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Based on observation, the facility failed to ensure that the cross corridor doors to a hazardous area were provided with a means to self close in an emergency. The deficient practice would affect staff in the facility. The facility had the capacity for 45 licensed beds with a census of 22 on the day of the survey.

Findings include:

During the facility tour on March 9, 2010 between 9:30 and 10:30 am, observation of the rated separation doors between the service corridor and the loading dock revealed both doors to were propped open by drop down door stops, preventing the doors from self closing in an emergency. This deficiency was noted by facility Maintenance Director and the Surveyor.

The finding was acknowledged by the Compliance Officer and by the Maintenance Director at the exit interview on March 10, 2010.

Actual NFPA Standard: NFPA 101;
19.2.2.2.6
Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

Based on observation and interview, the facility failed to provide adequate exit directional signage. This deficient practice affected the surgery, pre-op and post-op portions of the main floor, affecting all surgical patients and staff in the surgical suite. The Census was 22 on the date of the survey.

Findings include:

During the facility tour on March 9, 2010 between 3:00 and 4:30 pm, a lack of exit signage was observed in the Pre-op, post-op, and surgical corridor, and the need for a directional sign in the short stay hallway. Interview with the maintenance director confirmed that the facility was unaware of the requirements for directional signage within suites. Failure to provide adequate signage would effect timely evacuation in an emergency.

The finding was acknowledged by the Compliance Officer and verified by the Maintenance Director at the exit interview on March 10, 2010.

Actual NFPA standard:
NFPA 101, 2000 Edition 7.10.1.4 Exit Access.
Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.

Based on record review and staff interview it was determined that the facility had not ensured that all required fire drills were conducted for the previous 12 months. Census on the date of the survey was 22. The findings include:

Record review on March 09, 2010 at 10:46 a.m. disclosed that fire drill documentation was not available for two of four quarters in the last 12 months. Records indicated no night shift drills, three planned day shift drills and six actual occurrences (false alarms or sprinkler system testing). Maintenance Director stated during the exit interview on March 10, 2010 at 8:45 a.m. that fire drills forms and documentation were filled out for system testing, and acknowledged a lack of formal fire drills. Lack of fire drill training could result in staff not performing properly in a fire emergency.

The finding was acknowledged by the Compliance Officer and verified by the Maintenance Director at the exit interview on March 10, 2010

Based on observation, it was determined that the facility had not insured that the fire alarm system required for life safety is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. Census on the date of the survey was 22. The findings include:

Observation on March 09, 2010 at approximately 3:45 p.m., disclosed that facility had not insured protection of the fire alarm control unit. In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit(s) to provide notification of fire at that location. The origin and path of the fire may result in destruction of the control unit before a detector responds.

The finding was acknowledged by the Compliance Officer and verified by the Maintenance Director at the exit interview on March 10, 2010

Based on record review and staff interview it was determined that the facility had not ensured that the automatic fire sprinkler system was inspected as often as required. The deficient practice would affect all smoke compartments, residents and staff within the building. The census on the date of the survey was 22. The findings include:

Record review on March 09, 2010 at approximately 11:00 a.m. disclosed that annual sprinkler system documentation indicated the system was overdue for five year maintenance; internal valve inspection/obstruction investigation and the OS&Y valve supervisory signals were not being received at the FACP. Maintenance Director stated during interview on March 10, 2010 at 8:45 a.m. that he had not noted the deficiency on the sprinkler system report provided by the sprinkler contractor.

The finding was acknowledged by the Compliance Officer and verified by the Maintenance Director at the exit interview on March 10, 2010

Actual NFPA reference:
NFPA 25 Standard for the Inspection, Testing and Maintenance of Water Based Fire Protection Systems, Section 2.2, Table 2-1 Summary of Sprinkler System Inspection, Testing and Maintenance.

NFPA 101, Chapter 38, Section 3.1.1. - Any vertical opening shall be enclosed or protected in accordance with 8.2.5.

Based on observations during the tour of the outpatient urgent care clinic on March 09, 2010 at approximately 4:30 p.m. it was determined that the facility failed to ensure vertical separations are closed at all times.

The findings included:

During the tour of the Urgent Care clinic at 2327 Channing Way on March 09, 2010 observation revealed a self closing vertical separation door at the top of the basement stair being held open with a drop down style door stop. This was observed by the surveyors and the facility administrator. This deficiency would allow fire to spread unchecked between floors.

Actual Standard

NFPA 101, chapter 38 - 38.3.1.1
Any vertical opening shall be enclosed or protected in accordance with 8.2.5.

Based on observation and interview it was determined the facility had not ensured that "No Smoking Oxygen In Use" signs were displayed where oxygen was being stored. Census on the date of the survey was 22 residents.

The findings include:

Observation on March 09, 2010 at approximately 1:30 p.m. disclosed that medical gas room was not labeled for the use or no smoking. A "No Smoking Oxygen In Use" sign was not displayed where oxygen and other gases were being stored. Observation was witnessed and noted by surveyors and facility Maintenance Director.

The finding was acknowledged by the Compliance Officer and verified by the Maintenance Director at the exit interview on March 10, 2010

Actual NFPA Standard:
NFPA 99, 8-6.4.2 Signs.
Precautionary signs, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed wherever supplemental oxygen is in use, and in aisles and walkways leading to that area. They shall be attached to adjacent doorways or to building walls or be supported by other appropriate means.

Based on record review, it was determined the facility had not ensured that the emergency generator was being inspected weekly and load tested monthly in accordance with NFPA 99. The facility had a census of 22 on the date of the survey.

The findings include:

Record review of the generator log on March 09, 2010 at 11:20 a.m., disclosed that the facility was missing the February monthly testing on the generator log. This was noted by the Surveyor and the Maintenance Director.

The finding was acknowledged by the Compliance Officer and verified by the Maintenance Director at the exit interview on March 10, 2010


Actual NFPA standard:
NFPA 99 1999 edition
3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems
NFPA 110 1999 edition
6-4.1
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

Based on observations and staff interview, it was determined the facility had not ensured compliance with the requirement to maintain alcohol based hand rubs (ABHR) a sufficient distance from an ignition source . The facility had a census of 22 on the date of the survey.

The findings include:

Observations on March 09, 2010 between 1:00 p.m. and 4:30 p.m., disclosed that patient rooms 38 - 42, and in the hyperbaric suite had hand rub dispensers installed adjacent to or above the light switches.

This deficiency was corrected immediately by maintenance staff.

The finding was acknowledged by the Compliance Officer and verified by the Maintenance Director at the exit interview on March 10, 2010

Actual Standard:
Where Alcohol Based Hand Rub (ABHR) dispensers are installed in a corridor:
o The corridor is at least 6 feet wide
o The maximum individual fluid dispenser capacity shall be 1.2 liters (2 liters in suites of rooms)
o The dispensers have a minimum spacing of 4 ft from each other
o Not more than 10 gallons are used in a single smoke compartment outside a storage cabinet.
o Dispensers are not installed over or adjacent to an ignition source.
o If the floor is carpeted, the building is fully sprinklered. 19.3.2.7, CFR 403.744, 418.100, 460.72, 482.41, 483.70, 483.623, 485.623