Gordon Memorial Hospital District

“42 CFR 485.623 The facility must meet the applicable provisions of the 2012 Edition of the Life Safety Code of the National Fire Protection Association. This facility is governed by Chapter 19, Existing Health Care Occupancies of the 2012 Edition of the National Fire Protection Association [NFPA], Chapter 101: Life Safety Code. Gordon Memorial Hospital District is a single-story facility with a full basement. Patients are located on the main level of the facility. The 1964, and 1972 portions of the facility are of Type II (111) construction. The basement is used primarily for facility services. Supporting basement walls are of concrete block or poured concrete construction. Non supporting walls are of non-combustible or limited combustible construction. The main level supporting walls are of concrete block or poured concrete construction supporting the roof construction only. The main level non supporting walls are of non-combustible or limited combustible construction. Corridor walls on both levels extend to the floor above or to the bottom of the roof decking. Corridor walls on the main level are of one-hour fire rated construction and extend to the roof decking. All corridors throughout the facility are protected smoke detection connected to the building fire alarm system. All portions of the buildings fire alarm system and fire sprinkler system are interconnected to transmit an alarm throughout the building and to the local 911 Center for dispatching the local Fire Department. Gordon Memorial Hospital District was found to be not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR.623, Life Safety from fire, and the related National Fire Protection Association (NFPA) Standard 101-2012 edition.”

“Aisle, Corridor, or Ramp Width CFR(s): NFPA 101 Aisle, Corridor or Ramp Width 2012 EXISTING The width of aisles or corridors (clear or unobstructed) serving as exit access shall be at least 4 feet and maintained to provide the convenient removal of nonambulatory patients on stretchers, except as modified by 19.2.3.4, exceptions 1-5. 19.2.3.4, 19.2.3.5 This Standard is not met as evidenced by: 04548 Based on observation and staff interview, the facility failed to maintain exit corridors free of obstructions that projected from the wall into the corridor in 2 of 3 smoke compartments. This condition would slow the evacuation of patients served by these exits during an emergency. Findings are: Observation on 07-09-24 at 1:00 P. M and 1:15 PM revealed., 1. Four wheelchairs and a bed were stored in the ER Corridor. 2. Three cleaning carts with chemicals and trash were stored in the corridor across from the elevator. 3. A large trash dumpster at the bottom of the exit ramp between the hospital and clinic that encroached into the required corridor width. Interview on 07-09-24 at 1:15 P.M., with maintenance staff advised confirmed the storage in the corridors.”

“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: 04548 Based on observation and interview, the facility failed to provide any type of fire extinguishment protection over cooking equipment that produces grease-laden vapors and that might be a source of ignition. This deficient practice would allow a fire to spread and become uncontrollable. Findings are: 1. Observations on 07-09-24 at 1:30 P.M. revealed the facility was using a deep fat fryer appliance in the kitchen without the protection of a hood exhaust system and required hood fire suppression system. Interviews on 07/09/24 at 1:30 P.M., with the Maintenance staff confirmed this observation and advised that the facility was told that the appliance was not required to be under the exhaust hood and protected with the hood fire suppression system. 2. Observations on 07-09-24 at 12:45 P.M., revealed that the Radiology staff was using an air fryer within the radiology department without the protection of a hood exhaust system and required hood fire suppression system. Interviews on 07-09-24 at 12:45 P.M., with Maintenance staff confirmed the observation and was unaware of fryer being used.”

“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: 04548 Based on observation and interview, the facility did not ensure that doors to the corridors were provided with a means suitable for keeping the door closed. This deficient practice would not prevent the spread of fire and smoke. Findings are: 1. Observation on 07/09/24 at 11:30 A.M. revealed the doors to the clean utility room, CT suite, and the central exit stairs on first floor and lower level were blocked open with door wedges. During an Interview on 07/09/24 at 11:30 A.M. maintenance staff A confirmed the doors were blocked open. 2. Observation on 07/09/24 at 12:00 P.M., revealed the door to the Cardiac Rehab had a kick down plate installed on it which could prevent the door from being closed in an emergency. During an Interview on 07/09/24 at 12:00 P.M. maintenance staff A confirmed the kick down plate on the Cardiac Rehab door.”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 04548 Based on observation and interview, the facility failed to prohibit the use of extension cords as a substitute for adequate wiring. This deficient practice would create electrical injury and increase a fire hazard. Findings are: 1. Observation on 7/09/24 at 12:40 P.M., revealed, a zip wire extension cord plugged into a Three-way adaptor running up into the drop ceiling in Radiology. 2. Observation on 07-09-24 at 12:40 P.M., revealed in Radiology, a power cord to a grow light running through a door between the door and door frame where the cord was being pinched. During an interview on 7/09/24 at 12:40 P.M., Maintenance Staff A confirmed the extension cord and power cord running through the door and frame.”