Palo Alto County Hospital

“42 CFR 485.623(d) Palo Alto County Hospital was found to be not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 485.623(d), Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101 - 2012 edition. Palo Alto County Hospital is a one story building with a basement of Type II (111) construction that was built in 2000. The building is fully sprinklered and there is supervised smoke detection located in the corridors, resident rooms and the spaces open to the corridors. The facility has 25 certified beds. All 25 beds are certified for Medicare/Medicaid only. At the time of the survey the census was 0. The requirement at 42 CFR 485.623(d) is NOT MET as evidenced by:”

“Emergency Lighting CFR(s): NFPA 101 Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1 This Standard is not met as evidenced by: 51493 Based on record review and staff interview, the facility failed to test and maintain the emergency lighting system in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 7.9 and 19.2.9.1. A monthly test of the system for 30 seconds shall be conducted. A yearly test of the system for 90 minutes shall be conducted. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 0 residents. Findings include: Record review and staff interview on 11/22/24 at 8:59 a.m., revealed that the above facility was missing the September 2024 and October 2024 weekly 30 second testing of the emergency lighting system. Maintenance Director verified this finding during the interview.”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 51493 Based on record review and staff interview, the facility failed to inspect and service the Kitchen Hood and Duct Extinguishment System in accordance with National Fire Protection Association, NFPA 96, 2011 edition. The deficient practice affects facility staff in one out of seven smoke zones which includes Dining Room. The facility has a capacity of 25 with a census of 0 residents. Findings include: During the survey on 11/19/24 at 10:45 a.m. while the self-igniting burners on the commercial stove were tested, it was revealed that two of burners in the back right side and one of the front left burners would not automatically ignite. This increases the risk that the burner could inadvertently be left on would continue to release gas into the room. Staff interviewed stated that she didn’t know why it wasn’t lighting and stated that it doesn’t always work properly. Maintenance Director verified this finding during the survey.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 51493 Based on observation and interview, the facility failed to install, test, and maintain the fire alarm system within the building in accordance with the National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code and Signaling Code, 2010 edition. This deficient practice could affect all occupants within the facility. The facility had a capacity of 25 and a census of 0 residents at the time of the survey. Findings include: Observation and interview on 11/19/24 at 10:45 a.m., revealed the facility failed to maintain the fire alarm system in the Medical gas storage room. This room contained a smoke detector that was not securely fastened to the ceiling and was hanging by wires. The Maintenance Director confirmed this observation at the time of the survey.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 51493 Based on record review, observations and staff interview, this facility is not maintaining the sprinkler system in accordance with National Fire Protection Association, NFPA 25, 2011 edition and National Fire Protection Association, NFPA 13, 2010 edition. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 0 clients. Findings include: Observation and interview on 11/19/24 at 10:50 a.m. revealed a missing sprinkler e-ring cover on the sprinkler head in the storage room known as “EVS” storage room. Maintenance Director verified this observation during the survey process.”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 51493 Based on observation and interview, the facility did not ensure corridor doors were smoke resisting to resist the passage of smoke in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.3.6.1/19.3.6.1 and 18.3.6.3/19.3.6.3. This deficient practice affected one of eight smoke compartments. This facility had a capacity of 25 and a census of 0 residents at the time of the survey. Findings include: Observation and interview on 11/22/24 at 11:19 a.m., revealed an approximate 1/4 inch hole located above the door handle on the CT Control Room door due to the handle being coming away from the door and falling off. The Maintenance Director confirmed this finding at the time of the survey.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 51493 Based on observation and interview, the facility is not assuring that two of two smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.3.7.3 and allow the passage of smoke and fire to another smoke zone. It was determined the facility failed to maintain the 30 minute fire resistive rating of the smoke barrier. This deficient practice affects all residents, staff, and visitors in all smoke zones. The facility has a capacity of 25 with a census of 0. Findings include: 1. Observations and interview on 11/19/24 at 11:00 a.m., revealed ceiling paneling located in the Exam #1 in the restroom was missing. 2. Observations and interview on 11/19/24 at 11:16 a.m., revealed in the room labeled X-ray #1 had a two to three inch gap between the wall and ceiling panel were a number of pipes are running up the wall into the top of the ceiling into the ceiling panels. The Maintenance Director verified these observations during the survey process.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9 This Standard is not met as evidenced by: 51493 Based on observation and testing, the facility did not ensure fire rated smoke barriers doors were maintained and positive latching in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 8.3.3.1 and 4.6.12.3 and NFPA 80, Standard for Fire Doors and Other Opening Protectives, 2010 edition. This deficient practice affected all smoke zones in the facility. This facility had a capacity of 25 and a census of 0 patients at the time of the survey. Findings include: Observation and testing on 11/19/24 at approximately 10:47 a.m., revealed the all of the double smoke barrier doors between the Kitchen and Emergency room hallway could not fully close and was dragging on the floor. It was also observed that the double smoke barrier doors had at least a 1/4 inch gap between the two doors when it was forced closed. The Mainentance Director verified this finding during the interview.”