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The facility failed to provide an interior finish per code. Findings include:

During the survey, the following is an example of what was observed:
The Lab. next to the exit door had wood paneling, that could not be verified of having a class C flame spread rating.

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2000 NFPA 101, 19.3.3.1 Interior finish shall be in accordance with Section 10.2.
2000 NFPA 101, 19.3.3.2 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.
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The facility failed to maintain the corridor separation per code. Findings include:
During the survey, the following are examples of what was observed:
The following rooms, the corridor doors had been removed and the rooms did not have smoke detectors:
1. Pyxis Room
2. Patient Dining Room

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2000 NFPA 101, 19.3.6.1 Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5. (See also 19.2.5.9.)
Exception No. 1: Smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.3 shall be permitted to have spaces that are unlimited in size open to the corridor, provided that the following criteria are met:
(a) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas.
(b) The corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the smoke compartment in which the space is located is protected throughout by quick-response sprinklers.
(c) The open space is protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the entire space is arranged and located to allow direct supervision by the facility staff from a nurses ' station or similar space.
(d) The space does not obstruct access to required exits.
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The facility failed to maintain a corridor opening per code. Findings include:

During the survey, the following is an example of what was observed:
The corridor door for room 112 had a toe stop holding it open.

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2007 CMS - 2786R There is no impediment to the closing of the corridor doors.

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The facility failed to maintain separation of hazardous areas. Findings include: During the survey the following is an example of what was observed:

Unsealed penetrations around a water line in the wall of the boiler room.

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NFPA 101, 19.3.2.1 and 8.4.1 Hazardous areas to be provided with smoke-resisting partitions and doors when protection consists of an automatic extinguishing system. Doors shall be selfclosing with positive latching hardware.
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The facility failed to maintain the exit access per code. Findings include:
During the survey, the following are examples of what was observed:

1. When the door was fully open for the Nurses General Suppy storage room, the door was approximately 14" from the corridor wall.

2. When the door was fully open for the toilet, by patient room 108, the door was approximately 11" from the corridor wall.

3. When the door was fully open for the janitor room, by patient room 108, the door was approximately 10" from the corridor wall.


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4. The following corridor doors, when fully opened projected more than 7" into the corridor:
a. The Bathing Room across from room 109
b. The Restroom across from room 109

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2000 NFPA 101, 7.2.1.4.4 During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 in. (17.8 cm) into the required width of an aisle, corridor, passageway, or landing, when fully open. Doors shall not open directly onto a stair without a landing. The landing shall have a width not less than the width of the door. (See 7.2.1.3.)
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The facility failed to conduct fire drills per code. Findings include:

During the survey, the following is an example of what was observed:
The facility failed to provide documentation of conducting a first shift fire drill for the third quarter of 2011.

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2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
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The facility failed to provide complete/current documentation of the inspection of the fire alarm system. During the survey, the following is an example of what was observed:

Documentation was not provided for the annual inspection of the fire alarm system.
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NFPA 101, 9.6.1.4 The fire alarm system to be installed, tested, and maintained in accordance with the requirements of NFPA 70 and NFPA 72.
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The facility failed to perform sensitivity testing of the smoke detectors. Findings include: During the survey, the following is an example of what was observed:


Documentation provided by the facility during the survey did not indicate sensitivity testing of the smoke detectors. Detector sensitivity shall be checked with one year after installation and every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).
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Sprinkler coverage was observed during the survey not adequately provided. Findings include: During the survey, the following are examples of what was observed:

1. A sprinkler in X-Ray had build up of paint on the deflector.

2. A sprinkler in the riser room had build up of paint on the deflector.

3. A sprinkler in the janitor room by the Dining Room had build up of paint on the deflector.

4. A hole in the ceiling tile in X-Ray.


1999 NFPA 25, 2-2.1.1 and 2-4.1.2 Sprinklers that are painted, corroded or damaged shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.


NFPA 13 5-6., Sprinklers shall be arranged to be in compliance.


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5. The following patient room built in closets did not have automatic sprinkler coverage (two closets in each room):
a. 104
b. 109
c. 110

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2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
Table 19.1.6.2 Construction Type Limitations
Construction Type Stories
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)

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The facility failed to perform the required maintenance of the facility sprinkler system. Findings include: During the survey, the following are examples of what was observed:

1. Documentation provided by the facility concerning quarterly inspection of the sprinkler system indicated conducted on 3/29/2011, 2/28/2012, 5/17/2012.

2. Documentation was not provided by the facility for the five year replacement or calibration of the gauges.

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NFPA 101, 4.6.12, and NFPA 25, 2-2 and Table 2-1 Requires an inspection every quarter (three months).

NFPA 25, 9-2.8.2: Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

NFPA 25, 9-2.8.1: Gauges shall be inspected monthly to verify that they are in good condition and that normal pressure is being maintained. Exception: When other sections of this standard have different frequency requirements for specific gauges.





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3. The sprinkler head in the Storage Room across from room 118 had excessive foreign materials.
4. The following closets had obstructed automatic sprinkler heads:
a. Linen Closet across from room 111
b. The closet in the Breakroom
c. Patient Room closets through out the facility

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1998 NFPA 25, 2-2.1.1 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.
1999 NFPA 13, 5-5.6 The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.
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The facility failed to provide a fire extinguisher per code. Findings include:

During the survey, the following is an example of what was observed:
The fire extinguisher by room 119 was mounted at 71"

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1998 NFPA 10, 1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 31/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).
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The facility failed to provide a designated smoking area per code. Findings include:

During the survey, the following is an example of what was observed:
The designated smoking area did not have a metal container with self-closing cover device

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2000 NFPA 101, 19.7.4 Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
Exception: In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(2) Smoking by patients classified as not responsible shall be prohibited.
Exception: The requirement of 19.7.4(2) shall not apply where the patient is under direct supervision.
(3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
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* The facility failed to provide an HVAC system per code. Findings include:

During the survey, the following is an example of what was observed:
The facility was using the corridor as return air plenum
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1999 NFPA 90A, 2-3.11.1 Egress corridors in health care, detention and correctional, and residential occupancies shall not be used as a portion of a supply, return, or exhaust air system serving adjoining areas. An air transfer opening(s) shall not be permitted in walls or in doors separating egress corridors from adjoining areas.

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The facility failed to maintain the dietary hood. Findings include: During the survey, the following are examples of what was observed:

1. Documentation was not provided by the facility for cleaning of the hood, grease build up was observed by this surveyor on all filters.

2. Documentation provided by the facility for inspection of hood was last conducted on 4/23/2012. The facility was not able to provide any other inspection reports.

3. Documentation was not provided for last hydrostatic test of cylinder.

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NFPA 96, 8-3.1.2 When a vent cleaning service is used, certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company. It shall also indicate areas not cleaned.

NFPA 17, 9-3 and 1998 NFPA 17a, 5-3 Require inspection and servicing at least every six months by properly trained and qualified persons.

1998 NFPA 17, 9-5 Hydrostatic testing of the extinguishment cylinder shall not exceed 12 years.

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The facility failed to maintain the medical gas per code. Findings include:

During the survey, the following is an example of what was observed:
The facility had "H" type cylinders (each cylinder can hold up to 212 cubic feet of gas) in the following locations:
1. Four "H" cylinders were observed at the alcove to the Dining Room off the corridor. All four cylinders had oxygen in them.
2. Other "H" cylinders were observed being stored in unoccupied patient rooms through out the facility.

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HCFA Transmittal Notice Ref: S&C-07-10

1. Up to 300 cu ft of nonflammable medical gas can be located outside of an enclosure (per smoke compartment) at locations open to the corridor such as at a nurse ' s station or in a corridor of a healthcare facility.

2. The term " PRN " means " as needed. " An individual cylinder placed in a patient room for immediate use by a patient is not required to be stored in an enclosure and is considered in use. It should be secured to prevent tipping or damage to the cylinder. If the resident does not need the use of oxygen for an extended period of time, such as several days, then the medical gas container should be removed from the room and properly secured in an approved storage room.

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The facility failed to maintain the emergency generator per code. Findings include:

During the survey, the following are examples of what was observed:
1. The facility failed to provide documentation of weekly inspections from July 2011 through Dec. 2011
2. The facility failed to provide documentation of monthly load test for the following months:
a. July 2011
b. Nov. 2011
c. Dec. 2011

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1999 NFPA 110, 6-3.4 A written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises. The written record shall include the following:
(a) The date of the maintenance report
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer
1999 NFPA 110, 6-4.1 Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
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ITEM 1 IS A REWRITE FROM THE 2009 SURVEY

The facility failed to maintain the emergency lighting per code. Findings include:

During the survey, the following are examples of what was observed:
1. Per interview the emergency generator remote annunciator had been in trouble with a "low water temp", to keep the alarm from sounding the facility had turned the alarm ("horn") off.
2. The "line power" indicator was not illuminated
3. The "gen power" indicator did not illuminate when the emergency generator was placed under load
4. The facility failed to provide documentation of the thirty second monthly testing of the emergency battery back-up lighting for the following months:
a. July 2011
b. Nov. 2011
c. Dec. 2011
5. The facility failed to provide documentation of the ninety minute annual testing of the emergency battery back-up lighting for the past 12 months.

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1999 NFPA 99, 3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]
2000 NFPA 101, 7.9.3 Periodic Testing of Emergency Lighting Equipment.
A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
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The facility utilized extension cords without overcurrent protection. Findings include: During the survey, the following is an example of what was observed:


1. A two bulb fluorescent light had was plugged into an extension cord, because the cord would not reach the electrical outlet in the boiler room.
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1999 NFA 70, Article 240-4, and HFCA Transmittal Notice 22-99 prohibit the use of extension cords without overcurrent protection.


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The facility failed to maintain the electrical wiring and equipment per code. Findings include:

During the survey, the following are examples of what was observed:
2. The Employee Breakroom had the following:
a. A refrigerator and a microwave plugged into a surge protector
b. An extension cord was plugged into the surge protector (it was not in use at the time), the staff removed this extension cord in front of the surveyor

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1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

1999 NFPA 70, 400-7 (b) Attachment Plugs. Where used as permitted in subsections (a)(3), (a)(6), and (a)(8), each flexible cord shall be equipped with an attachment plug and shall be energized from a receptacle outlet.