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The facility failed to maintain the permitted building construction type per code. Findings include:

During the survey, the following is an example of what was observed:
The one hour ceiling membrane had an unsealed penetration in it in the Fire Alarm Panel Closet.

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2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
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The facility failed to maintain the corridor openings per code. Findings include:

During the survey, the following are examples of what was observed:
1. Storage Room by the Whirlpool Room - could not close the corridor door due an object inside the room blocking the swing of the door.
2. Storage Room at the Business Office - the corridor door was not positive latching
3. Medical Waste Room - corridor door did not have positive latching hardware
4. Storage Room at Kitchen Exit - corridor door did not have positive latching hardware
5. Kitchen corridor door was not positive latching
6. Radiology Office corridor door had a self-closing device, but was being held open by a wedge

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2007 CMS - 2786R There is no impediment to the closing of the corridor doors.

2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
2000 NFPA 101, 19.3.6.3.3 Hold-open devices that release when the door is pushed or pulled shall be permitted.
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The facility failed to maintain the hazardous areas per code. Findings include:

During the survey, the following are examples of what was observed:
The following storage rooms with combustibles, over 50 sq. ft. were observed without 45 minute fire rated doors and the doors did not have self-closing devices:
1. Insurance Office/File Storage Room
2. Medical Records Storage Room

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2000 NFPA 101, 8.4.1.3 Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.
2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

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A) The facility failed to provide a reliable means of egress to the public way. findings include: During the survey, the following are examples of what was observed:

1. The Exit Discharge for the Exit by Patient Room 119, was not provided with an all weather surface to the public way.

2. The Exit Discharge for the Exit by the Lab, was not provided with an all weather surface to the public way.
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NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

NFPA 101, A.7.1.10.1 *A proper means of egress allows unobstructed travel at all times. Any type of barrier including, but not limited to, the accumulations of snow and ice in those climates subject to such accumulations is an impediment to free movement in the means of egress.


27382


B) The facility failed to maintain the exit access per code. Findings include:
During the survey, the following are examples of what was observed:
The following corridor doors when fully opened projected more than 7" into the corridor:
3. Storage Room next to Pharmacy
4. Fire Alarm Panel Closet
5. Nursing Supply Closet next to the Fire Alarm Panel Closet
6. Storage Room #1 across from Central Supply
7. Storage Room #2 across from Central Supply
8. Men's and Ladies' Restrooms across from Central Supply
9. E.R. Bathroom

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2000 NFPA 101, 7.2.1.4.4 During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 in. (17.8 cm) into the required width of an aisle, corridor, passageway, or landing, when fully open. Doors shall not open directly onto a stair without a landing. The landing shall have a width not less than the width of the door. (See 7.2.1.3.)
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The facility failed to conduct fire drills per code. Findings include:

During the survey, the following is an example of what was observed:
The facility did not conduct fire drills for the first or second shift (facility only has two shifts) for the first quarter of 2012, the facility did an in-service during this quarter

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2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
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The facility failed to perform sensitivity testing of the smoke detectors. Findings include: During the survey, the following is an example of what was observed:


Documentation provided during the survey indicated last sensitivity test of the smoke detectors were conducted on 2/6/2009.
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Detector sensitivity shall be checked one year after installation and every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).
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The facility failed to maintain the fire extinguishers per code. Findings include:

During the survey, the following is an example of what was observed:
Fire extinguishers throughout the facility were mounted approximately 6'-0" from the floor.
_________________
1998 NFPA 10, 1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 31/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).
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The facility failed to provide metal self-closing containers for disposing of cigarette butts and ashes from ashtrays. Findings include: During the survey, the following is an example of what was observed:

The facility has two designated smoking areas, one by the deliveries door, the other by the front entrance to the facility. Neither location was provide with noncombustible ashtrays, or metal containers with self-closing cover devices. Smoking materials were observed by this surveyor discarded on the ground.

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NFPA 101, 19.7.4 Ashtrays of noncombustible material and safe design, and metal self-closing containers for disposing of cigarette butts and ashes from ashtrays, shall be provided.
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The facility failed to adequately perform testing and inspection of the dietary hood
extinguishment system. Findings include: During the survey, the following is an example of what was observed:


Documentation provided by the facility during the survey indicated inspection of the dietary hood extinguishment system during the preceding twelve months was conducted on 1/30/2012, the facility provided an invoice which indicated service was conducted on 7/19/2011. But could not provide the inspection report.

____________________
NFPA 17, 9-3 and 1998 NFPA 17a, 5-3 Require inspection and servicing at least every six months by properly trained and qualified persons.
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The facility failed to prohibit portable space heating devices per code. Findings include:

During the survey, the following is an example of what was observed:
Administrator's Office had a portable heating device, that was not plugged in at the time of the survey, but had been used in the past colder months.

_________________

2000 NFPA 101, 19.7.8 Portable space-heating devices shall be prohibited in all health care occupancies.
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The facility failed to maintain the curtains/draperies per code. Findings include:

During the survey, the following is an example of what was observed:
The facility failed to provide flame resistant documentation on the curtains in Medical Records.

____________________
2000 NFPA 101, 10.3.1 Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

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The facility failed to provide the emergency generator with a remote annunciator per code. Findings include: During the survey, the following is an example of what was observed:

The generator is equiped with the annunciator to read all required functions of the generator, at the generator panel.
__________________
1999 NFPA 99, 3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.) The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows: (a) Individual visual signals shall indicate the following: 1. When the emergency or auxiliary power source is operating to supply power to load 2. When the battery charger is malfunctioning (b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following: 1. Low lubricating oil pressure 2. Low water temperature (below those required in 3-4.1.1.9) 3. Excessive water temperature 4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply 5. Overcrank (failed to start) 6. Overspeed Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]
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The facility failed to provide receptacles for appliances. Findings include: During the survey, the following is an example of what was observed:


A junction box was missing the cover in the riser room.
_____________________
1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.
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The facility failed to maintain the permitted building construction type per code. Findings include:

During the survey, the following is an example of what was observed:
The one hour ceiling membrane had an unsealed penetration in it in the Fire Alarm Panel Closet.

_____________________

2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
.

.
The facility failed to maintain the corridor openings per code. Findings include:

During the survey, the following are examples of what was observed:
1. Storage Room by the Whirlpool Room - could not close the corridor door due an object inside the room blocking the swing of the door.
2. Storage Room at the Business Office - the corridor door was not positive latching
3. Medical Waste Room - corridor door did not have positive latching hardware
4. Storage Room at Kitchen Exit - corridor door did not have positive latching hardware
5. Kitchen corridor door was not positive latching
6. Radiology Office corridor door had a self-closing device, but was being held open by a wedge

__________________
2007 CMS - 2786R There is no impediment to the closing of the corridor doors.

2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
2000 NFPA 101, 19.3.6.3.3 Hold-open devices that release when the door is pushed or pulled shall be permitted.
.

.
The facility failed to maintain the hazardous areas per code. Findings include:

During the survey, the following are examples of what was observed:
The following storage rooms with combustibles, over 50 sq. ft. were observed without 45 minute fire rated doors and the doors did not have self-closing devices:
1. Insurance Office/File Storage Room
2. Medical Records Storage Room

________________
2000 NFPA 101, 8.4.1.3 Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.
2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

.

.
A) The facility failed to provide a reliable means of egress to the public way. findings include: During the survey, the following are examples of what was observed:

1. The Exit Discharge for the Exit by Patient Room 119, was not provided with an all weather surface to the public way.

2. The Exit Discharge for the Exit by the Lab, was not provided with an all weather surface to the public way.
____________________
NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

NFPA 101, A.7.1.10.1 *A proper means of egress allows unobstructed travel at all times. Any type of barrier including, but not limited to, the accumulations of snow and ice in those climates subject to such accumulations is an impediment to free movement in the means of egress.


27382


B) The facility failed to maintain the exit access per code. Findings include:
During the survey, the following are examples of what was observed:
The following corridor doors when fully opened projected more than 7" into the corridor:
3. Storage Room next to Pharmacy
4. Fire Alarm Panel Closet
5. Nursing Supply Closet next to the Fire Alarm Panel Closet
6. Storage Room #1 across from Central Supply
7. Storage Room #2 across from Central Supply
8. Men's and Ladies' Restrooms across from Central Supply
9. E.R. Bathroom

___________________
2000 NFPA 101, 7.2.1.4.4 During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 in. (17.8 cm) into the required width of an aisle, corridor, passageway, or landing, when fully open. Doors shall not open directly onto a stair without a landing. The landing shall have a width not less than the width of the door. (See 7.2.1.3.)
.

.
The facility failed to conduct fire drills per code. Findings include:

During the survey, the following is an example of what was observed:
The facility did not conduct fire drills for the first or second shift (facility only has two shifts) for the first quarter of 2012, the facility did an in-service during this quarter

________________
2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
.

.
The facility failed to perform sensitivity testing of the smoke detectors. Findings include: During the survey, the following is an example of what was observed:


Documentation provided during the survey indicated last sensitivity test of the smoke detectors were conducted on 2/6/2009.
_____________________
Detector sensitivity shall be checked one year after installation and every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).
.

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The facility failed to maintain the fire extinguishers per code. Findings include:

During the survey, the following is an example of what was observed:
Fire extinguishers throughout the facility were mounted approximately 6'-0" from the floor.
_________________
1998 NFPA 10, 1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 31/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).
.

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The facility failed to provide metal self-closing containers for disposing of cigarette butts and ashes from ashtrays. Findings include: During the survey, the following is an example of what was observed:

The facility has two designated smoking areas, one by the deliveries door, the other by the front entrance to the facility. Neither location was provide with noncombustible ashtrays, or metal containers with self-closing cover devices. Smoking materials were observed by this surveyor discarded on the ground.

____________________
NFPA 101, 19.7.4 Ashtrays of noncombustible material and safe design, and metal self-closing containers for disposing of cigarette butts and ashes from ashtrays, shall be provided.
.

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The facility failed to adequately perform testing and inspection of the dietary hood
extinguishment system. Findings include: During the survey, the following is an example of what was observed:


Documentation provided by the facility during the survey indicated inspection of the dietary hood extinguishment system during the preceding twelve months was conducted on 1/30/2012, the facility provided an invoice which indicated service was conducted on 7/19/2011. But could not provide the inspection report.

____________________
NFPA 17, 9-3 and 1998 NFPA 17a, 5-3 Require inspection and servicing at least every six months by properly trained and qualified persons.
.

.
The facility failed to prohibit portable space heating devices per code. Findings include:

During the survey, the following is an example of what was observed:
Administrator's Office had a portable heating device, that was not plugged in at the time of the survey, but had been used in the past colder months.

_________________

2000 NFPA 101, 19.7.8 Portable space-heating devices shall be prohibited in all health care occupancies.
.

.
The facility failed to maintain the curtains/draperies per code. Findings include:

During the survey, the following is an example of what was observed:
The facility failed to provide flame resistant documentation on the curtains in Medical Records.

____________________
2000 NFPA 101, 10.3.1 Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

.

.
The facility failed to provide the emergency generator with a remote annunciator per code. Findings include: During the survey, the following is an example of what was observed:

The generator is equiped with the annunciator to read all required functions of the generator, at the generator panel.
__________________
1999 NFPA 99, 3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.) The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows: (a) Individual visual signals shall indicate the following: 1. When the emergency or auxiliary power source is operating to supply power to load 2. When the battery charger is malfunctioning (b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following: 1. Low lubricating oil pressure 2. Low water temperature (below those required in 3-4.1.1.9) 3. Excessive water temperature 4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply 5. Overcrank (failed to start) 6. Overspeed Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]
.

.
The facility failed to provide receptacles for appliances. Findings include: During the survey, the following is an example of what was observed:


A junction box was missing the cover in the riser room.
_____________________
1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.
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