HospitalInspections.org

Based on observation and interview the facility failed to provide two-hour fire rated separation between the hospital and the attached business occupancy and the attached long term care facility by not having listed wall assemblies and by not having walls that are complete from exterior wall to exterior wall and from floor to floor or floor to roof deck and by having non-rated windows in the wall assemblies and by having doors in openings that do not have the required minimum one and one-half hour fire rating. The facility also allowed unsealed penetrations of portions of the walls that were designed to a two-hour fire-rated design. This deficiency has the potential to allow a fire to spread beyond the compartment of origin and extends travel distances beyond the required limits. The deficient practice affects all residents, staff and visitors of the facility.
Findings are:
Observation on February 25, 2014 at 9:30am revealed that there was a penetration of the two-hour fire wall above doors 1159A that was not fire-stopped to a listed design for a two-hour fire rating.
An interview with Maintenance B on February 25, 2014 at 9:30am revealed that doors 1159A and the adjacent wall were to be part of the two-hour fire-rated separation and that the hole around a communications cable was not fire-stopped.
Observation on February 25, 2014 at 9:39am revealed that there were several unsealed penetrations of the two-hour fire-rated wall above the ceiling in room 1159 and that the wall was not complete from floor to roof deck.
An interview with Maintenance B on February 25, 2014 at 9:39am revealed that the north wall of room 1159 was part of the two-hour fire rated separation and that there were several unsealed penetrations and that the wall was not complete from floor to roof deck.
Observation on February 25, 2014 at 9:43am revealed that the two-hour fire wall in room 1231 had several penetrations that were not fire-stopped and that the wall was not complete from floor to roof deck and the joints in the fire code drywall were not taped.
An interview with Maintenance B on February 25, 2014 at 9:43am revealed that the wall in room 1231 was to be part of the two-hour fire-rated separation and that there were several unsealed penetrations of the wall and that the drywall did not extend from floor to roof deck and that the joints in the outer layer of drywall were not taped.
Observations on February 25, 2014 between 9:45am and 10:15am revealed that the rest of the wall between the facility and the Outpatient rehab area was not a two-hour fire-rated assembly and that the wall contained windows that were not fire-rated.
An interview with Maintenance B on February 25, 2014 between 9:45 and 10:15 revealed that rest of the wall between the facility and the outpatient rehab building was not a listed two-hour assembly and that the window was not fire-rated.

Based on observation and interview, the facility failed to provide documentation for interior finish that has a flame spread rating of Class A or Class B for corridors and exit ways. This practice affects all staff, residents and visitors on the first level of the facility. The facility census was 61 and capacity of 87.

A. Findings are:
Observations on 2-26-14 at 12:11 pm revealed, mini blinds covering windows in the corridor outside three patient rooms in the TBI area on the first floor.

During an interview on 2-26-14 at 12:11 pm, Maintenance A confirmed the mini-blinds and failed to provide documentation.


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B. Findings are:
1. Documentation review on 2/25/2014 at 11:32 a.m. revealed that the rigid vinyl
sheets indicate that the information will be provided to verify the flame spread
rating of the material, but no documentation of the actual flame spread can be
found.
2. Documentation review on 2/25/2014 at 2:25 p.m. revealed that the paperwork for the carpet in the facility is over 10 years old and gives no location to where the product was installed in the facility.
Maintenance A confirmed the findings.


NFPA Standard:
19.3.3.2 Interior Wall and Ceiling Finish.
Interior wall and ceiling finish materials complying with 10.2.3 shall be permitted as follows:
(1) Existing materials - Class A or Class B
Exception: In rooms protected by an approved, supervised automatic sprinkler system, existing Class C interior finish shall be permitted to be continued to be used on walls and ceilings within rooms separated from the exit access corridors in accordance with 19.3.6.
(2) Newly installed materials - Class A
Exception No. 1: Newly installed walls and ceilings shall be permitted to have Class A or Class B interior finish in individual rooms having a capacity not exceeding four persons.
Exception No. 2: Newly installed corridor wall finish not exceeding 4 ft (1.2 m) in height that is restricted to the lower half of the wall shall be permitted to be Class A or Class B.

Based on observation and interview, the facility failed to provide documentation to verify interior finishes for rooms and spaces not used for corridors or exit ways that have a flame spread rating of Class A or Class B. The facility census was 61 and capacity of 87.

A. Findings are:
Observations on 2-25-14 at 2:03 pm revealed, a f 6 foot by 8 foot fabric corvered accordion room divider in Kits Academy.

During an interview on 2-25-14 at 2:03 pm, Maintenance A confirmed the room divider and failed to provide documentation for a fire rating. Maintenance A stated that the room divider had been installed approximately six month ago.



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B. Findings are:
Observation during the facility tour on 2/26/14, at 11:54 am revealed mattress foam was attached to the walls in the 603C A/V Room.
In an interview conducted at the time of observation, (2/26/14, at 11:54 am), Maintenance C stated that documentation to verify the flame spread rating of the foam failed to be available for review.


NFPA Standard:
Ceiling and wall materials shall be limited as specified in 2000 NFPA 101, 10.2.3 Existing materials may be Class A or Class B except that rooms protected by an approved, supervised automatic sprinkler system use of existing Class C finish shall be permitted within rooms separated from the exit access corridors in accordance with 19.3.6. New materials must be Class A except that new walls/ceilings shall be permitted to have Class A or Class B finish in individual rooms having a capacity of four persons. Newly installed corridor wall finish not exceeding 4 feet in height on the lower half of the wall shall be permitted to be Class A or Class B. 2000 NFPA 101, 19.3.3.2

Based on observation and interview, the facility failed to separate corridors from use areas by at least ?-hour fire resistance rating. This deficient practice affected patients, staff and visitors. The facility census was 123 and capacity of 125.

Findings are:
Observations on 2-26-14 at 1:45 pm revealed, an approximate 8 inch by 12 inch air grill above the door to Room 3024B.

During an interview on 2:26-14 at 1:45 pm, Maintenance D confirmed the air grill above the door.

NFPA Standard:
Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, and shall have a fire resistance rating of not less than 1/2 hour. Exception: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system, a corridor shall be permitted to be separated from all other areas by non-rated partitions and terminate at the ceiling if the ceiling is constructed to limit the transfer of smoke. Exception: Existing corridor partitions shall be permitted to terminate at ceilings that are not an integral part of a floor construction if 5 ft or more of space exists between the top of the ceiling subsystem and the bottom of the floor or roof above, provided that the ceiling is a fire-rated assembly tested to have a fire resistance rating of not less than 1 hour in compliance with the provisions of 8.2.3.1. 2000 NFPA 101, 19.3.6.2

Based on observation and interview the facility failed to maintain the doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas such that they are substantial doors, such as those constructed of 1 3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes and are provided with a positive latching means for keeping the door closed. They shall also resist the passage of smoke. This practice affected all residents, staff, and visitors on the first floors of the facility. The facility census was 61 and capacity of 87.

A. Findings are:
Observations on 2-25-14 at 11:49 am and 1:48 pm revealed:
1. Room 141 door failed to latch within the door frame.
2. The dutch door to the Mail Room had an approximate 1 inch gap between the leafs and the top leaf failed to latch within the door frame.

During an interview on 2-25-14 at 1:48 pm, Maintenance A confirmed the findings.


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B. Findings are:
Observation during the facility tour on 2/25/14, from 10:41 am to 2/26/14, at 11:21 am revealed:
1. The Room 100 Door failed to latch when pulled shut. A lift vest obstructed the door.
2. Both Accounting Doors failed to have latching hardware installed in the room doors.
3. The 506 Employee Lounge Door failed to latch when swung shut.
4. The 0522 Office Door failed to latch when swung shut.
In an interview conducted at the time of observation, (2/25/14, from 10:41 am to 2/26/14, at 11:21 am), Maintenance C acknowledged that the doors failed to latch.

NFPA Standard:
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, the door construction requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke. 2000 NFPA 101, 19.3.6.3.1*

Dutch doors shall be permitted where they conform to 19.3.6.3. In addition, both the upper leaf and lower leaf shall be equipped with a latching device, and the meeting edges of the upper and lower leaves shall be equipped with an astragal, a rabbet, or a bevel. 2000 NFPA 101, 19.3.6.3.6

Based on observation and interview, the facility failed to maintain the vertical opening from the main floor to the lower level which provides a minimum 1-hour fire rating. This deficient practice affected all patients, staff, and visitors on first, second and lower levels of the facility. The facility census was 61 and capacity of 87.

A. Findings are:
Observations on 2-25-14 between 12:04 pm to 3:37 pm revealed:
1. The upper level stair door at the St. James entrance failed to latch within the door frame.
2. The lower level stair door at the St. James entrance failed to latch within the door frame.
3. The lower level stair door within Pediatrics failed to latch within the door frame.
4. Facility failed to verify the fire rating for the stair doors into the St. James entrance.

During an interview on 2-25-14 between 12:04 pm to 3:37 pm, Maintenance A confirmed the findings.



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B. Findings are:
Observation during the facility tour on 2/25/14, from 2:37 pm to 2:40 pm revealed:
1. Through-floor/ceiling penetrations around pipes in Room 0125 failed to be sealed.
2. Through-floor/ceiling penetrations in Room 162A failed to be sealed.
In an interview conducted at the time of observation, (on 2/25/14, from 2:37 pm to 2:40 pm), Maintenance C confirmed the findings.

NFPA Standard:
Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.
Exception No. 1: Unprotected vertical openings in accordance with 8.2.5.8 shall be permitted.
Exception No. 2: Exception No. 1 to 8.2.5.6(1) shall not apply to patient sleeping and treatment rooms.
Exception No. 3: Multilevel patient sleeping areas in psychiatric facilities shall be permitted without enclosure protection between levels, provided that all the following conditions are met:
a) The entire normally occupied area, including all communicating floor levels, is sufficiently open and unobstructed so that a fire or other dangerous condition in any part is obvious to the occupants or supervisory personnel in the area.
b) Egress capacity is sufficient to provide simultaneously for all the occupants of all communicating levels and areas, with all communicating levels in the same fire area being considered as a single floor area for purposes of determination of required egress capacity.
c) The height between the highest and lowest finished floor levels shall not exceed 13 ft (4 m); the number of levels shall not be restricted.
Exception No. 4: Unprotected openings in accordance with 8.2.5.5 shall not be permitted.
Exception No. 5: Where a full enclosure of a stairway that is not a required exit is impracticable, the required enclosure shall be permitted to be limited to that necessary to prevent a fire originating in any story from spreading to any other story.
19.3.1.2
A door in a stair enclosure shall be self-closing and shall normally be kept in the closed position.
Exception: Doors in stair enclosures held open under the conditions specified by 19.2.2.2.6 and 19.2.2.2.7
2000 NFPA 101, 19.3.1.1

Based on observation and interview, the facility failed to provide NO Exit signs at Courtyard doors that could be mistakenly identified by residents, staff or visitors to be used to evacuate the building in case of an emergency. This deficient practice affects all occupants in the areas of those doors. The facility census was 61 and capacity of 87.

A. Findings are:
Observations on 2-25-14 at 3:52 pm revealed, the interior playground doors failed to provide a NO Exit sign.

During an interview on 1-8-14 at 3:52 pm, Maintenance A confirmed that doors leading into the Playground failed to provide NO Exit signage.



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NFPA Standard:
Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows:
NO
EXIT
Such sign shall have the word NO in letters 2 in. (5 cm) high with a stroke width of 3/8 in. (1 cm) and the word EXIT in letters 1 in. (2.5 cm) high, with the word EXIT below the word NO.
Exception: This requirement shall not apply to approved existing signs.
2000 NFPA 101, 7.10.8.1

Based on observation and staff interview, the facility failed to provide smoke barriers with at least ? hour fire resistance rating. This condition had the potential to allow smoke to migrate between smoke compartments. Facility census was 61.

Findings are:
Observation during the facility tour on 2/25/14, from 3:13 pm to 3:16 pm revealed:
1. Holes above the 1186A Smoke Doors failed to be sealed.
2. Holes above the 0175A Smoke Doors failed to be sealed.
3. A hole around a data cable above the 1159A Smoke Doors failed to be sealed.
In an interview conducted at the time of observation, (2/25/14, from 3:13 pm to 3:16 pm), Maintenance C confirmed the unsealed penetrations in the barrier walls.

Based on observation and interview, the facility failed to ensure that smoke separation doors protecting corridor openings in a sprinklered building are capable of resisting the passage of smoke. This deficient practice affected all patients, staff and visitors, as the doors would not prevent the spread of smoke. The facility census was 61 and capacity of 87.

A. Findings are:
Observations on 2-25-14 at 12:05 pm and 1:50 pm revealed:
1. The smoke separation double doors near Room 131 equipped with latching device failed to close and latch.
2. The east smoke separation door 0101 equipped with latching device failed to latch.

During an interview on 2-25-14 at 12:05 pm and 1:50 pm, Maintenance A confirmed the door hardware failed to latch.



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B. Findings are:
Observations during the facility tour on 2/25/14, from 2:07 pm to 2/26/14 at 2:19 pm revealed:
1. The 0140A Smoke Doors failed to have the gap between the meeting edges of the doors sealed.
2. The 0115 Smoke Doors failed to have the gap between the meeting edges of the doors sealed.
3. The 0617 Smoke Doors failed to have the gap between the meeting edges of the doors sealed.
4. The 0617A Smoke Doors failed to have the gap between the meeting edges of the doors sealed.
5. The 0514 Smoke doors failed to have a gap between the meeting edges of the doors sealed.
6. The 6000 Institute Smoke Doors failed to have the gap between the meeting edges of the doors sealed.
In an interview conducted at the time of observations, (2/25/14, from 2:07 pm to 2/26/14 at 2:19 pm), Maintenance C acknowledged the condition of the doors.


NFPA Standard:
Requires doors in smoke barriers to be self-closing and resist the passage of smoke, NFPA 101, 19.3.7.6*.

Based on interview and observation the facility failed to provide smoke protection for hazard areas, by not assuring doors would latch within the door frame or ceiling and doors were smoke tight. This practice affected all patients, visitors and staff that use the first floor and lower level. The facility census was 61 and capacity of 87.

A. Findings are:
Observations on 2-26-14 between 10:28 am and 3:26 pm revealed:
1. The door to Locker Room 1219 failed to latch within the door frame.
2. The door to Storage Room 1198 failed to latch within the door frame.
3. The door to Computer Storage 0527 failed to latch within the door frame.
4. The Copy Room 0528B over 50 square feet, filled with combustible supplies failed to provide a door and was open to the corridor.
5. Holes in several ceiling tiles in the Housekeeping Room 0105A.
6. Holes in several ceiling tiles in Room 0152.
7. The gap between the double doors to the Air Handling unit room was greater than 1/8 inch.
8. The door to the Electrical Room in the Fish Tank area failed to latch within the door frame.
9. The gap between the double doors to the Toy/Equipment Room in Pediatrics was greater than 1/8 " .

During an interview on 2-26-14 between 10:28 am and 3:26 pm, Maintenance A confirmed the findings.



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B. Findings are:
Observations during the facility tour on 2/25/14, from 11:23 am to 2/26/14, at 2:24 pm revealed:
1. Holes in the Perkins Place Closet failed to be sealed with an approved fire caulk.
2. Ceiling penetrations in the 5051E Air Handler Room failed to be sealed.
3. The East and West 0111 Environmental Doors failed to latch when swung shut.
4. The south and east 0306 Soiled Laundry Room Doors failed to latch when self-closed.
5. Penetrations in the corroder wall of both Rooms 130 and 130A failed to be sealed.
6. The Boiler Room Door 0132 failed to have a self-closure installed on the door.
7. A gap between the 0512 Air Handler Room Door failed to be sealed.
8. The File Storage Room 0510 failed to have a self-closure installed on the door.
9. The Accounting Store Room 509 failed to have a self-closure installed on the door.
10. The 0522 Office Storage Room Door failed to have a self-closure installed on the door.
11. The Electrical Room 0616 Door failed to latch when self-closed.
12. Storage Room Doors 0611 and 0603B failed to have self-closures installed on the doors.
13. Combustible storage was observed in Room 6010. The storage failed to be removed, or a self-closure failed to be installed on the room door.
In an interview conducted at the time of observations (2/25/14, from 11:23 am to 2/26/14, at 2:24 pm), Maintenance C acknowledged the findings.



NFPA Standard:
Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Based on observation and interview, the facility failed to prevent an exit stairwell to be free of the storage of combustibles. This deficient practice has the potential to fill the stair well with smoke and gasses which affects occupants during an emergency. The facility census was 61 and capacity of 87.

Findings are:
Observations on 2-25-14 at 11:58 am and 12:12 pm revealed:
1. The east stair enclosure contained a chair stored within the exiting enclosure.
2. The St. James entrance stair enclosure contained a large plastic container with ice melt in individual packages along with signage for the intended use.

During an interview on 2-25-14 at 10:18 am, Maintenance A confirmed the items within the stair in the exit stair enclosure.

NFPA Standard:
There shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress. 2000 NFPA 101, 7.2.2.5.3

Based on observation and interview the facility failed to allow egress from the access-controlled egress doors at the front exit as required by the NFPA (National Fire Protection Association) by allowing the exit doors to be turned off and manually locked. This deficient practice was found to place affects all patients, staff and visitors in the facility in immediate jeopordy (IJ).

A. Findings are:
Observations on 2-27-14 at 8:45 am revealed:
1. 2 of 2 access-controlled doors at the front lobby were equipped with a thumb turn locks.
2. Signage to call the Operator after hours to unlock doors.
3. The controlled access doors failed to provide signage instruction to operate doors manually. The doors failed to operate when the thumb turn lock were engaged.
4. Switch to turn off power to the doors was not secured, so that the doors could be inadvertently turned off.

During an interview on 2-27-14 at 8:45 am, Maintenance A confirmed the findings and immediately instructed staff to correct findings.

Observations on 2-27-14 at 9:20 am revealed, the doors were modified and locks were removed which abated the IJ.

7.2.1.6.2 Access-Controlled Egress Doors.
Where permitted in Chapters 11 through 42, doors in the means of egress shall be permitted to be equipped with an approved entrance and egress access control system, provided that the following criteria are met.
a) A sensor shall be provided on the egress side and arranged to detect an occupant approaching the doors, and the doors shall be arranged to unlock in the direction of egress upon detection of an approaching occupant or loss of power to the sensor.
b) Loss of power to the part of the access control system that locks the doors shall automatically unlock the doors in the direction of egress.
c) The doors shall be arranged to unlock in the direction of egress from a manual release device located 40 in. to 48 in. (102 cm to 122 cm) vertically above the floor and within 5 ft (1.5 m) of the secured doors. The manual release device shall be readily accessible and clearly identified by a sign that reads as follows: PUSH TO EXIT
d) When operated, the manual release device shall result in direct interruption of power to the lock - independent of the access control system electronics - and the doors shall remain unlocked for not less than 30 seconds.
e) Activation of the building fire-protective signaling system, if provided, shall automatically unlock the doors in the direction of egress, and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.
f) Activation of the building automatic sprinkler or fire detection system, if provided, shall automatically unlock the doors in the direction of egress and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.



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B. Findings include:
1. Observation on 2/26/2014 at 11:40 a.m. revealed a horizontal accordion gate that is able to be placed across the marked exit corridors, on the North side of the Gym, by the therapy tractor and vehicles. Maintenance A confirmed the findings.

Based on observation and interview the facility failed to provide egress lighting from the chapel exits outside the building to a safe distance or to the public way. This deficient practice would affect all persons using the chapel in the event they needed to exit the facility after sunset.
Findings are:
Observation on February 27, 2014 at 9:45am revealed that there were no lighting fixtures installed outside of the building outside the two exits from the chapel where there were sidewalks that needed to be traversed to get a safe distance from the building in the event of an emergency.
An interview with Maintenance D on February 27, 2014 at 9:45am revealed that there were no lights installed outside the facility in the area of the exits from the chapel to provide the required egress illumination.

Based on documentation review, observation and interview, the facility failed to provide emergency egress lighting to public way and failed verify that the exterior lighting was on the Life Safety Branch of the electrical system, the facility failed to provide documetation that the emergency lighting was tested. These deficient practice affects all patients, staff and visitors in the St. Joseph facility. The facility census was 123 and capacity of 125.

A. Findings are:
Observations on 2-26-14 at 2:25 pm revealed:
1. The facility failed to provide egress lighting to the public way from the 3-C Lounge exit door.
2. The facility failed to verify if the exterior lights on the building at the exit from 3-C were on the Life Safety Branch of the electrical system.

During an interview at 2-26-14 at 2:25 pm, Maintenance D confirmed the lack of lighting to the public way and failed to verify if the lights provided were on the Life Safety Branch.

NFPA Standard:
Illumination of means of egress shall be provided in accordance with Section 7.8 for every building and structure where required in Chapters 11 through 42. For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, aisles, corridors, ramps, escalators, walkways, and exit passageways leading to a public way. 2000 NFPA 101, 7.8.1.1*



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B. Findings are:
1. Documentation review on 2/25/2014 at 10:55 a.m. revealed that the weekly emergency light test papers showed very little information.
2. Documentation review on 2/25/2014 at 10:56 a.m. revealed that no documentation was provided to indicate emergency lighting had been tested to the 1 ? hour annual requirement.
Maintenance A confirmed the findings.

Based on observation and interview, the facility failed to provide exit and directional signs to indicate the continuous path of egress on the first floor. This deficient practice effected all patients, staff and visitors in that area of the facility. The facility census was 61 and capacity of 87.

Findings are:
Observations on 2-25-14 between 11:40 am and 1:55 pm revealed:
1. No exit sign to indicate the second exit, above the smoke doors looking south while standing in the corridor near the TBI Nurse Station.
2. No exit sign to indicate the second exit, above the smoke doors looking south while standing in the corridor near the TBI Nurse Station.
3. No exit sign to indicate the second exit above the smoke doors looking north in the lower level near the Copier Room.

During an interview on 2-25-14 between 11:40 am and 1:55 pm, Maintenance A confirmed the lack of exit signage.

NFPA Standard:
Means of egress shall have signs in accordance with Section 7.10
2000, NFPA, 18.2.10.1 Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access. 2000, NFPA, 7.10.1.2



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B. Findings are:
Observations during the facility tour on 2/25/14, from 11:48 am to 2:12 pm revealed:
1. An exit sign failed to be visible in the exit corridor when looking south towards the 1159A smoke doors.
2. An exit sign failed to be visible in the exit corridor when looking towards Door 0120.
In an interview conducted at the time of observations (2/25/14, from 11:48 am to 2:12 pm), Maintenance C acknowledged that exit signs were not visible in these areas.

Based on observation and documentation review, the facility failed to train staff in the response to an actual fire event. The facility failed to have a safety plan that trained staff to respond and/or evacuate the smoke compartment of the actual fire. This deficient practice was found to place affects all patients, staff and visitors in the facility in immediate jeopordy (IJ).

Findings are:
During a fire alarm activation (not a drill) on 2-26-14 at approximately 9:10 am revealed:
1. Staff failed to respond or evacuate the area where smoke was observed.
2. Staff failed to clear corridors of patients and equipment.

During documentation review on 2-26-14 of the facility safety plan, the facility failed to
Include as part of the plan that staff need to remove themselves and patients from the area where fire/smoke is located and to respond to the event accordingly.

During an interview on 2-26-14 at 1:45 pm, Administration A confirmed the findings.

During documentation review at 4:45 pm, of the proposed training and modifications to the fire plan, the IJ was abated.


NFPA Standard:
For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy ' s fire safety plan. 2000 NFPA 101, 19.7.2.1*

A written health care occupancy fire safety plan shall provide for the following:
1) Use of alarms
2) Transmission of alarm to fire department
3) Response to alarms
4) Isolation of fire
5) Evacuation of immediate area
6) Evacuation of smoke compartment
7) Preparation of floors and building for evacuation
8) Extinguishment of fire
2000 NFPA 101, 19.7.2.2

All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following conditions:
1) When the individual who discovers a fire must immediately go to the aid of an endangered person
2) During a malfunction of the building fire alarm system
3) Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.
2000 NFPA 101, 19.7.2.3

Based on observation and interview the facility failed to have the fire alarm system installed and maintained in accordance with NFPA 72, The National Fire Alarm Code, by not providing the required minimum sound levels of 60dba throughout the facility, by not having uniform signals throughout, by not having the electrical branch circuits identified at the fire alarm control units and by not providing mechanical protection for the fire alarm electrical branch circuits. This deficient practice has the potential to delay response to a fire alarm by not providing notification to the staff and by allowing parts of the fire alarm to shut off inadvertently and by preventing rapid access to fire alarm circuits in an emergency. This deficient practice affects all residents, staff, and visitors of the facility.The facility census was 123 and capacity of 125.

A. Findings are:
Observations on 3-3-14 at 10:18 am and 10:31 am revealed:
1. During a fire alarm test, not enough sound was heard near Room 342.
2. During a fire alarm test, several types of sounds could be heard from another building while standing near Room 323.
3. During a fire alarm test, several types of sounds could be heard from another building while standing in the corridor near the Nebraska Room.

During an interview on 3-3-14 at 10:21 am and 10:31 am, Maintenance A confirmed several different sounds during a fire alarm test.

NFPA Standard:
Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in the same building. 2000 NFPA 101, 9.6.3.9

State Fire Marshal- Formal Interpretation, 01-02

State Fire Marshal- Formal Interpretation, 03-04



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B.Findings are:
Observation on February 25, 2014 at 2:42pm revealed that the electrical circuit in the life safety branch panel EMLSJ02-A for the fire alarm system was not mechanically protected.
An interview with Maintenance B on February 25, 2014 at 2:42pm revealed that there was no mechanical protective device installed on the breaker labeled fire alarm in the Life Safety branch panel EMLSJ02-A.
Observation on March 3, 2014 at 10:19am revealed that during fire alarm testing there was not the required minimum 60dba of audible notification in the area of rooms 410 and 405.
An interview with Maintenance B on March 3, 2014 at 10:19am revealed that during a test of the fire alarm system there was not the required 60dba reading on the meter in the area of rooms 410 and 405.
Observation on March 3, 2014 at 10:24am revealed that during fire alarm testing there was not the required minimum 60dba of audible notification in the area of rooms 342 and 339.
An interview with Maintenance B on March 3, 2014 at 10:24am revealed that during a test of the fire alarm system there was not the required 60dba reading on the meter in the area of rooms 342 and 339.
Observation on March 3, 2014 at 10:34am revealed that during fire alarm testing there was not the required minimum 60dba of audible notification in the receiving dock area.
An interview with Maintenance B on March 3, 2014 at 10:34am revealed that during a test of the fire alarm system there was not the required 60dba reading on the meter in the area of the receiving dock.



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C. Findings are:
1. Observation on 3/3/2014 at 10:19 a.m. revealed a fire alarm device, in the St. Joe Wing, across from room 4032 that was not working. Maintenance E confirmed the findings.
2. Documentation review on 2/25/2014 at 10:56 a.m. revealed the fire alarm inspection reports show no calibration testing.
3. Documentation review on 2/25/2014 at 10:57 a.m. revealed that the inspection report from April, 2012 indicate deficiencies in the notes and no documentation can be found to show those deficiencies have been corrected.
4. Documentation review on 2/25/2014 at 10:59 a.m. reveal that the in a one year time frame, no smoke detectors were tested for functionality.
5. Documentation review on 2/25/2014 at 1:38 p.m. revealed that no documentation was provided indicating central receiving station is receiving fire alarms and no daily dialer test.
6. Documentation review on 2/25/2014 at 2:00 p.m. revealed that no documentation was provided for the testing and maintenance on the smoke control system.
Maintenance A confirmed the findings.

Based on observation and interview the facility failed to install the automatic sprinkler system to provide complete coverage for all portions of the building in accordance with NFPA 13. The facility failed to identify multiple fire department connections and multiple post indicator valves as to the areas of the fcilicty that they served. This practice affected all patients, visitors and staff that use the facility. The facility census was 61 and capacity of 87.

A. Findings are:
Observations on 2-25-14 at 10:45 am revealed, the facility failed to provide automatic sprinkler protection under a heating duct greater than four feet in the Air Handling Room in Pediatrics.

During an interview on 2-25-14 at 10:45 am, Maintenance A confirmed the lack of sprinkler protection under the duct.

NFPA Standard:
Where required by 19.1.61 health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. 2000 NFPA 101, 19.3.5


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B. Findings are:
Observation on February 27, 2014 between 9:50am and 10:15am during a tour of the exterior of the building revealed that there were three post indicating valves and five fire department connections on the exterior of the building and none of them were marked to indicate the areas of the building served.
An interview with Maintenance E on February 27, 2014 between 9:50am and 10:15 am during a tour of the exterior of the building revealed that there was no signage at any of the post indicating valves or any of the fire department connections on the building.
NFPA 13, 1999ed. 3-8.3* Identification of Valves.
All control, drain, and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs. The sign shall be secured with corrosion-resistant wire, chain, or other approved means.
NFPA 13, 1999ed. 5-15.2.3.4
Where a fire department connection services only a portion of a building, a sign shall be attached indicating the portions of the building served.
NFPA 13,1999ed. 5-15.2.3.5
Fire department connections shall be on the street side of buildings and shall be located and arranged so that hose lines can be readily and conveniently attached to the inlets without interference from any nearby objects including buildings, fences, posts, or other fire department connections.
Each fire department connection to sprinkler systems shall be designated by a sign having raised or engraved letters at least 1 in. (25.4 mm) in height on plate or fitting reading service design - for example,
AUTOSPKR., OPEN SPKR. AND STANDPIPE
A sign shall also indicate the pressure required at the inlets to deliver the greatest system demand.


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C. Findings are:
Observation during the facility tour on 2/25/14, from 1:50 pm to 2/26/14, at 2:47 pm revealed:
1. Two upright sprinklers by Door 0111 in Environmental Services failed to be installed within 12 inches of the deck.
2. Sprinkler coverage failed to be installed in the Elevator Equipment Room across from 0104.
3. The 5061 Stairwell failed to be sprinkled at the top and bottom. The stairwell only had sprinkler coverage installed at the top of the stairwell.
4. Upright sprinklers in the 117 Soiled Room failed to be installed within 12 inches of the deck.
In an interview conducted at the time of observation and record review, (2/25/14, from 1:50 pm to 2/26/14, at 2:47 pm), Maintenance C acknowledged the findings.

Actual NFPA Standard:
NFPA 13, 5-6.4 Deflector Position (Standard Pendent and Upright Spray Sprinklers).
5-6.4.1 Distance Below Ceilings.
5-6.4.1.1
Under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm).
5-6.4.1.2
Under obstructed construction, the sprinkler deflector shall be located within the horizontal planes of 1 in. to 6 in. (25.4 mm to 152 mm) below the structural members and a maximum distance of 22 in. (559 mm) below the ceiling/roof deck.
NFPA 13, 5-13.3.2
In noncombustible stair shafts with noncombustible stairs, sprinklers shall be installed at the top of the shaft and under the first landing above the bottom of the shaft.
5-1.1*
The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution

Based on observation and staff interview, the facility failed to monitor sprinkler shutoff valves by the fire alarm. This condition would allow the valves to be closed without notification to occupants. Facility census was 61.

Findings are:
Observation during the facility tour on 2/25/14, at 2:10 pm revealed the shutoff valves for the canopy sprinkler system in Room 140A failed to be monitored by the fire alarm.
In an interview conducted at the time of observation, (2/25/14, at 2:10 pm), Maintenance C confirmed that the valves were not monitored.

Based on documentation review, observation and interview, the facility failed to maintain the sprinkler system in accordance with the 1998 Edition of NFPA 25, by ensuring that sprinkler heads are installed as required. The facility also failed to maintain the system with an acceptable clearance around sprinkler heads to prevent obstructions to spray patterns. The facility census was 61 and capacity of 87.

A. Findings are:
Observations on 2-2-14 between 11:11 am and 3:17 pm revealed:
1. Missing sprinkler escutcheon in Patient Restroom 145.
2. Missing sprinkler escutcheon in Patient Restroom 144.
3. Obstruction to the sprinkler head in the Toy Storage Closet in Pediatrics.

During an interview on 1-22-13 between 11:11 am and 3:17 pm, Maintenance A confirmed all the findings.

NFPA Standard:
A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. 1999 NFPA 13, 12.1

NFPA Standard:
Unacceptable obstructions to spray patterns shall be corrected. 1998 NFPA 25, 2-2.1.2

Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. 1998 NFPA 25, 2-2.1.1

B. Findings are:
1. Documentation review on 2/25/2014 at 11:00 a.m. revealed that the only
sprinkler reports that were provided were for the St. James building and for the
year 2013.
2. Documentation review on 2/25/2014 at 2:40 p.m. revealed that only 1 internal five year pipe inspection was provided. No other systems had documentation to show this test has been completed.
Maintenance A confirmed the findings.


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C. Findings are:
Observation during the facility tour on 2/25/14, from 11:28 am to 2/26/14, at 11:59 am revealed:
1. A TV on a swivel in Room 120 failed to not obstruct the sidewall sprinkler head.
2. A sprinkler escutcheon in 1185 failed to be replaced.
3. A light in the 50541 Storage Room failed to be installed so that it did not obstruct the sprinkler head.
4. A light in the 5054F Storage Room failed to be installed so that it did not obstruct the sprinkler head.
5. A missing ceiling tile in the Riser Room of Office 0518 failed to be replaced.
6. A loose escutcheon failed to be secured in the HIM Office 0520 behind the reception desk.
7. A missing escutcheon in the Lab by the cooler failed to be replaced.
8. A missing escutcheon failed to be replaced in Room 0526.
9. A missing escutcheon in the Lower Level Elevator Equipment Room failed to be replaced.
10. A corroded sprinkler head in the 0615 Pool Equipment Room failed to be replaced.
11. A missing sprinkler escutcheon above cabinets in Office 610 failed to be replaced.
12. A missing sprinkler escutcheon outside of the Education Hall failed to be replaced.
13. A missing sprinkler escutcheon in the middle of the Accounting Store Room 509 failed to be replaced.
14. A missing sprinkler escutcheon in the office by the AV Room failed to be replaced.
15. A missing sprinkler escutcheon in the 6007 Stairwell, near the AV Room, failed to be replaced.
In an interview conducted at the time of observation, (2/25/14, from 11:28 am to 2/26/14, at 11:59 am), Maintenance C confirmed the findings.

Actual NFPA Standard:
5-6.5.1.2
Sprinklers shall be arranged to comply with 5-5.5.2, Table 5-6.5.1.2, and Figure 5-6.5.1.2(a).

Based on observation and interview, the facility failed to have portable fire extinguishers maintained per requirements of NFPA 10. This practice has the potential to affect all staff, patients and visitors of the facility. The facility has a capacity of 112.

Findings are:
1. Observation on 2/26/2014 at 11:21 a.m. revealed the fire extinguisher in the Hanger shop area had an inspection tag that was out of date. Maintenance G confirmed the findings.
2. Observation on 2/26/2014 at 11:47 a.m. revealed the fire extinguisher, across from the entrance to the Doris Campbell Resource Center, had not had a monthly inspection since December, 2013. Maintenance G confirmed the findings.

Based on observation, interview and record review the facility failed to install and maintain the kitchen hood and suppression system in accordance with NFPA 17A and NFPA 96 by having two separate suppression systems in hoods that are immediately adjacent to each other and the systems do not operate as one, by not having all heat producing appliances under the hoods shut down upon activation of the suppression system, by not having the manual activators identified as to the area protected, by not providing proper coverage for appliances, by not having a positive placement means to ensure that upon moving the appliances are returned to the correct location for the suppression system, by having unsealed penetrations of the hood allowing grease to build up in other areas and by failing to protect the flexible gas lines to the appliances from being sheared off by a listed restraint cable per the manufacturers installation instructions. The facility failed to provide documentation that the kitchen hood and suppression system is being inspected and maintained per the requirements of NFPA 96. This deficient practice has the potential to allow a fire in the kitchen to spread due to the build-up of grease and the inability of the suppression system to protect the appliances. This deficient practice could affect all persons in the kitchen, serving area, and the dining room.
A. Findings are:
Observation on February 26, 2014 at 2:14pm revealed that the nozzles for the hood suppression system for the serving line were not located in accordance with the listing and the directions of the manufacturer.
An interview with Maintenance B on February 26, 2014 at 2:14pm revealed that a deep fryer had been removed over one year ago and some of the appliances on the serving line had been relocated without re-evaluation of the suppression system.
A record review on February 26, 2014 of the last two hood inspection reports for the serving line, dated 6/27/13 and 12/13/13 still indicate that the fryer is in place and that nothing has changed.
Observation on February 26, 2014 at 2:40pm revealed that the two hoods in the kitchen area were immediately adjacent to each other but had separate suppression systems that did not operate together.
An interview with Maintenance B on February 26, 2014 at 2:40pm revealed that the two hood systems had separate manual activation devices and that the hoods were immediately adjacent to each other but operated separately.
A record review on February 26, 2014 at 2:40pm of the last two hood inspection reports dated 6/27/13 and 12/13/13 for the Ansul hood suppression system in the kitchen indicated that during the December inspection the gas ovens under the hood did not shut down upon activation of the suppression system and this deficiency was not noted in the June report.
An interview with Maintenance B on February 26, 2014 at 2:40pm revealed that the facility was unaware of the comments on the report and that nothing has changed with the system or appliances for several years.
Observation on February 26, 2014 at 2:40pm revealed that there were several unsealed penetrations of the interior of the east kitchen hood.
A record review on February 26, 2014 at 2:40pm of the last two hood inspection reports dated 6/27/13 and 12/13/13 for the east kitchen hood revealed that the December report indicated that there were holes in the hood that needed sealing and that these deficiencies were not noted on the June inspection report.
An interview with Maintenance B on February 26, 2014 at 2:40pm revealed that there were several unsealed penetrations of the east kitchen hood and that the hood had been in this same condition for many years without any changes.
Observation on February 26, 2014 at 2:40pm revealed that there were three manual pull stations for the kitchen and serving area hood systems and none of them were marked to identify the hazards protected.
An interview with Maintenance B on February 26, 2014 at 2:40pm revealed that while the pull stations were not located immediately adjacent to each other it was impossible to tell what pull station activated which suppression system.
Observation on February 26, 2014 at 2:40pm revealed that some of the appliances under the hood were on wheels and were being protected by wet chemical suppression systems and that there was no positive placement device installed to ensure that when moved for cleaning they are returned to the proper design location for the suppression system.
An interview with Maintenance B on February 26, 2014 at 2:40pm revealed that the appliance on wheels moved freely and that there was nothing installed to ensure that when moved for cleaning they are returned to the correct design location.
Observation on February 26, 2014 at 2:40pm revealed that the gas appliances on wheels under the hood were connected with listed flexible gas lines that require a restraint cable to prevent the gas line from being damaged and that no such cables installed.
An interview with Maintenance B on February 26, 2014 at 2:40pm revealed that there were listed flexible gas lines to the gas griddle and gas range and that there were not any restraint cables installed between the appliance and the building structure to prevent damage to gas line.
NFPA 96, 2001ed.
3.3.39 Single Hazard Area. Where two or more hazards can be simultaneously involved in fire by reason of their proximity, as determined by the authority having jurisdiction.
10.3.1 Fixed pipe extinguishing systems in a single hazard area (see Section 3.3 for the definition of single hazard area) shall be arranged for simultaneous automatic operation upon actuation of any one of the systems.
10.4.3 Any gas appliance not requiring protection, but located under the same ventilating equipment, shall also automatically shut off upon activation of any extinguishing system..
10.5.1 A readily accessible means for manual activation shall be located between 1067 mm and 1219 mm (42 in. and 48 in.) above the floor, be accessible in the event of a fire, be located in a path of egress, and clearly identify the hazard protected.
10.9.2.2 The installer shall provide certification to the authority having jurisdiction that the installation is in agreement with the terms of the listing and the manufacturer ' s instructions and/or approved design.
12.1.2.2* Cooking appliances requiring protection shall not be moved, modified, or rearranged without prior reevaluation of the fire-extinguishing system by the system installer or servicing agent, unless otherwise allowed by the design of the fire-extinguishing system.
12.1.2.3 The fire-extinguishing system shall not require reevaluation where the cooking appliances are moved to perform maintenance and cleaning provided the appliances are returned to approved design location prior to cooking operations, and any disconnected fire-extinguishing system nozzles attached to the appliances are reconnected in accordance with the manufacturer ' s listed design manual.
12.1.2.3.1 An approved method shall be provided that will ensure that the appliance is returned to an approved design location.


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B. Findings are:
1. Documentation review on 2/25/2014 at 10:50 a.m. revealed that the kitchen hood inspection report cites holes in the hood that need to be sealed and no documentation to show that has been completed.
Maintenance A confirmed the findings.

Based on observation and interview the facility failed to maintain the facility free of heat producing devices in all areas of the building and failed to provide documentation for the heating requirements. This deficient practice affected all patients, staff and visitors in the areas of the heating device. The facility census was 61 and capacity of 87.

A. Findings are:
Observations on 2-25-14 at 11:38 am and 1:45 pm revealed:
1. Staff sitting on a heating pad in the Case Management Office 1-C.
2. Space heater under the desk in the Mail Room.

During an interview on 2-25-14 at 11:38 am and 1:45, Maintenance A confirmed the heating devices and failed to provide documentation.

NFPA Standard:
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?. 2000 NFPA 101, 19.7.8



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B. Findings are:
Observation during the facility tour on 2/25/14, from 12:02 pm to 2/26/14, at 11:47 am revealed:
1. An oil filled heater was observed in the 1st Floor West, K. Grabouski ' s Office.
2. An oil filled heater was observed in the 0138D Office.
3. An oil filled heater was observed in the 0138G Office.
4. An oil filled heater was observed in the 124 Office.
5. An oil filled heater was observed in the 0521 Office.
6. An oil filled heater was observed in the 0525 Office.
7. An oil filled heater was observed in the 610 Office.
Documentation of the maximum heating element temperature failed to be provided.
In an interview conducted at the time of observation, (2/25/14, from 12:02 pm to 2/26/14, at 11:47 am), Maintenance C confirmed that the documentation could not be provided.

Based on observation and interview, the facility failed to maintain the means of egress free of all obstructions or impediments to full instant use in the case of fire or other emergency. This deficient practice affected all patients, visitors and staff that are in the areas of obstructions. The facility census was 61 and capacity of 87.

A. Findings are:
Observations on 2-26-14 at 3:05 pm and 3:21 pm revealed:
1. Three wagons and three strollers stored in the Pediatric exit corridor near the ambulance bay obstructed the corridor down to 67 inches from 72 inches.
2. Four " WOW ' s " (computers on wheels) stored in the Pediatric corridors for longer than thirty minutes.

During an interview on 2-26-14 at 3:05 pm and 3:21 pm, Maintenance A confirmed the obstructions in the exit corridors.

NFPA Standard:
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. 7.1.10.1


27395

B. Findings are:
Observation during the facility tour on 2/25/14, at 1:58 pm revealed a candy machine obstructed the exit corridor by the vending machines in the Lower Level West Exit Corridor.
In an interview conducted at the time of observation, (2/25/14, at 1:58 pm), Maintenance C acknowledged the findings.

Based on observation and record review the facility failed to maintain draperies, curtains, and other loosely hanging fabrics such that they are in compliance with NFPA 701 " Standard Methods of Fire Tests for Flame Propagation of Textiles and Films. " This deficient practice could allow a fire to spread rapidly and would affect all persons in the serving area and dining area.
A. Findings are:
Observation on February 26, 2014 at 2:14pm revealed that there were several drapery awnings in the serving area on the walls marking the different areas.
A record review of the requested documentation for all curtains, draperies and hanging fabrics documentation found no documentation that the materials in the serving area were in compliance with NFPA 701.



27394

B. Findings are:
1. Documentation review on 2/25/2014 at 11:30 a.m. revealed that the paperwork for the privacy curtains shows no proof that the curtains are flame retardant. The paperwork only states that the curtains have been tested, but does not state to what standard and the results.
2. Documentation review on 2/25/2014 at 12:07 p.m. reveal that the paperwork for the vinyl blinds in patient rooms is very faded and unable to be read to verify if the blinds meet all code requirements.
3. Documentation review on 2/25/2014 at 2:20 p.m. revealed that the paperwork for the mattresses does not specify that it meets the NFPA code requirements.
Maintenance A confirmed the findings.

Based on observation and interview, the facility failed to install electrical receptacles at the required 5 feet above the floor in the oxygen storage room. This deficient practice would affect all patients in the area of the oxygen storage room. The facility census was 61 and capacity of 87.

Findings are:
Observations on 2-25-14 at 11:25 am revealed, an outlet in the oxygen storage room within Room 1221 that was installed below five foot from the floor.

During an interview on 2-25-14 at 11:25 am, Maintenance A confirmed the outlet in the oxygen storage room.

NFPA Standard:
Electric installation in storage locations for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 5 ft above the floor as a precaution against their physical damage. 1999 NFPA 99, 4.3.1.1.2

Based on observation and interview the facility failed to maintain the bulk liquid oxygen system in accordance with NFPA 99 by not having the required signage on the tanks and by allowing parking within ten feet of the tank. This deficient practice has the potential of rendering the oxygen supply system for both the normal and reserve systems inoperable in the case of an accident or fire around the bulk oxygen tanks. This deficient practice could affect all residents on oxygen within the facility.
Findings are:
Observation on February 26, 2014 between 9:15am and 10:00am revealed that the bulk oxygen tanks were not permanently placarded with " OXYGEN-NO SMOKING-NO OPEN FLAMES " signs.
An interview with Maintenance B on February 26, 2014 between 9:15am and 10:00am revealed that there was no such placarding on the bulk oxygen tanks.
Observation on February 26, 2014 between 9:15am and 10:00am revealed that there was a facility vehicle parked on the south side of the main bulk oxygen tank within 10 feet of the tank.
An interview with Maintenance B on February 26, 2014 between 9:15am and 10:00am revealed that the vehicle did belong to the facility and that it was parked less than 10 feet from the tank.
NFPA 50, 2001ed. 2.2.12
The minimum distance from any bulk oxygen system to any public sidewalk or parked vehicle shall be 10 ft (3 m).
NFPA 50, 2001ed. 3.5.8.
The bulk oxygen storage location shall be permanently placarded to indicate " OXYGEN - NO SMOKING - NO OPEN FLAMES. "

Based on observation and interview the facility failed to install and maintain the emergency generator in accordance with NPFA 110 by not having the generator room separated from the remainder of the building by a minimum of two-hour fire-rated construction and by not having a remote shut-down for the generator outside the generator room itself. This deficient practice has the potential for a problem with the emergency generator to spread outside the generator room and limit the ability to control the problem with the generator in an emergency. This deficient practice would affect all residents, staff and visitors of the facility.
A. Findings are:
Observation on February 25, 2014 at 10:16am revealed that the generator room was not separated from the remainder of the building by a minimum of two-hour fire-rated construction by having many penetrations of the walls that were not fire-stopped to listed design to maintain the fire resistance rating of the wall.
An interview with Maintenance B on February 25, 2014 at 10:16am revealed that the penetrations of the walls of the emergency generator room were not sealed at all.
Observation on February 25, 2014 at 10:23am revealed that the door to the emergency generator room, while rated, was not self-closing and positive latching in accordance with NFPA 80.
An interview with Maintenance B on February 25, 2014 at 10:23am revealed that the door to the emergency generator room was not self-closing and positive latching when opened.
Observation on February 25, 2014 at 10:44am revealed that there was no remote shutdown for the emergency generator other than the one located on the generator itself.
An interview with Maintenance B on February 25, 2014 at 10:44am revealed that there was no other shutdown device for the emergency generator other than the device on the generator itself.
NFPA 110, 2002ed. 7.2.1.1
The room shall have a minimum 2-hour fire rating or be located in an adequate enclosure located outside the building capable of resisting the entrance of snow or rain at a maximum wind velocity required by local building codes.
NFPA 110, 2002ed. 5.6.5.6
All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building.



27395

Based on observation and staff interview, the facility failed to secure a carbon dioxide tank. This condition had the potential to allow the tank to tip over and break off the valve. Facility census was 61.

B. Findings are:
Observation during the facility tour on 2/26/14, at 8:59 am revealed a carbon dioxide tank in the 0516 Office failed to be secured to prevent the tank from falling or being knocked over.
In an interview conducted at the time of observation, (2/26/14, at 8:59 am), Maintenance C acknowledged that the tank failed to be secured.

Actual NFPA Standard:
NFPA 55, 6-6 Securing Cylinders.
Compressed or liquefied gas cylinders in use or in storage shall be secured to prevent them from falling or being knocked over.

Based on observation and interview, the facility failed to provide documentation that the laboratory has fire and evacuation policies in place and practices those procedures. This practice has the potential to affect all staff, patients and visitors of the facility.

Findings are:
1. Documentation review on 2/25/2014 at 10:30 a.m. revealed that no documentation was provided to show that special fire drills and evacuation drills were being conducted in the laboratory area.
Maintenance A confirmed the findings.

Based on observation and interview, the facility failed to post oxygen signage on Room 1221. This deficient practice was located on the first level and would affect all patients in the area. The facility census was 61 and capacity of 87.

Findings are:
Observations on 2-25-14 at 11:42 am revealed, oxygen stored in Room 1221, the facility failed to provide oxygen in use signage.

During an interview on 2-25-14 at 11:42 am, Maintenance A confirmed the lack of signage on the door.

NFPA Standard:
Precautionary signs, readable from a distance of 5 feet, 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. 1999 NFPA 99, 8-6.4.2

Based on observation and staff interview, the facility failed to provide a 1-hour rated fire separation between the transferring of oxygen, and areas where patients are housed. This condition had the potential of a fire in the Oxygen Transferring Room to migrate into the exit corridor. Facility census was 123.

Findings are:
Observation during the facility tour on 2/27/14, at 9:27 am revealed the 3012 Oxygen Transfer Room Door failed to have a tag to verify the fire resistance rating of the door was 45-minutes.
In an interview conducted at the time of observation, (2/27/14, at 9:27 am), Maintenance C confirmed that the door did not possess a tag.

NFPA 99, 1999 ed, 8-6.2.5.2 8-6.2.5.2 Transferring Liquid Oxygen.
Transferring of liquid oxygen from one container to another shall be accomplished at a location specifically designated for the transferring that is as follows:
(a) Separated from any portion of a facility wherein patients are housed, examined, or treated by a separation of a fire barrier of 1-hour fire-resistive construction

Based on observation and interview, the facility failed to provide documentation that the generator is properly tested at weekly and under load on a monthly basis. This practice has the potential to affect all staff, patients and visitors to the facility.

Findings are:
1. Documentation review on 2/25/2014 at 10:33 a.m. revealed that no documentation was provided that showed the generator monthly load testing.
2. Documentation review on 2/25/2014 at 10:34 a.m. revealed that no documentation was provided to show the time of transfer for the generator.
3. Documentation review on 2/25/2014 at 10:41 a.m. revealed that no documentation was provided to show the annual load bank test.
Maintenance A confirmed the findings.

Based on observation and interview the facility failed to maintain the Type I essential electrical system of the facility by having loads intermixed between the Life Safety Branch, The Critical Branch, and the Equipment System and by not having the required loads connected to proper branch of the Essential Electrical System. This deficient practice has the potential to affect all residents, staff and visitors of the facility by affecting the egress lighting and emergency systems of the facility.
Findings are:
Observation on February 25, 2014 at 10:33am revealed that the Life Safety panel EWSB contained Critical branch loads for the Nurse Call system.
An interview with Maintenance B on February 25, 2014 at 10:33am revealed that circuits #2 and #6 were labeled as nurse call power and are not permitted on the life safety branch.
Observation on February 25, 2014 at 10:41am revealed that the Critical branch panel ECWB contained non-critical loads for television systems and boiler controls.
An interview with Maintenance B on February 25, 2014 at 10:41am revealed that circuit #7 was labeled for CATV/Tel Elec. Rm. 004 and circuit #11 was labeled Boiler level control and that these were not permitted on the critical branch.
Observation on February 25, 2014 at 11:03am revealed that the Critical Branch panel ECXB contained loads that are required to be on the Life Safety branch.
An interview with Maintenance B on February 25, 2014 at 11:03am revealed that circuit #13 was labeled FACP PAD and that this was a fire alarm circuit and is required to be connected to the Life Safety branch.
Observation on February 25, 2014 at 11:20am revealed that the Life Safety branch panel ESH2 contained non-life safety loads for some procedure room lighting.
An interview with Maintenance B on February 25, 2014 at 11:20am revealed that circuit #6 was labeled as Procedure 2320 lights and that this task lighting was not permitted on the life safety branch.

NFPA 70, 1999ed.
517.30 Essential Electrical Systems for Hospitals.
(A) Applicability. The requirements of Part III, 517.30 through 517.35, shall apply to hospitals where an essential electrical system is required.
(B) General.
(1) Separate Systems. Essential electrical systems for hospitals shall be comprised of two separate systems capable of supplying a limited amount of lighting and power service, which is considered essential for life safety and effective hospital operation during the time the normal electrical service is interrupted for any reason. These two systems shall be the emergency system and the equipment system.
(2) Emergency Systems. The emergency system shall be limited to circuits essential to life safety and critical patient care. These are designated the life safety branch and the critical branch.
(3) Equipment System. The equipment system shall supply major electrical equipment necessary for patient care and basic hospital operation.
(4) Transfer Switches. The number of transfer switches to be used shall be based on reliability, design, and load considerations. Each branch of the emergency system and each equipment system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA.
(5) Other Loads. Loads served by the generating equipment not specifically named in Article 517 shall be served by their own transfer switches such that these loads:
(1) Shall not be transferred if the transfer will overload the generating equipment.
(2) Shall be automatically shed upon generating equipment overloading.
(6) Contiguous Facilities. Hospital power sources and alternate power sources shall be permitted to serve the essential electrical systems of contiguous or same site facilities. [NFPA 99, 3.4.2.2.1, 12.3.3.2]
(C) Wiring Requirements.
(1) Separation from Other Circuits. The life safety branch and critical branch of the emergency system shall be kept entirely independent of all other wiring and equipment and shall not enter the same raceways, boxes, or cabinets with each other or other wiring.
Wiring of the life safety branch and the critical branch shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits not part of the branch where such wiring is as follows:
(1) In transfer equipment enclosures, or
(2) In exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(3) In a common junction box attached to exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(4) For two or more emergency circuits supplied from the same branch
The wiring of the equipment system shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits that are not part of the emergency system.
(2) Isolated Power Systems. Where isolated power systems are installed in any of the areas in 517.33(A)(1) and (A)(2), each system shall be supplied by an individual circuit serving no other load.
(3) Mechanical Protection of the Emergency System. The wiring of the emergency system of a hospital shall be mechanically protected by installation in nonflexible metal raceways, or shall be wired with Type MI cable.
Exception No. 1: Flexible power cords of appliances, or other utilization equipment, connected to the emergency system shall not be required to be enclosed in raceways.
Exception No. 2: Secondary circuits of transformer-powered communications or signaling systems shall not be required to be enclosed in raceways unless otherwise specified by Chapters 7 or 8.
Exception No. 3: Schedule 80 rigid nonmetallic conduit shall be permitted if the branch circuits do not serve patient care areas and it is not prohibited elsewhere in this Code.
Exception No. 4: Where encased in not less than 50 mm (2 in.) of concrete, Schedule 40 rigid nonmetallic conduit or electrical nonmetallic tubing shall be permitted if the branch circuits do not serve patient care areas.
Exception No. 5: Flexible metal raceways and cable assemblies shall be permitted to be used in listed prefabricated medical headwalls, listed office furnishings, or where necessary for flexible connection to equipment.
(D) Capacity of Systems. The essential electrical system shall have adequate capacity to meet the demand for the operation of all functions and equipment to be served by each system and branch.
Feeders shall be sized in accordance with Articles 215 and 220. The generator set(s) shall have sufficient capacity and proper rating to meet the demand produced by the load of the essential electrical system(s) at any given time.
Demand calculations for sizing of the generator set(s) shall be based on the following:
(1) Prudent demand factors and historical data, or
(2) Connected load, or
(3) Feeder calculation procedures described in Article 220, or
(4) Any combination of the above
The sizing requirements in 700.5 and 701.6 shall not apply to hospital generator set(s).
(E) Receptacle Identification. The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable. [NFPA 99, 3.4.2.2.4(b)2]
517.31 Emergency System.
Those functions of patient care depending on lighting or appliances that are connected to the emergency system shall be divided into two mandatory branches: the life safety branch and the critical branch, described in 517.32 and 517.33. The branches of the emergency system shall be installed and connected to the alternate power source so that all functions specified herein for the emergency system shall be automatically restored to operation within 10 seconds after interruption of the normal source. [NFPA 99, 3.4.2.2.2(a), 3.5.2.2.2]
517.32 Life Safety Branch.
No function other than those listed in 517.32(A) through (G) shall be connected to the life safety branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment.
(A) Illumination of Means of Egress. Illumination of means of egress, such as lighting required for corridors, passageways, stairways, and landings at exit doors, and all necessary ways of approach to exits. Switching arrangements to transfer patient corridor lighting in hospitals from general illumination circuits to night illumination circuits shall be permitted, provided only one of two circuits can be selected and both circuits cannot be extinguished at the same time.
(B) Exit Signs. Exit signs and exit directional signs.
(C) Alarm and Alerting Systems. Alarm and alerting systems including the following:
(1) Fire alarms
(2) Alarms required for systems used for the piping of nonflammable medical gases
(D) Communications Systems. Hospital communications systems, where used for issuing instructions during emergency conditions.
(E) Generator Set Location. Task illumination battery charger for emergency battery-powered lighting unit(s) and selected receptacles at the generator set location.
(F) Elevators. Elevator cab lighting, control, communications, and signal systems.
(G) Automatic Doors. Automatically operated doors used for building egress. [NFPA 99, 3.4.2.2.2(b)]
517.33 Critical Branch.
(A) Task Illumination and Selected Receptacles. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and special power circuits serving the following areas and functions related to patient care:
(1) Critical care areas that utilize anesthetizing gases - task illumination, selected receptacles, and fixed equipment
(2) The isolated power systems in special environments
(3) Patient care areas - task illumination and selected receptacles in the following:
a. Infant nurseries
b. Medication preparation areas
c. Pharmacy dispensing areas
d. Selected acute nursing areas
e. Psychiatric bed areas (omit receptacles)
f. Ward treatment rooms
g. Nurses ' stations (unless adequately lighted by corridor luminaires)
(4) Additional specialized patient care task illumination and receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7) Telephone equipment rooms and closets
(8) Task illumination, selected receptacles, and selected power circuits for the following:
a. General care beds (at least one duplex receptacle per patient bedroom)
b. Angiographic labs
c. Cardiac catheterization labs
d. Coronary care units
e. Hemodialysis rooms or areas
f. Emergency room treatment areas (selected)
g. Human physiology labs
h. Intensive care units
i. Postoperative recovery rooms (selected)
(9) Additional task illumination, receptacles, and selected power circuits needed for effective hospital operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch. [NFPA 99, 3.4.2.2.2(c)]
(B) Subdivision of the Critical Branch. It shall be permitted to subdivide the critical branch into two or more branches.
517.34 Equipment System Connection to Alternate Power Source.
The equipment system shall be installed and connected to the alternate power source such that the equipment described in 517.34(A) is automatically restored to operation at appropriate time-lag intervals following the energizing of the emergency system. Its arrangement shall also provide for the subsequent connection of equipment described in 517.34(B). [NFPA 99, 3.4.2.2.3(b)]
Exception: For essential electrical systems under 150 kVA, deletion of the time-lag intervals feature for delayed automatic connection to the equipment system shall be permitted.
(A) Equipment for Delayed Automatic Connection. The following equipment shall be arranged for delayed automatic connection to the alternate power source.
(1) Central suction systems serving medical and surgical functions, including controls. Such suction systems shall be permitted on the critical branch.
(2) Sump pumps and other equipment required to operate for the safety of major apparatus, including associated control systems and alarms.
(3) Compressed air systems serving medical and surgical functions, including controls. Such air systems shall be permitted on the critical branch.
(4) Smoke control and stair pressurization systems, or both.
(5) Kitchen hood supply or exhaust systems, or both, if required to operate during a fire in or under the hood. [NFPA 99, 3.4.2.2.3(d)]
Exception: Sequential delayed automatic connection to the alternate power source to prevent overloading the generator shall be permitted where engineering studies indicate it is necessary.
(B) Equipment for Delayed Automatic or Manual Connection. The following equipment shall be arranged for either delayed automatic or manual connection to the alternate power source:
(1) Heating equipment to provide heating for operating, delivery, labor, recovery, intensive care, coronary care, nurseries, infection/isolation rooms, emergency treatment spaces, and general patient rooms and pressure maintenance (jockey or make-up) pump(s) for water-based fire protection systems.
Exception: Heating of general patient rooms and infection/isolation rooms during disruption of the normal source shall not be required under any of the following conditions:
(a) The outside design temperature is higher than -6.7?C (20?F).
(b) The outside design temperature is lower than -6.7?C (20?F), and where a selected room(s) is provided for the needs of all confined patients, only such room(s) need be heated.
(c) The facility is served by a dual source of normal power.
(2) An elevator(s) selected to provide service to patient, surgical, obstetrical, and ground floors during interruption of normal power. In instances where interruption of normal power would result in other elevators stopping between floors, throw-over facilities shall be provided to allow the temporary operation of any elevator for the release of patients or other persons who may be confined between floors.
(3) Supply, return, and exhaust ventilating systems for airborne infectious/isolation rooms, protective environment rooms, exhaust fans for laboratory fume hoods, nuclear medicine areas where radioactive material is used, ethylene oxide evacuation and anesthesia evacuation. Where delayed automatic connection is not appropriate, such ventilation systems shall be permitted to be placed on the critical branch. [NFPA 99, 3.4.2.2.3(e)(4)]
(4) Hyperbaric facilities.
(5) Hypobaric facilities.
(6) Automatically operated doors.
(7) Minimal electrically heated autoclaving equipment shall be permitted to be arranged for either automatic or manual connection to the alternate source.
(8) Controls for equipment listed in 517.34.
(9) Other selected equipment shall be permitted to be served by the equipment system. [NFPA 99, 3.4.2.2.3(e)]

Based on staff interview and observation, the facility failed to ensure all electrical is installed in accordance with National Fire Protection Association 70 (electrical code). This practice affected all patients, visitors and staff that are in the area of power strips, extension cords, outlets and panels boxes. The facility census was 61 and capacity of 87.

A. Findings are:
Observations on 2-26-14 between 11:19 am an 2:33 pm to revealed:
1. Refrigerator and coffee pot plugged into an extension cord in 1222 Office.
2. Power strip used as permanent wiring for a refrigerator and microwave in 1220 Office.
3. Power strip used as permanent wiring for a portable blood pressure machine in Room 1221.
4. Non-hospital grade used in patient area for a television and WII equipment in the Ocean Room.
5. Extension cord in Patient Room 142.
6. Power strip used as permanent wiring for television in Patient Room 132.
7. Refrigerator plugged into a power strip in Communication Disorder Office.
8. Power strip used as permanent wiring in Office 0528.
9. Non-hospital grade power strip used in patient area for two computers in the Kits Academy.
10. The outlets in the Pediatric kitchen where patient care is given failed to provide tamper resistant outlets.
11. Obstruction to panel boxes MPXP, RPXB and ECXBA in the discharge soiled linen room in the lower level across from Room L64.

During an interview on 2-26-14 between 11:19 am an 2:33 pm, Maintenance A confirmed all the findings.

Official State Interpretation- 08-01

NFPA Standard:
Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8, 1999

Sufficient access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment. 1999 NFPA 70, 110.26

(c) Pediatric Locations. Fifteen- and 20-ampere, 125-volt receptacles intended to supply patient care areas of pediatric wards, rooms, or areas shall be listed tamper resistant or shall employ a listed tamper resistant cover. 1999 NFPA 70, 517-18



20404

Based on observation and interview the facility failed to identify the multiple main disconnects and to identify the type, size and location of the emergency power supply system at the main service disconnect for the building to alert responding personnel that there is an alternate source of power in the building and that shutting off the main service disconnect will not turn off all power in the building in the case of an emergency. The facility also failed to correctly identify all feeders and branch circuits and failed to maintain the integrity of the electrical equipment. This deficient practice has the potential to affect all occupants of the facility.
Findings are:
Observation on February 25, 2014 at 10:27am revealed that there were unidentified loads being served from the equipment system panel EQH.
An interview with Maintenance B on February 25, 2014 at 10:27am revealed that there was a 60 amp three pole breaker in slots 34, 36, & 38 that was in the on position and that the circuit directory indicated these as open spaces.
Observation on February 25, 2014 at 10:41am revealed that the Critical branch panel ECWB was not dead front.
An interview with Maintenance B on February 25, 2014 at 10:41am revealed that slots 8, 10, & 12 in critical branch panel ECWB were open to exposed live buss and that the cover was not dead front.
Observation on February 25, 2014 at 10:42am revealed that there was no signage installed at the main electrical service disconnect to indicate the presence of an emergency power system.
An interview with Maintenance B on February 25, 2014 at 10:42am revealed that there was no signage at the main service disconnect to indicate the presence and type of emergency system installed for the facility.
Observation on February 25, 2014 at 10:58am revealed that the circuit directory for the equipment system panel ECXC was not complete.
An interview with Maintenance B on February 25, 2014 at 10:58am revealed that there were circuits in the equipment system panel ECXC were not identified to their use.
Observation on February 25, 2014 at 11:03am revealed that the circuit directory for the critical branch panel ECXB was not complete and accurate.
An interview with Maintenance B on February 25, 2014 at 11:03am revealed that there was a 30 amp three pole breaker in slots 7,9, & 11 that was not identified as to its use.
Observation on February 25, 2014 at 11:17am revealed that the normal panel HW2 was not dead front.
An interview with Maintenance B on February 25, 2014 at 11:17am revealed that the high voltage panel HW2 had two openings that were just covered with duct tape and not dead front.
NFPA 70, 1999ed. 700-8(a) Emergency Sources. A sign shall be placed at the service entrance equipment indicating type and location of on-site emergency power sources.
NFPA 70, 1999ed. 110-22 Identification of Disconnecting means. Each disconnecting means required by this code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.
NFPA 70, 1999ed. 384-18 Enclosure. Panelboards shall be mounted in cabinets, cutout boxes, or enclosures designed for the purpose and shall be dead front.



27395

B. Findings are:
Observation during the facility tour on 2/25/14, from 10:59 am to 2/26/14, at 2:25 pm revealed:
1. A microwave and a mini fridge failed to be plugged in direct in Office 1169.
2. A microwave and a mini fridge failed to be plugged in direct in Office 1185.
3. A coffee maker and a refrigerator failed to be plugged in direct in Office 5054L.
4. A microwave and a mini fridge failed to be plugged in direct in Office 5054G.
5. Power strips failed to be plugged in direct in Office 5054C.
6. A junction box failed to have a cover installed in the cage area of Environmental Services.
7. A blanket warmer failed to be plugged in direct in Room 0138H.
8. A coffee maker and a microwave failed to be plugged in direct in Office 0137.
9. A junction box failed to have a cover installed above the Generator in 0130A.
10. A microwave failed to be plugged in direct in the Maintenance Room 0134. A refrigerator failed to be plugged in so an extension cord was not used in lieu of permanent wiring.
11. Chemical pumps in 0113 failed to be plugged in so an extension cord was not used in lieu of permanent wiring.
12. Exposed wiring for a heater in Office 0516 failed to be installed in a junction box. Carts failed to be stored at least three feet from electrical panels.
13. A junction box failed to have a cover installed above Z. Roberts Cubicle in Accounting.
14. A microwave and toaster failed to be plugged in direct in 0507B.
15. A coffee maker failed to be plugged in direct in the middle cubicle in Accounting.
16. A coffee maker failed to be plugged in direct in the 0518C Office.
17. A microwave, coffee maker, toaster and refrigerator failed to be plugged in direct in the 0518 Office.
18. Power strips failed to be plugged in direct for a fan in 0521.
19. Power strips failed to be plugged in direct in 0521 in the back left and right cubicles.
20. A power strip failed to be installed so that it did not hang from the cords in Office 0522E.
21. A refrigerator failed to be plugged in direct in the Lab Office. A combination of power strips and an extension cord were observed.
22. A junction box failed to have a cover installed in the 0619 Chemical Storage Closet.
23. A microwave failed to be plugged in direct in the back of the 610 Office.
24. An electrical cord failed to be installed so that it was not taped to the floor in the AV Room; so that it would not overheat.
25. Power strips failed to be plugged in direct left of the door in 0310.
26. Power strips failed to be plugged in direct, and an extension failed to be removed from 0610.
In an interview conducted at the time of observation (2/25/14, from 10:59 am to 2/26/14, at 2:25 pm), Maintenance C acknowledged the findings.

Based on observation and interview the facility failed to have Alcohol Based Hand Rub (ABHR) dispensers installed so that they are not above or immediately adjacent to an electrical ignition source. This deficient practice affected all residents, staff, and visitors in the areas of the ABHR. The facility capacity is 87 and the census was 61.

A. Findings are:
Observations on 2-25-14 between 11:18 am and 2:25 pm revealed:
1. ABHR dispenser installed adjacent to light switch in Room 152.
2. ABHR dispenser installed adjacent to light switch in Room 150.
3. ABHR dispenser installed adjacent to light switch in Room 145.
4. ABHR dispenser installed adjacent to light switch in Room 144.
5. ABHR dispenser installed adjacent to light switch in Room 141.
6. ABHR dispenser installed adjacent to light switch in Room 134.
7. ABHR dispenser installed adjacent to light switch in Room 131.
8. ABHR dispenser installed adjacent to light switch in Room 136.
9. ABHR dispenser installed adjacent to light switch in Room 128.
10. ABHR dispenser installed adjacent to light switch in Shower Room 1-C.
11. ABHR dispenser installed adjacent to light switch in 1-E Soiled/Trash Room.
12. ABHR dispenser installed adjacent to light switch in Room 152.
13. ABHR dispenser installed adjacent to light switch in Outpatients Pediatrics Office.
14. ABHR dispenser install above a light switch in the north-east corner of Outpatient Pediatrics Therapy Room.
15. ABHR dispenser installed adjacent to light switch in the Pediatric Kitchen.

During an interview on 2-25-14 between 11:18 am and 2:25 pm, Maintenance A confirmed the ABHR dispensers were installed immediately adjacent or above to electrical sources.

Regulation:
Nebraska State Fire Marshal Official Interpretation 05-04



27395

B. Findings are:
Observations on 2/25/14, from 11:20 am to 2:11 pm revealed:
1. An ABHR failed to be installed so that it was not directly adjacent to a light switch in the Perkins Place - 1st Floor West.
2. An ABHR failed to be installed so that it was not directly adjacent to a light switch in Room 1182.
3. An ABHR failed to be installed so that it was not over a light switch in Room 0140.
In an interview conducted at the time of observation, (2/25/14, from 11:20 am to 2:11 pm), Maintenance C confirmed the location of the ABHR.