly plugged in to the wall outlet receptacles, and observed that the light bulbs located in the following rooms were not protected from physical damage.

1. Fifth Floor, Room 5-1 mechanical room no light covers
2. Fifth floor break room, hard wired eleven 110 outlet power strip with a refrigerator and microwave plugged in. To include exposed energized electrical
3. Fourth Floor, Therapy storage, two light units no covers
4. Eye Center, Pre-Admit, four way 110 outlet, microwave and refrigerator plugged in

During the exit conference on March 6, 2013, the above findings were again acknowledged by the CEO, VP Support Services, Lead Accreditation Specialist, Sr. Director Regulatory Functions, CNO and the Director of Facilities
.
The use of multiple outlet adapters could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.
Failure to keep light guards on the light could cause accidental damage or possibly a fire, which could cause harm to the patients.

B. O'Rielly Care Center

On March 6, 2013 the surveyor, accompanied by the VP of Support Services, Director of Facilities, Life Safety Associate and the Lead Accreditation Specialist, observed two refrigerators plugged into multi-outlet power strip and not directly plugged in to the wall outlet receptacles in the second floor Nurses station, and observed that the light bulb located in the electrical room did not have a protective cover, to include the door is vented to the corridor.

During the exit conference on March 6, 2013, the above findings were again acknowledged by the CEO, VP Support Services, Lead Accreditation Specialist, Sr. Director Regulatory Functions, CNO and the Director of Facilities.

The use of multiple outlet adapters could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.
Failure to keep light guards on the light could cause accidental damage or possibly a fire, which could cause harm to the patients.

K154 IS A CONDITION OF PARTICIPATION

Based on Policy review the facility failed to provide a written policy, for staff members to follow, when the automatic sprinkler system is out of service and document the Fire Watch.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.3.5.1 "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Chapter 9, Section 9.7.6.1 "Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service."

Chapter 3 DEFINITIONS

3.3.77* FIRE WATCH. A PERSON OR PERSONS ASSIGNED TO AN AREA FOR THE PURPOSE OF PROTECTING THE OCCUPANTS FROM FIRE OR SIMILAR EMERGENCIES.

Findings Include:

On March 5, 2013, the surveyor, accompanied by the Director of Facilities and the Life Safety Associate, reviewed the fire disaster plan for the facility. The surveyor reviewed a written policy for an out of service sprinkler system. The facility did not have Fire Watch documentation at the time of records review for the construction in progress.
The CATH Lab has major construction in progress from January 2013 to Approximately May 2013. All sprinklers were removed from the construction area. The surveyor asked several times if there was a dedicated FIRE WATCH. The surveyor was told "Security has increased there rounds" at the time of survey there was no written documentation of Securities rounds. The surveyor observed Security in the area on three occasions, security did not enter the construction area. In the construction area the temporary lighting had plastic overlapping the lights, evidence of burnt plastic, and combustibles are throughout the area. The facility did not have documentation notifying any Authorities Having Jurisdiction of the Fire Watch..

During the exit conference on March 6, 2013, the above findings were again acknowledged by the CEO, VP Support Services, Lead Accreditation Specialist, Sr. Director Regulatory Functions, CNO and the Director of Facilities.

Failing to provide a written policy for an out of service sprinkler system, will cause staff members to delay protection of the patients and the repair of the sprinkler system.

K155 IS A CONDITION OF PARTICIPATION

Based on Policy review the facility failed to provide a written policy, for staff members to follow, when a fire alarm system is out of service and document the Fire Watch.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.4.1. "Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6." Chapter 9, Section 9.6.1.8, "Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service."

Chapter 3 DEFINITIONS

3.3.77* FIRE WATCH. A PERSON OR PERSONS ASSIGNED TO AN AREA FOR THE PURPOSE OF PROTECTING THE OCCUPANTS FROM FIRE OR SIMILAR EMERGENCIES.

Findings Include:

On March 5, 2013, the surveyor, accompanied by the Director of Facilities and the Life Safety Associate, reviewed the fire disaster plan for the facility. The surveyor reviewed a written policy for an out of service Fire Alarm. system. The facility did not have Fire Watch documentation at the time of records review for the construction in project.
The CATH Lab has major construction in progress from January 2013 to Approximately May 2013. All smoke detectors were removed from the construction area. The surveyor asked several times if there was a dedicated FIRE WATCH. The surveyor was told "Security has increased there rounds" at the time of survey there was no written documentation of Securities rounds. The surveyor observed Security in the area on three occasions, security did not enter the construction area. In the construction area the temporary lighting had plastic overlapping the lights, evidence of burnt plastic, and combustibles are throughout the area. The facility did not have documentation notifying any Authorities Having Jurisdiction.

During the exit conference on March 6, 2013, the above findings were again acknowledged by the CEO, VP Support Services, Lead Accreditation Specialist, Sr. Director Regulatory Functions, CNO and the Director of Facilities.

Failing to provide a written policy for an out of service fire alarm system, will cause staff members to delay protection of the patients and the repair of the fire alarm system.