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Based on observations made on January 4 and 5, 2012, the facility failed to maintain the fire resistance rating of two-hour fire barriers and the communicating openings in the barriers.

The findings include:

1. The one and one-half hour fire rated door between the Laboratory waiting room and the Doctor's lounge area of the Clinic was exercised at 3:33 p.m. on January 4, 2012. The door did not close and latch with the efforts of the self-closing device.

2. The two-hour wall assembly above the suspended ceiling of the fire rated doorway between the Laboratory waiting room and the Doctor's lounge of the Clinic was examined at 8:49 a.m. on January 5, 2012. An open penetration for wiring and IT cable was found to be unsealed. A fire rated material for use in two-hour walls must be used to seal this penetration on both sides of the barrier wall.

Based on observations made on January 4 and 5, 2012, the facility failed to maintain the fire resistive rating and construction of ceiling, floor and wall assemblies.

The findings include:

1. The room currently housing the IT functions and wiring was examined at 3:20 p.m. on January 4, 2012. There were four unsealed holes in the east wall assembly of the room.

2. The remote annunciator for the generator located at the nurse's station was examined at 3:50 p.m. on January 4, 2012. Two unsealed holes were observed to be around the edges of the annunciator panel.

3. Due to damage from one of the cross-corridor doors by the Emergency Room waiting area there was an open hole punched through the wall assembly by the fire extinguisher cabinet in the corridor as observed at 4:05 p.m. on January 4, 2012.

4. The room housing the Autoclave was examined at 7:50 a.m. on January 5, 2012. A pipe running from the crawl space below and through the ceiling assembly of this room did not have the open penetrations around it sealed completely in either the floor or ceiling assemblies.

5. The medical records dead file room was examined at 7:52 a.m. on January 5, 2012. A hole in the upper portion of the south wall of this room around a drain pipe was unsealed.

6. The room identified as the storage/soda pop room by the lounge on the east portion of the facility was examined at 8:00 a.m. on January 5, 2012. An open hole near a junction box in the upper porting of the south wall of this room was unsealed.

Based on observations made on January 4 and 5, 2012, the facility failed to provide a number of corridor doors with a means suitable for keeping the door closed, failed to assure that there was no impediment to closing corridor doors and failed to assure that corridor doors were capable of being opened completely for means of egress.

The findings include:

1. During the course of the survey and tour of the building on both January 4 and 5, 2012, numerous corridor doors were found to have latching hardware installed but lacked the strike plate to effect a positive latch when closed. The corridor doors to the following rooms lacked a strike plate:
a) Room 110.
b) Room 111.
c) Room 112.
d) Room 114.
e) Room 115.
f) The anteroom to room 117.
g) Room 118.
h) Room 119.
i) Room 120.
j) Room 130.
k) Room 131.
l) Room 132.
m) Room 134.
n) Room 135.
o) Room 136.

2. Three corridor doors to rooms had dead bolt lock mechanisms installed as the latching hardware on these doors. The doors lacked a positive latching hardware device suitable to keep the doors closed whenever the dead bolt locks were in the recessed position. Unless all staff carry a key to secure the dead bolt locks in case of a fire emergency the doors shall have other latching hardware that does not require special knowledge or keys to keep the door closed. The three doors with dead bolt only hardware were:
a) The two doors to the Marketing offices as observed at 3:14 p.m. on January 4, 2012.
b) The door to the X-Ray Tech sleeping room as observed at 3:36 p.m. on January 4, 2012.

Whenever a door or window opening is no longer in use, the opening shall be filled with construction equivalent to that of the wall per section 15-1.1 of NFPA 80, 1999 Edition.

3. The east door of the set of doors to the Marketing offices was observed to have items stored against it at 3:14 p.m. on January 4, 2012 . These items inhibited the door from being used as a means of egress. The items must be removed so no impediment exist and opening the door or the door, if no longer considered to be in use, filled with construction to meet the one-hour rating of the corridor wall.

4. An exercise pulley system used for physical therapy was attached to the top of the corridor door to the Physical Therapy room as observed at 7:42 a.m. on January 5, 2012. The attachment impeded the door from closing and latching. Note: The device was removed from the door to allow it to close and latch after the observation was made and confirmed by the surveyor while on-site.

Any door in a means of egress shall be of the side-hinged or pivoted-swinging type. The door shall be designed and installed so that it is capable of swinging from any position to the full required width of the opening in which it is installed per section 7.2.1.4.1 of the Life Safety Code.

5. The east corridor door of the autoclave/storage room had items stored on a shelf unit next to the door that protruded into the swing of that door and prevented it from opening 90? to its full width as observed at 7:50 a.m. on January 5, 2012.

Based on observations made on January 5, 2012, the facility failed to maintain the fire resistive rating of smoke barriers.

The findings include:

In accordance with NFPA 101 Life Safety Code, 2000 Edition and Section 8.3.6.1
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

The smoke barrier above the suspended ceiling of the conference room was examined at 8:47 a.m. on January 5, 2012. In the west wall of this smoke barrier two open holes were observed. One was a square hole for a flexible conduit and the other was a rectangular hole for a 2-inch conduit. An acceptable fire stop material of at least 1/2 hour shall be applied to the penetrations per the requirements of the manufacturer.

Based on observations made on January 4, 2012, the facility failed to assure that smoke barrier doors closed tightly to prevent the passage of smoke.

The findings include:

The set of smoke barrier doors in the corridor outside of the conference room were exercised at 3:57 p.m. on January 4, 2012. The doors were equipped with latching hardware. Although not required, the latching hardware has the ability to interfere with the door closing tightly if not functioning properly. One of the set of doors recoiled from its latching mechanism when exercised and did not close tightly to resist the passage of smoke.

Based on observations made on January 5, 2012, the facility failed to assure that lighting was maintained and provided so as not to leave exit discharges in darkness.

The findings include:

1. The exit discharge from the wing north of the nurse's station was examined at 7:20 a.m. on January 5, 2012. Sunrise was at 7:52 a.m. Mountain Standard Time and the area was still in darkness at the time of the observation. The exit discharge had a motion detector light fixture to provide illumination and when tested the light did come on, thus leaving the exit discharge in the dark.

2. The exit discharge from the north wing of what had been previously the Long Term Care portion of the building was examined at 7:22 a.m. on January 5, 2012. Sunrise was at 7:52 a.m. Mountain Standard Time and the area was still in darkness at the time of the observation. The exit discharge had a two-bulb light fixture to provide illumination and at the time of the observation both bulbs were not working, thus leaving the exit discharge in the dark.

Based on review of the maintenance records for the generator and other maintenance logs on January 4, 2012, the facility failed to provide written documentation that battery-powered emergency lights were being tested on a monthly and annual basis.

The findings include:

A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds per section 7.9.3 of the Life Safety Code . An annual test shall be conducted on every required battery-powered emergency lighting system for not less than one and one-half hours (90 minutes). 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.

The maintenance records for the generator and other maintenance logs were reviewed at the facility on January 4, 2012. A battery-powered emergency light was in use in the boiler room illuminating the transfer switch, the kill switch for the generator and the area of the exit stairway from the boiler room to the exterior. No written documentation was available that this light fixture was tested on a monthly or annual basis.

Based on observations made on January 5, 2012, the facility failed to assure that the addresses for initiation devices for the fire alarm system corresponded to the correct locations within the building.

The findings include:

A fire drill was conducted at 9:37 a.m. on January 5, 2012. A pull station on the wing to the north of the nurse's station was activated to initiate the drill. The addressable fire alarm panel showed that the alarm initiated in the "West Hall" and staff were directed to that corridor to perform the "RACE" functions including closing the corridor doors and bringing fire extinguishers to that area. The staff did not respond to the north hall where the pull station was activated due to their interpretation that the west corridor was the zone where the fire was reported. The fire alarm panel must identify by zone or other means the correct location of the initiation device so that confusion as to the location of the fire does not occur.

Based on observations made on January 4, 2012, the facility failed to assure that there was no obstruction to the coverage pattern or area of a sprinkler.

The findings include:

The kitchen pantry room was examined at 2:35 p.m. on January 4, 2012. A sprinkler was located high in the ceiling portion of the room and in close proximity to two ducts on either side of it. Because of the height of the sprinkler and the location of the ducts the sprinkler was obstructed from providing full coverage for all items stored in this room.

Based on observations made on January 4, 2012, the facility failed to maintain fire extinguishers in accordance with the standards of NFPA 10, 1998 Edition.

The findings include:

Fire extinguishers mounted in cabinets or wall recesses shall be placed so that the fire extinguisher operating instructions face outward. The location of such fire extinguishers shall be marked conspicuously per section 1-6.12 of NFPA 10.

1. The cabinet housing the Fire Alarm Control Panel was originally a fire extinguisher and fire hose cabinet. Although the cabinet still contains a fire extinguisher as observed at 3:27 p.m. on January 4, 2012, there was no sign or marking on the outside door of the cabinet that a fire extinguisher was accessible or located within that cabinet for use.

Every 6 years, stored-pressure fire extinguishers that require a 12-year hydrostatic test shall be emptied and subjected to the applicable maintenance procedures per sections 4-4.3, 4-4.4, 4-4.4.1 and 4-4.4.2 of NFPA 10. When the applicable maintenance procedures are performed during periodic recharging or hydrostatic testing, the 6-year requirement shall begin from that date. At intervals not exceeding those specified in Table 5-2 of NFPA 10, fire extinguishers shall be hydrostatically retested per section 5-2 of NFPA 10. Extinguishers that pass both 6-year test and the hydrostatic retest shall have the maintenance information recorded on a label securely affixed to the shell showing month and year of the service, the name or initials of the person performing the work and the name of the agency performing the maintenance. Each extinguisher that has undergone maintenance that includes internal examination or that has been recharged shall have a " Verification of Service " collar located around the neck of the container.

2. A Halon extinguisher was located in the Laboratory as observed at 3:30 p.m. on January 4, 2012. The extinguisher had two service labels on it. One was for a six year service in 1991 and the other was for hydrostatic retesting in 1997. There were no other labels verifying as to whether the subsequent six year maintenance due in 2003 or the subsequent hydrostatic retesting due in 2009 were performed.

Based on observations made on January 5, 2012, the facility failed to assure that all hanging curtains or valances were flame resistant in accordance with NFPA 701, 1999 Edition.

The findings include:

1. The valance hung at the doorway of room 135 was examined at 7:45 a.m. on January 5, 2012. There was no label or tag attached to the valance attesting to it being flame resistant or having been treated with a flame resistant product made for application to fabrics.

2. The green curtains hung in the windows of room 136 were examined at 7:47 a.m. on January 5, 2012. There was no label or tag attached to the curtains attesting to their being flame resistant or having been treated with a flame resistant product made for application to fabrics.

3. The brown curtains hung in the windows of room 132 were examined at 7:54 a.m. on January 5, 2012. There was no label or tag attached to the curtains attesting to their being flame resistant or having been treated with a flame resistant product made for application to fabrics.

4. The white curtains hung in the windows of room 130 were examined at 7:57 a.m. on January 5, 2012. There was no label or tag attached to the curtains attesting to their being flame resistant or having been treated with a flame resistant product made for application to fabrics.

5. The flower design curtains hung in the windows of room 138 were examined at 8:11 a.m. on January 5, 2012. There was no label or tag attached to the curtains attesting to their being flame resistant or having been treated with a flame resistant product made for application to fabrics.

Based on review of the generator testing and inspection logs on January 4, 2012, the facility failed to document that the weekly inspection of the generator was conducted in accordance with NFPA 99 standards.

The findings include:

A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction per section 3-4.4.2 of NFPA 99, 1999 Edition.

The generator testing and inspection logs were reviewed at the facility on January 4, 2012. The monthly load tests were documented and current on a log sheet. Although the generator was run on a weekly schedule each Monday per the timer set in the transfer switch control panel, there was no written record that weekly inspections were being performed.

Based on observations made on January 4 and 5, 2012, the facility failed to maintain the electrical system and/or its components in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition, the standards of NFPA 99, 1999 Edition and/or interpretations from the Centers for Medicare and Medicaid Services (CMS).

The findings include:

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4(b)(3) of NFPA 70 and 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99. The limited use of circuit breaker protected power strips is acceptable provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to a power strip (these items must be directly connected to an appropriate receptacle).

1. A small dorm type refrigerator was in use in the Medical Records Department Head office as observed at 2:48 p.m. on January 4, 2012. The refrigerator was plugged into a power strip.

2. Room 135 was examined at 7:45 a.m. on January 5, 2012. Two items were observed in this room:
a) An extension cord, without built-in circuit breaker protection, was in use servicing a fan. Note: The extension cord was removed from the room after the observation was made and confirmed by the surveyor while on-site.
b) An oxygen concentrator was plugged into a power strip.

Each disconnecting means and each service at the point where it originates shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident per Article 110-22 of NFPA 70.

3. Panel board "A" located in a closet of the X-Ray area was examined at 3:39 p.m. on January 4, 2012. The sheet listing the services for all the breakers in the panel was missing.

Based on observations made on January 4 and 5, 2012, the facility failed to maintain the fire resistance rating of two-hour fire barriers and the communicating openings in the barriers.

The findings include:

1. The one and one-half hour fire rated door between the Laboratory waiting room and the Doctor's lounge area of the Clinic was exercised at 3:33 p.m. on January 4, 2012. The door did not close and latch with the efforts of the self-closing device.

2. The two-hour wall assembly above the suspended ceiling of the fire rated doorway between the Laboratory waiting room and the Doctor's lounge of the Clinic was examined at 8:49 a.m. on January 5, 2012. An open penetration for wiring and IT cable was found to be unsealed. A fire rated material for use in two-hour walls must be used to seal this penetration on both sides of the barrier wall.

Based on observations made on January 4 and 5, 2012, the facility failed to maintain the fire resistive rating and construction of ceiling, floor and wall assemblies.

The findings include:

1. The room currently housing the IT functions and wiring was examined at 3:20 p.m. on January 4, 2012. There were four unsealed holes in the east wall assembly of the room.

2. The remote annunciator for the generator located at the nurse's station was examined at 3:50 p.m. on January 4, 2012. Two unsealed holes were observed to be around the edges of the annunciator panel.

3. Due to damage from one of the cross-corridor doors by the Emergency Room waiting area there was an open hole punched through the wall assembly by the fire extinguisher cabinet in the corridor as observed at 4:05 p.m. on January 4, 2012.

4. The room housing the Autoclave was examined at 7:50 a.m. on January 5, 2012. A pipe running from the crawl space below and through the ceiling assembly of this room did not have the open penetrations around it sealed completely in either the floor or ceiling assemblies.

5. The medical records dead file room was examined at 7:52 a.m. on January 5, 2012. A hole in the upper portion of the south wall of this room around a drain pipe was unsealed.

6. The room identified as the storage/soda pop room by the lounge on the east portion of the facility was examined at 8:00 a.m. on January 5, 2012. An open hole near a junction box in the upper porting of the south wall of this room was unsealed.

Based on observations made on January 4 and 5, 2012, the facility failed to provide a number of corridor doors with a means suitable for keeping the door closed, failed to assure that there was no impediment to closing corridor doors and failed to assure that corridor doors were capable of being opened completely for means of egress.

The findings include:

1. During the course of the survey and tour of the building on both January 4 and 5, 2012, numerous corridor doors were found to have latching hardware installed but lacked the strike plate to effect a positive latch when closed. The corridor doors to the following rooms lacked a strike plate:
a) Room 110.
b) Room 111.
c) Room 112.
d) Room 114.
e) Room 115.
f) The anteroom to room 117.
g) Room 118.
h) Room 119.
i) Room 120.
j) Room 130.
k) Room 131.
l) Room 132.
m) Room 134.
n) Room 135.
o) Room 136.

2. Three corridor doors to rooms had dead bolt lock mechanisms installed as the latching hardware on these doors. The doors lacked a positive latching hardware device suitable to keep the doors closed whenever the dead bolt locks were in the recessed position. Unless all staff carry a key to secure the dead bolt locks in case of a fire emergency the doors shall have other latching hardware that does not require special knowledge or keys to keep the door closed. The three doors with dead bolt only hardware were:
a) The two doors to the Marketing offices as observed at 3:14 p.m. on January 4, 2012.
b) The door to the X-Ray Tech sleeping room as observed at 3:36 p.m. on January 4, 2012.

Whenever a door or window opening is no longer in use, the opening shall be filled with construction equivalent to that of the wall per section 15-1.1 of NFPA 80, 1999 Edition.

3. The east door of the set of doors to the Marketing offices was observed to have items stored against it at 3:14 p.m. on January 4, 2012 . These items inhibited the door from being used as a means of egress. The items must be removed so no impediment exist and opening the door or the door, if no longer considered to be in use, filled with construction to meet the one-hour rating of the corridor wall.

4. An exercise pulley system used for physical therapy was attached to the top of the corridor door to the Physical Therapy room as observed at 7:42 a.m. on January 5, 2012. The attachment impeded the door from closing and latching. Note: The device was removed from the door to allow it to close and latch after the observation was made and confirmed by the surveyor while on-site.

Any door in a means of egress shall be of the side-hinged or pivoted-swinging type. The door shall be designed and installed so that it is capable of swinging from any position to the full required width of the opening in which it is installed per section 7.2.1.4.1 of the Life Safety Code.

5. The east corridor door of the autoclave/storage room had items stored on a shelf unit next to the door that protruded into the swing of that door and prevented it from opening 90? to its full width as observed at 7:50 a.m. on January 5, 2012.

Based on observations made on January 5, 2012, the facility failed to maintain the fire resistive rating of smoke barriers.

The findings include:

In accordance with NFPA 101 Life Safety Code, 2000 Edition and Section 8.3.6.1
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

The smoke barrier above the suspended ceiling of the conference room was examined at 8:47 a.m. on January 5, 2012. In the west wall of this smoke barrier two open holes were observed. One was a square hole for a flexible conduit and the other was a rectangular hole for a 2-inch conduit. An acceptable fire stop material of at least 1/2 hour shall be applied to the penetrations per the requirements of the manufacturer.

Based on observations made on January 4, 2012, the facility failed to assure that smoke barrier doors closed tightly to prevent the passage of smoke.

The findings include:

The set of smoke barrier doors in the corridor outside of the conference room were exercised at 3:57 p.m. on January 4, 2012. The doors were equipped with latching hardware. Although not required, the latching hardware has the ability to interfere with the door closing tightly if not functioning properly. One of the set of doors recoiled from its latching mechanism when exercised and did not close tightly to resist the passage of smoke.

Based on observations made on January 5, 2012, the facility failed to assure that lighting was maintained and provided so as not to leave exit discharges in darkness.

The findings include:

1. The exit discharge from the wing north of the nurse's station was examined at 7:20 a.m. on January 5, 2012. Sunrise was at 7:52 a.m. Mountain Standard Time and the area was still in darkness at the time of the observation. The exit discharge had a motion detector light fixture to provide illumination and when tested the light did come on, thus leaving the exit discharge in the dark.

2. The exit discharge from the north wing of what had been previously the Long Term Care portion of the building was examined at 7:22 a.m. on January 5, 2012. Sunrise was at 7:52 a.m. Mountain Standard Time and the area was still in darkness at the time of the observation. The exit discharge had a two-bulb light fixture to provide illumination and at the time of the observation both bulbs were not working, thus leaving the exit discharge in the dark.

Based on review of the maintenance records for the generator and other maintenance logs on January 4, 2012, the facility failed to provide written documentation that battery-powered emergency lights were being tested on a monthly and annual basis.

The findings include:

A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds per section 7.9.3 of the Life Safety Code . An annual test shall be conducted on every required battery-powered emergency lighting system for not less than one and one-half hours (90 minutes). 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.

The maintenance records for the generator and other maintenance logs were reviewed at the facility on January 4, 2012. A battery-powered emergency light was in use in the boiler room illuminating the transfer switch, the kill switch for the generator and the area of the exit stairway from the boiler room to the exterior. No written documentation was available that this light fixture was tested on a monthly or annual basis.

Based on observations made on January 5, 2012, the facility failed to assure that the addresses for initiation devices for the fire alarm system corresponded to the correct locations within the building.

The findings include:

A fire drill was conducted at 9:37 a.m. on January 5, 2012. A pull station on the wing to the north of the nurse's station was activated to initiate the drill. The addressable fire alarm panel showed that the alarm initiated in the "West Hall" and staff were directed to that corridor to perform the "RACE" functions including closing the corridor doors and bringing fire extinguishers to that area. The staff did not respond to the north hall where the pull station was activated due to their interpretation that the west corridor was the zone where the fire was reported. The fire alarm panel must identify by zone or other means the correct location of the initiation device so that confusion as to the location of the fire does not occur.

Based on observations made on January 4, 2012, the facility failed to assure that there was no obstruction to the coverage pattern or area of a sprinkler.

The findings include:

The kitchen pantry room was examined at 2:35 p.m. on January 4, 2012. A sprinkler was located high in the ceiling portion of the room and in close proximity to two ducts on either side of it. Because of the height of the sprinkler and the location of the ducts the sprinkler was obstructed from providing full coverage for all items stored in this room.

Based on observations made on January 4, 2012, the facility failed to maintain fire extinguishers in accordance with the standards of NFPA 10, 1998 Edition.

The findings include:

Fire extinguishers mounted in cabinets or wall recesses shall be placed so that the fire extinguisher operating instructions face outward. The location of such fire extinguishers shall be marked conspicuously per section 1-6.12 of NFPA 10.

1. The cabinet housing the Fire Alarm Control Panel was originally a fire extinguisher and fire hose cabinet. Although the cabinet still contains a fire extinguisher as observed at 3:27 p.m. on January 4, 2012, there was no sign or marking on the outside door of the cabinet that a fire extinguisher was accessible or located within that cabinet for use.

Every 6 years, stored-pressure fire extinguishers that require a 12-year hydrostatic test shall be emptied and subjected to the applicable maintenance procedures per sections 4-4.3, 4-4.4, 4-4.4.1 and 4-4.4.2 of NFPA 10. When the applicable maintenance procedures are performed during periodic recharging or hydrostatic testing, the 6-year requirement shall begin from that date. At intervals not exceeding those specified in Table 5-2 of NFPA 10, fire extinguishers shall be hydrostatically retested per section 5-2 of NFPA 10. Extinguishers that pass both 6-year test and the hydrostatic retest shall have the maintenance information recorded on a label securely affixed to the shell showing month and year of the service, the name or initials of the person performing the work and the name of the agency performing the maintenance. Each extinguisher that has undergone maintenance that includes internal examination or that has been recharged shall have a " Verification of Service " collar located around the neck of the container.

2. A Halon extinguisher was located in the Laboratory as observed at 3:30 p.m. on January 4, 2012. The extinguisher had two service labels on it. One was for a six year service in 1991 and the other was for hydrostatic retesting in 1997. There were no other labels verifying as to whether the subsequent six year maintenance due in 2003 or the subsequent hydrostatic retesting due in 2009 were performed.

Based on observations made on January 5, 2012, the facility failed to assure that all hanging curtains or valances were flame resistant in accordance with NFPA 701, 1999 Edition.

The findings include:

1. The valance hung at the doorway of room 135 was examined at 7:45 a.m. on January 5, 2012. There was no label or tag attached to the valance attesting to it being flame resistant or having been treated with a flame resistant product made for application to fabrics.

2. The green curtains hung in the windows of room 136 were examined at 7:47 a.m. on January 5, 2012. There was no label or tag attached to the curtains attesting to their being flame resistant or having been treated with a flame resistant product made for application to fabrics.

3. The brown curtains hung in the windows of room 132 were examined at 7:54 a.m. on January 5, 2012. There was no label or tag attached to the curtains attesting to their being flame resistant or having been treated with a flame resistant product made for application to fabrics.

4. The white curtains hung in the windows of room 130 were examined at 7:57 a.m. on January 5, 2012. There was no label or tag attached to the curtains attesting to their being flame resistant or having been treated with a flame resistant product made for application to fabrics.

5. The flower design curtains hung in the windows of room 138 were examined at 8:11 a.m. on January 5, 2012. There was no label or tag attached to the curtains attesting to their being flame resistant or having been treated with a flame resistant product made for application to fabrics.

Based on review of the generator testing and inspection logs on January 4, 2012, the facility failed to document that the weekly inspection of the generator was conducted in accordance with NFPA 99 standards.

The findings include:

A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction per section 3-4.4.2 of NFPA 99, 1999 Edition.

The generator testing and inspection logs were reviewed at the facility on January 4, 2012. The monthly load tests were documented and current on a log sheet. Although the generator was run on a weekly schedule each Monday per the timer set in the transfer switch control panel, there was no written record that weekly inspections were being performed.

Based on observations made on January 4 and 5, 2012, the facility failed to maintain the electrical system and/or its components in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition, the standards of NFPA 99, 1999 Edition and/or interpretations from the Centers for Medicare and Medicaid Services (CMS).

The findings include:

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4(b)(3) of NFPA 70 and 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99. The limited use of circuit breaker protected power strips is acceptable provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to a power strip (these items must be directly connected to an appropriate receptacle).

1. A small dorm type refrigerator was in use in the Medical Records Department Head office as observed at 2:48 p.m. on January 4, 2012. The refrigerator was plugged into a power strip.

2. Room 135 was examined at 7:45 a.m. on January 5, 2012. Two items were observed in this room:
a) An extension cord, without built-in circuit breaker protection, was in use servicing a fan. Note: The extension cord was removed from the room after the observation was made and confirmed by the surveyor while on-site.
b) An oxygen concentrator was plugged into a power strip.

Each disconnecting means and each service at the point where it originates shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident per Article 110-22 of NFPA 70.

3. Panel board "A" located in a closet of the X-Ray area was examined at 3:39 p.m. on January 4, 2012. The sheet listing the services for all the breakers in the panel was missing.