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Based on observation, the facility failed to maintain the integrity of their building construction. This was evidenced by unsealed penetrations at one location in the facility. This affected one of five smoke compartments and could result in the spread of smoke or fire to other locations in the facility.

Findings:

During a facility tour with staff, on 5/18/11 at 1:13 p.m., there were five approximately one quarter inch diameter unsealed penetrations in the wall of the Basement Level elevator room. The penetrations were located near the light switch in that room.

Based on observation, the facility failed to maintain their corridor doors. This was evidenced by two doors that were obstructed from closing. This affected two of five smoke compartments and could result in a delay to contain smoke or fire to a room.

Findings:

During a facility tour with staff on 5/18/11, the corridor doors in the facility were observed.

1. At 1:30 p.m., the Pharmacy corridor roll down fire door was observed. The roll down fire door was obstructed from closing by a small potted plant and a lamp that were placed directly in the path of the door.

2. At 2:24 p.m., the door to the Dry Storage Room located in the kitchen was equipped with a self-closing device. The door was held in the open position and was obstructed from closing by a food storage bin placed directly in the swing path of the door.

Based on observation, the facility failed to ensure that their smoke barrier doors could prevent the passage of smoke from one compartment to another compartment. This was evidenced by one set of smoke barrier doors that did not have rabbets, bevels, or astragals to cover the gap between the meeting edges. This affected one of five smoke compartments and could result in the spread of smoke or fire to other smoke compartments.

NFPA 101, 2000 edition
18.3.7.8 Rabbets, bevels, or astragals shall be required at the meeting edges, and stops shall be required at the head and sides of door frames in smoke barriers. Positive latching hardware shall not be required. Center mullions shall be prohibited.

Findings:

During a facility tour with staff, on 5/19/11 at 9:49 a.m., the smoke barrier doors near the Basement Level elevator were observed. The smoke barrier doors had an approximately one quarter inch wide gap between the two door leaves. The smoke barrier doors were not equipped with any rabbets, bevels, or astragals.

Based on record review and interview, the facility failed to maintain their automatic fire sprinkler system. This was evidenced by the facility's failure to conduct one of four quarterly sprinkler system inspections. This affected five of five smoke compartments and could result in a delayed notification of a malfunctioning automatic fire sprinkler system.

NFPA 25, 1998 edition
1-8.2 Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.
2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.
2-3.3 Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.
3-2.1 Components of standpipe and hose systems shall be visually inspected quarterly or as specifies in Table 3-1.
9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

Findings:

During record review, on 5/18/11 at 11:33 a.m., the documents for the quarterly sprinkler system inspections were reviewed. There were no documents that indicated the facility had conducted a quarterly sprinkler system inspection during the third quarter of 2010. Plant Operations Staff 2 was interviewed and indicated that the facility did not have a quarterly sprinkler system inspection during that quarter.

Based on observation, the facility failed to maintain their portable fire extinguishers. This was evidenced by one fire extinguisher that was not mounted. This affected one of five smoke compartments and could result in damage to a portable fire extinguisher.

NFPA 10, 1998 edition
1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

Findings:

During a facility tour with staff, on 5/18/11 at 1:12 p.m., the portable fire extinguisher located in the Basement Level elevator room was free standing and unsecured on the floor in that room.

Based on record review and interview, the facility failed to maintain their kitchen hood and exhaust. This was evidenced by the facility' s failure to provide documentation to indicate that their kitchen hood and exhaust were cleaned. This affected one of five smoke compartments and could result in a grease fire to ignite in the kitchen.

NFPA 96, 1998 edition
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. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1.
Table 8-3.1
Systems serving solid fuel cooking operations - Monthly
Systems serving high-volume cooking operations such as 24-hour cooking, charbroiling or wok cooking - Quarterly
Systems serving moderate-volume cooking operations - Semiannually
Systems serving low-volume cooking operations, such as churches, day camps, seasonal businesses, or senior centers - Annually

Findings:

During record review, on 5/18/11 at 11:00 a.m., the facility ' s kitchen hood and exhaust cleaning records were requested. There were no records that indicated the facility had their kitchen hood and exhaust professionally cleaned since occupying the building in June 2010. Plant Operations Staff 2 was interviewed and indicated that he believed a vendor did come in and cleaned the hood within the past 12 months. Plant Operations Staff 2 called the vendor who he believed cleaned the kitchen hood and exhaust. The vendor indicated that they did not clean the kitchen hood and exhaust.

Based on observation and interview, the facility failed to to ensure that portable space heaters exceeding 212 degress farhenheit were not used in non-resident areas. This was evidenced by one portable space heater located in a non-patient sleeping area that was not tested to ensure it did not exceed 212 degrees Fahrenheit. This affected one of five smoke compartments and could result in a portable space heater ignited fire.

Findings:

During a facility tour with staff, on 5/18/11 at 2:40 p.m., a portable space heater located in the Director of Quality Management ' s Office was observed under a desk. There was no documentation that indicated the space heater would not exceed 212 degrees Fahrenheit. The portable space heater was a coiled type heater. Plant Operations Staff 2 was interviewed at that time. Plant Operations Staff 2 indicated that the space heater had not been tested by facility staff to ensure it did not exceed 212 degrees Fahrenheit.

Based on record review and interview, the facility failed to maintain a safe level of relative humidity in their anesthetizing locations. This was evidenced by the facility's failure to maintain the relative humidity levels at their anesthetizing locations at thirty-five percent or above. This affected two of two operating rooms and could result in a fire emergency due to electrostatic charges in an oxygen-rich environment.

Findings:

During record review, on 5/18/11 at 10:27 a.m., the facility's relative humidity logs for their anesthetizing locations were observed. The facility had a policy to maintain relative humidity in their anesthetizing locations between thirty and sixty percent. Two of two operating rooms had recorded relative humidity levels below thirty-five percent on multiple instances during the past twelve months.

Operating Room 1 had recorded a relative humidity level below thirty-five percent on ninety-nine days during the past twelve months.

Operating Room 2 had recorded a relative humidity level below thirty-five percent on one hundred and eighteen days during the past twelve months.

There were no relative humidity logs for the month of July 2010. Plant Operations Staff 2 was interviewed at that time. Plant Operations Staff 2 indicated that he could not locate the relative humidity logs for July 2010.

Based on record review and interview, the facility failed to maintain a policy and procedure to respond to a chemical spill in their Laboratory. This was evidenced by the facility ' s failure to provide a copy of their Laboratory chemical spill emergency policy and procedure. This affected one of five smoke compartments and could result in a delayed response to a Laboratory chemical spill.

Findings:

During record review, on 5/18/11 from 9:30 a.m. to 12:00 p.m., the Laboratory chemical spill emergency policy and procedure was requested. Plant Operations Staff 1 provided policies and procedures for blood spills, infectious waste disposal, and diesel fuel spills. There was no policy and procedure detailing an emergency response to Laboratory chemical spills. Plant Operations Staff 1 indicated that there may be a Laboratory chemical spill policy somewhere but he could not locate it.

Based on observation, the facility failed to maintain their electrical equipment and utilities. This was evidenced by a miniature refrigerator that was plugged into a surge protected multi-outlet extension cord instead of directly to a dedicated wall outlet. This affected one of five smoke compartments and could result in an electrical fire to occur.

NFPA 70, 1999 edition
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.
400-8 Unless specifically permitted in Section 400-7, flexible cord 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
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code

Findings:

During a facility tour with staff, on 5/18/11 at 1:35 p.m., a miniature refrigerator in the Clinical Laboratory near the small storage closet was plugged into a surge protected multi-outlet extension cord.

Based on observation, the facility failed to ensure that their alcohol based hand rub dispensers were installed away from any ignition sources. This was evidenced by the mounting of one alcohol based hand rub dispenser over an ignition source. This affected one of five smoke compartments and could result in an alcohol based hand rub ignited fire.

Findings:

During a facility tour with staff, on 5/18/11 at 1:56 p.m., an alcohol based hand rub dispenser in the Our Serenity Corner Room was mounted on the wall approximately five inches above a light switch. The hand rub was 62.5% ethyl alcohol by volume.