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Based on observation and confirmed by staff, the facility failed to maintain the corridor doors to resist the passage of smoke. The Centers for Medicare & Medicaid Services S&C-07-18 states that a gap at a meeting edge of a two leaf corridor door is permitted to exceed 1/8-inch provided that the meeting edges of the leaves are equipped with an astragal, a rabbet, or a bevel. It also states that a in a fully sprinklered smoke compartment , a gap between the face of a corridor door and the door stop should not exceed ½-inch.

THE FINDINGS INCLUDE:

During the afternoon hours of 11/5/13 and the morning hours of 11/6/13 it was observed that the following corridor doors did not meet the requirements of Section 19.3.6.3:

1. A set of two leaf corridor doors to the Housekeeping Linen, located in the basement, did not resist the passage of smoke due to the 1/2 inch gap at the meeting edges.

2. The corridor door to resident room 215, located on the second floor, did not resist the passage of smoke due to the 1/2 inch gap at the meeting edges.

3. The corridor door to resident room number 227 would not close and latch due to an isolation station, used to store infection control supplies, being hung over the door.

This was acknowledged by Hospital staff during the survey and at the exit interview.


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Based on observations, the facility failed to assure that vertical shafts are enclosed as required. This deficient practice could affect all patients that utilize the main lobby entrance as well as staff and visitors, if proper compartmentalization is not achieved during an emergency.


THE FINDINGS INCLUDE:

Observations while touring the facility on 11/5/13 and 11/6/13 revealed that the third floor level Medical Office Building doors connecting the Main Lobby to the Medical Office Building do not provide the required one-hour fire resistive rating.
- The connecting single leaf door is not equipped with a self closing device and does not close when released from the open position.
- The connecting double leaf(s)opening are each equipped with kick-type door stops that prevent each leaf from closing when released from the open position
- In addition, the two door leaf(s) are labeled for a 20-minute fire rating.

These items fail to meet the requirements of sections 8.2.3.2.1 and 8.2.3.2.3.2.1.

This was acknowledged by Hospital staff during the survey and at the exit interview.

Based on observations, the facility failed to ensure that doors in the path of egress are in accordance with Chapter 7. Section 7.1.10.1 requires every exit, exit access and exit discharge to be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Section 7.2.1.5.1 requires doors to be arranged to be opened readily from the egress side whenever the building is occupied. Section No. 7.7.3 states that the exit discharge be arranged and marked to make clear the direction of egress to the public way. Stairs shall be arranged so as to make clear the direction of egress to a public way. Stairs that continue more than one-half story beyond the level of exit discharge shall be interrupted at the level of exit discharge by partitions, doors, or other effective means.

THE FINDINGS INCLUDE:

Observations while touring the facility on 11/5/13 and 11/6/13 revealed that the stair "G" and stair "H" discharge from each stair tower on the first floor level. Both stairs continue one story below the first floor level discharge and neither stair is equipped with suitable effective means to prohibit travel beyond the level of exit discharge as required by section 7.7.3

This was acknowledged by the Hospital staff during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that fire drills are conducted as required.

THE FINDINGS INCLUDE:

- While performing the record review on 11/5/13 at approximately 10:00 A.M., it was observed that the fire drills are not conducted as required. Although the facility is conducting the required amount of fire drills, the conditions of the drills are not varied as required. According to the documentation provided during survey, the fire drills occurred during the following dates & times:

1st Shift (7:00 A.M. - 3:00 P.M.): 10/7/13 @ 10:45 A.M.; 7/25/13 @ 2:00 P.M.; 4/8/13 @ 1:37 P.M.; 1/25/13 @ 2:30 P.M.; 1/15/12 @ 2:45 P.M. and 9/22/12 @ 2:45 P.M.

2nd Shift (3:00 P.M. - 11:00 P.M.): 8/29/13 @ 5:02 P.M..; 5/13/13 @ 4:45 P.M.; 2/25/13 @ 5:00 P.M.; 11/26/12 @ 4:30 P.M.; and 8/20/12 @ 8:00 P.M.

3rd Shift (11:00 P.M. - 7:00 A.M.): 9/9/13 @ 11:30 P.M.; 6/17/13 @ no time specified; 3/18/13 @ no time specified; 12/5/12 @ 5:00 A.M.; and 9/5/12 @ 6:00 A.M.

The following deficiencies were noted during the review process:

1) The conditions/times are not varied during the 1st shift drills Five of the six conducted drills were held between 1:37 P.M. and 2:45 P.M.

2) The conditions/times are not varied during the 2nd shift drills Four of the five conducted drills were held between 4:30 P.M. and 5:02 P.M.

3) Two of the drills conducted during the 3rd shift did not identify the times at which the drills were conducted.

This was acknowledged by the Hospital staff during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that all sprinkler control valves are properly supervised. Section 9.7.2.1 states 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.


THE FINDINGS INCLUDE:

While touring the facility on the afternoon of 11/5/13, it was observed that not all sprinkler control valves are electronically supervised as required. The Post Indicator Valve (P.I.V.), located on the exterior of the building by the discharge of Stairway "M", was provided with a lock but it was not provided with a tamper switch in accordance with NFPA 101, Section 9.7.2.1.

This was acknowledged by Hospital staff during the survey and at the exit interview.

Based on observations and records provided, the facility failed to properly maintain the sprinkler system. NFPA #25 section 1-4.2 states the responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.
Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer ' s instructions. These tasks shall be performed by personnel who have developed competence through training and experience.
Section 5-3.2.1 states a weekly test of electric motor-driven pump assemblies shall be conducted without flowing water. This test shall be conducted by starting the pump automatically. The pump shall run a minimum of 10 minutes.

Section 5-3.2.4 states the pertinent visual observations or adjustments specified in the following checklists shall be conducted while the pump is running.

Section 5-3.2.4.1 outlines the Pump System Procedure and what must be documented.
(a) Record the system suction and discharge pressure gauge readings.
(b) Check the pump packing glands for slight discharge.
(c) Adjust gland nuts if necessary.
(d) Check for unusual noise or vibration.
(e) Check packing boxes, bearings, or pump casing for overheating.
(f) Record the pump starting pressure.

Section 5-3.2.4.2 outlines the Electrical System Procedure and what must be documented.
(a) Observe the time for motor to accelerate to full speed.
(b) Record the time controller is on first step (for reduced voltage or reduced current starting).
(c) Record the time pump runs after starting (for automatic stop controllers).

THE FINDINGS INCLUDE:

- While performing the record review of the sprinkler system on 11/5/13 at approximately 11:15 A.M., it was observed that all of the testing/inspection criteria is not documented as required. The test/inspection forms provided only state the fire pump was run for a 10-minute churn test. There is no other information provided regarding the other testing criteria.

This was acknowledged by the Hospital staff during the exit interview process.

Based on observations, the facility failed to enforce the smoking policy for the building.

THE FINDINGS INCLUDE:

The facility did not provide metal containers with self-closing covers into which ashtrays can be emptied in the designated smoking area located outside the main entrance. During the afternoon hours of 11/6/13 a dozen or more cigarette butts were observed on the grounds around the smoking area.

This was acknowledged by Hospital staff during the survey and at the exit interview.

Based on observations and confirmed by staff, the facility failed to ensure that Utilities comply with the provisions of Section 9-1. Gas equipment shall be installed in accordance with NFPA 54, 90A, and per the manufacturer ' s specifications. NFPA 54, Section 6.4.3 requires that provisions for makeup air be provided with a minimum free area of one square inch for each 1000 Btu per hour total input rating of the dryers installed. NOTE: A 100 square inch louvered opening provides approximately 75 square inches of free area.

THE FINDINGS INCLUDE:

Based on observations during the afternoon hours of 11/5/13 there were two functioning gas fired dryers located in the laundry room in the basement level which were not provided with adequate makeup air for combustion. Each of these dryers has an input rating of 165,000 Btu per hour. They were provided with makeup air supplied by an 8" x 16" louver which allows approximately 96 square inches of free area for natural ventilation. This is not in compliance with NFPA 54 which requires a total of 330 square inches of free area for natural ventilation for the installed and functioning dryers.

This was acknowledged by Hospital staff during the survey and at the exit interview.

Based on observations, the facility failed to ensure that utilities comply with the provisions of Section 9.1. Section 9.1.2 requires electrical wiring and equipment to be installed in accordance with NFPA 70.
Article 400-8 prohibits flexible cords from being used for:
1. 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,
5. Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors, and
6. Where installed in raceways, except as otherwise permitted in this Code. LSC 19.5.1

THE FINDINGS INCLUDE:

Observations while touring the facility on the afternoon of 11/5/13, revealed a strip-type surge arrestor extension cord was utilized to supplement power in Resident Room 201. In addition, an extension cord was being utilized for two computers in the 4th floor Patient Conference Room. Flexible cords are not a substitute for fixed wiring.

This was acknowledged by staff during the survey and at the exit interview.