Madonna Rehabilitation Specialty Hospital Lincoln

“42 CFR 482.41 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. Madonna Rehabilitation Specialty Hospital located on the second floor of a three-story building. Is a Type II (111) construction that was built in 1958 with a new addition built in 2021 which has a 2 hour fire rated separation and is fully sprinklered. There is supervised smoke detection located in the corridors and all open areas to the corridor. There is a 2 hour fire rated separation between the hospital and business occupancy. The facility has 77 certified beds. At the time of the survey the census was 23. Madonna Rehabilitation Specialty Hospital was found not to be in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 482.41, Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101 - 2012 edition.”

“Building Rehabilitation CFR(s): NFPA 101 Building Rehabilitation Repair, Renovation, Modification, or Reconstruction Any building undergoing repair, renovation, modification, or reconstruction complies with both of the following: * Requirements of Chapter 18 and 19 * Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6 18.1.1.4.3, 19.1.1.4.3, 43.1.2.1 Change of Use or Change of Occupancy Any building undergoing change of use or change of occupancy classification complies with the requirements of Section 43.7, unless permitted by 18.1.1.4.2 or 19.1.1.4.2 18.1.1.4.2 (4.6.7 and 4.6.11), 19.1.1.4.2 (4.6.7 and 4.6.11), 43.1.2.2 (43.7) Additions Any building undergoing an addition shall comply with the requirements of Section 43.8. If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a 2-hour fire resistance rating constructed of materials as required for the addition. Communicating openings occur only in corridors and are protected by approved self-closing fire doors with at least a 1-1/2-hour fire resistance rating. Additions comply with the requirements of Section 43.8. 18.1.1.4.1 (4.6.7 and 4.6.11), 18.1.1.4.1.1 (8.3), 18.1.1.4.1.2, 18.1.1.4.1.3, 19.1.1.4.1 (4.6.7 and 4.6.11), 19.1.1.4.1.1 (8.3), 19.1.1.4.1.2, 19.1.1.4.1.3, 43.1.2.3(43.8) This Standard is not met as evidenced by: 13879 Based on observation and interview, the facility failed to assure construction was separated from occupied areas. These deficient practices would allow smoke, fire and gasses to spread throughout the exit corridors. The facility has the capacity for 77 beds with a census of 23 on the day of survey. Findings are: Observation on 12-18-23 at 1:15 pm revealed: 1. No fire rated separation between the occupied health care area and areas under construction, non-rated, non-latching double doors and a glass door were installed. During an interview on 12-18-23 at 1:15 pm, Staff A confirmed the lack of separation between the construction area and occupied areas.”

“Multiple Occupancies CFR(s): NFPA 101 Multiple Occupancies - Sections of Health Care Facilities Sections of health care facilities classified as other occupancies meet all of the following: o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access. o They are separated from areas of health care occupancies by construction having a minimum two hour fire resistance rating in accordance with Chapter 8. o The entire building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served. 19.1.3.3, 42 CFR 482.41, 42 CFR 485.623 This Standard is not met as evidenced by: 13879 Based on observation and interview, the facility failed to maintain a 2-hour fire separation. This deficient practice would allow smoke, fire and gases to migrate from the Hospital into the Business occupancy link. The facility has the capacity for 77 beds with a census of 23 on the day of survey. Findings are: Observation on 12-8-23 between 2:09 pm and 2:19 pm revealed: 1. The south 1 ½ -hour fire rated double doors next to room S40 failed to latch within the doorframe. 2. 2A103 1 ½ -hour fire rated double doors failed to latch within the doorframe. 3. 2A103 1 ½ -hour fire rated north door failed to latch within the doorframe. During an interview on 12-8-23 between 2:09 pm and 2:19 pm, Staff A confirmed the 1 ½ hour fire rated doors failed to latch within the doorframe.”

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This Standard is not met as evidenced by: 13879 Based on observation and interview, the facility failed to maintain means of egress free of obstructions. This deficient practice would delay egress and not impede it to full instant use in the case of fire or other emergencies. The facility has the capacity for 77 beds with a census of 23 on the day of survey. Findings are: Observations on 12-18-23 at 1:28 pm revealed, numerous construction barriers obstructing the corridors. During interview on 12-18-23 at 1:28 pm, Staff A confirmed the barriers in the corridor.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 13879 Based on observation and staff interview, the facility failed to provide self-closing devices and failed to assure enclosures for hazardous areas to separate them from the rest of the facility. This deficient practice would allow fire, smoke and gases to migrate into the exit corridors. The facility has the capacity for 77 beds with a census of 23 on the day of survey. Finding are: Observation on 12-18-23 between 1:31 pm and 2:20 pm, revealed the following: 1. 2C108 room door failed to provide a self-closing device. 2. 2277 clean supply room door equipped with a self-closing device failed to latch within the doorframe. 3. 2B123 door equipped with a self-closing device had tape covering the latch, the door failed latch within the doorframe. 4. 2B125 IT room door failed to provide a self-closing device. 5. 2321 employee only door equipped with self-closing device failed to latch within doorframe. 6. 2A135 equipment storage room over 100 square feet, failed to provide a self-closing device. 7. 2A137 storage room door equipped with a self-closing device, failed to latch within the doorframe. During interview on 12-18-23 between 1:31 pm and 2:20 pm, Staff A confirmed the findings.”

“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: 13879 Based on observation and interview, the facility failed to assure that tiles were placed in the ceiling grid within hazardous areas. This deficient practice would not allow the fire sprinkler system to operate as designed. The facility has the capacity for 77 beds with a census of 23 on the day of survey. Findings are: Observations on 12-18-23 at 1:51 pm and 1:54 pm revealed: 1. Room 2272 open ceiling tile. 2. Room 2275 two open ceiling tiles. During an interview on 12-18-23 at 1:51 pm and 1:54 pm, Staff A confirmed the missing ceiling tiles.”

“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: 13879 Based on observation and interview, the facility failed to assure doors to the corridor would latch. This deficient practice would allow smoke, fire and gasses to enter the exit corridor. The facility has the capacity for 77 beds with a census of 23 on the day of survey. Findings are: Observations on 12-18-23 at 1:49 pm revealed, 2C103 door equipped with a small leaf failed to auto latch within the doorframe. During an interview on 12-18-23 at 1:49 pm, Staff A confirmed the doors failed to latch within the doorframe when closed.”

“Rubbish Chutes, Incinerators, and Laundry Chu CFR(s): NFPA 101 Rubbish Chutes, Incinerators, and Laundry Chutes 2012 EXISTING (1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5. (2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7. (3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.) (4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use. 19.5.4, 9.5, 8.4, NFPA 82 This Standard is not met as evidenced by: 13879 Based on observation and interview the facility failed to assure that the fire-rated door to the soiled linen/trash would latch within the doorframe. This deficient practice had the potential to spread smoke, gasses and fire outside the room into the corridor. The facility has the capacity for 77 beds with a census of 23 on the day of survey. Findings are: Observations on 12-18-23 at 2:14 pm revealed: 1. The fire rated door to the soiled linen chute failed to latch within the frame. 2. The fire rated door to the rubbish chute failed to latch within the frame. During an interview on 12-18-23 at 2:14 pm, Staff A confirmed the chute doors failed to latch within the frame. NFPA Standard: NFPA 82, 1999, 3-2.2.9 Gravity chutes shall be constructed so that the base opening of the chute or shaft, or both, shall be protected by an approved automatic-closing or self-closing 1-hour fire door suitable for a Class B opening.”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 13879 Based on observation and interview, the facility failed to conduct electrical receptacle testing for newly installed hospital grade outlets. These deficient practices would create electrical injury and fire hazards. The facility has the capacity for 77 beds with a census of 23 on the day of survey. Findings are: Observations on 12-18-23 between 1:30 pm and 2:30 pm revealed, newly installed hospital grade outlets throughout the facility. During an interview 12-18-23 between 1:30 pm and 2:30 pm, Staff A confirmed the lack of testing of newly installed hospital grade outlets. NFPA Standard: NFPA 99, 2012, 6.3.4.1.1 Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device. 2012 NFPA 99 6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection. 6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified. 6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. 6.3.3.2.4”

“Electrical Equipment - Other CFR(s): NFPA 101 Electrical Equipment - Other List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 10 (NFPA 99) This Standard is not met as evidenced by: 13879 Based on observation and interview, the facility failed to assure that electrical adaptors were not in use. This deficient practice would increase the potential for an electrical fire. The facility has the capacity for 77 beds with a census of 23 on the day of survey. Findings are: Observations on 12-18-23 at 1:46 pm revealed, an electrical adaptor plugged into a floor fan in Therapy room 2C105. During an interview on 12-18-23 at 1:46 pm, Staff A confirmed the use of electrical adaptor.”