The Good Shepherd Rehabilitation Hospital

“Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: *Required manual fire alarm system; and *Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and *Automatic sprinkler system, if installed; and *Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This Standard is not met as evidenced by: 32692 Based on observation and interview, it was determined the facility failed to maintain required self closing doors on two of four floors. Findings include; 1. Observation on May 22, 2024, between 9:22 a.m., and 10:53 a.m., revealed the following; a. At 9:22 a.m., 3rd floor, stairtower # 1 had a gap in excess of tolerance on the strike side. b. At 10:30 a.m., 1st floor, double doors into the soiled linen staging area failed to latch when tested. c. At 10:53 a.m., 1st floor, double doors into the electric room, #155 were not self closing and lacked self closing devices. Interview with the facilities director and facility maintenance representative on May 22, 2024, at 11:30 a.m., confirmed the self closing door deficiencies.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure 2012 New Hazardous areas are protected in accordance with 18.3.2.1. The areas shall be enclosed with a 1-hour fire-rated barrier, with a 3/4-hour fire-rated door without windows (in accordance with 8.7.1.1). Doors shall be self-closing or automatic-closing in accordance with 7.2.1.8. Hazardous areas are protected by a sprinkler system in accordance with 9.7, 18.3.2.1, and 8.4. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 18.3.2.1, 7.2.1.8, 8.4, 8.7, 9.7 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 and less than 100 square feet) g. Combustible Storage Rooms/Spaces (over 100 square feet) h. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 32692 Based on observation and interview, it was determined the facility failed to maintain hazardous areas on one of four floors. Findings include; 1. Observation on May 22, 2024, at 10:44 a.m., revealed an open wiring penetration around a blue wire above the exit doors in the boiler room, 1st floor. Interview with the facilities director and facility maintenance representative on May 22, 2024, at 11:30 a.m., confirmed the open wiring penetration. 2. Observation on May 22, 2024, at 11:00 a.m., revealed an open 3 inch square hole in the wall above the door in electrical room 118, on the 1st floor. Interview with the facilities director and facility maintenance representative on May 22, 2024, at 11:30 a.m., confirmed the open penetration of the wall.”

“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: 32692 Based on document review and interview, it was determined the facility failed to maintain one of one kitchen hood suppression systems. Findings include; 1. Document review and interview on May 21, 2024, revealed the facility could not produce documentation that the kitchen hood suppression system had been inspected since June 2023. Interview with the facilities director and facility maintenance representative on May 22, 2024, at 11:30 a.m., confirmed the suppression system inspection was not completed.”

“Corridor - Doors CFR(s): NFPA 101 Doors protecting corridor openings shall be constructed to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have self-latching and 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 18.3.6.3.6 are permitted. 18.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatic closing devices, etc. This Standard is not met as evidenced by: 32692 Based on observation and interview, it was determined the facility failed to maintain corridor doors on two of four floors. Findings include: 1. Observation on May 22, 2024, between 9:00 a.m., and 9:40 a.m., revealed the following; a. At 9:00 a.m., 3rd floor, the double doors at elevator 3 failed to latch. b. At 9:40 a.m., 2nd floor, dining room 267 failed to latch in the frame. Interview with the facilities director and facility maintenance representative on May 22, 2024, at 11:30 a.m., confirmed the doors lacked positive latching.”

“Gas and Vacuum Piped Systems - Other CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Other List in the REMARKS section any NFPA 99 Chapter 5 Gas and Vacuum Systems 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 5 (NFPA 99) This Standard is not met as evidenced by: 32692 Based on observation and interview, it was determined the facility failed to maintain the piped in medical gas system in one of five smoke compartments. Findings include: 1. Observation on May 21, 2024, at 1:34 p.m., revealed steel metallic cabling in contact with the copper medical gas lines above the ceiling near the clean supply room on the 1st floor. Interview with the facilities director and facility maintenance representative on May 22, 2024, at 11:30 a.m., confirmed the dissimilar metal in contact with the copper tubing.”

“Gas and Vacuum Piped Systems - Maintenance Pr CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Maintenance Program Medical gas, vacuum, WAGD, or support gas systems have documented maintenance programs. The program includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets. Inspection and maintenance schedules are established through risk assessment considering manufacturer recommendations. Inspection procedures and testing methods are established through risk assessment. Persons maintaining systems are qualified as demonstrated by training and certification or credentialing to the requirements of AASE 6030 or 6040. 5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14, 5.3.13.4.2 (NFPA 99) This Standard is not met as evidenced by: 32692 Based on observation and interview, it was determined the facility failed to maintain the medical gas system on one of four floors. Findings include: 1. Observation on May 22, 2024, revealed the medical gas alarm panel at the NE nurse station, near room 410, 4th floor was not powered and the display was not showing any function. Interview with the facilities director and facility maintenance representative on May 22, 2024, at 11:30 a.m., confirmed the med-gas alarm panel was not functioning.”

“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: 32692 Based on observation and interview, it was determined the facility failed to maintain power cords in one of five smoke compartments. Findings include: 1. Observation on May 21, 2024, at 1:07 p.m., revealed the bed cord in exam room 2 on the 1st floor was pinched to the floor by the bed. Interview with the facilities director and facility maintenance representative on May 22, 2024, at 11:30 a.m., confirmed the cord was pinched.”