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The facility failed to maintain the smoke barriers per code. Findings include:

During the survey, the following are examples of what was observed:
1. Court Room corridor double doors:
a. The right leaf was not positive latching
b. Were not smoke resistive
2. The following corridor doors had holes in them at the door knobs:
a. Room 418 - Clean Supply Room
b. Room 513 - Group Room for the 500 Hall

____________________

2000 NFPA 101, 18.3.6.3.2 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.

2000 NFPA 101, 18.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.

.

The facility failed to maintain the smoke barriers per code. Findings include:

During the survey, the following are examples of what was observed:
1. The smoke barrier at room 701 (Library) had an approximately 3" hole all the way through both layers of sheetrock.
2. The smoke barrier by room 404 had an unsealed penetration of pink wires.
3. The smoke barrier by the Nurses' Station for 500 Hall had an unsealed penetration of pink wires.

___________________


2000 NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
2000 NFPA 101, 8.2.4.4.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through smoke partitions shall be protected as follows:
(1) The space between the penetrating item and the smoke partition shall meet one of the following conditions:
a. It shall be filled with a material that is capable of limiting the transfer of smoke.
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 partition, the sleeve shall be solidly set in the smoke partition, 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 limiting the transfer of smoke.b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibrations into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke partitions.
b. It shall be made by an approved device that is designed for the specific purpose

.

The facility failed to maintain the smoke doors per code. Findings include:

During the survey, the following are examples of what was observed:
The following smoke doors did not release under activation of the fire alarm:
1. The smoke doors by room 743
2. The smoke doors by room 710

__________________

2000 NFPA 101, 18.2.2.2.6 Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure (except boiler rooms, heater rooms, and mechanical equipment rooms) shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.
.

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

1. The Exit Discharge for the Exit by 600 Hall Dayroom, was not provided with an all weather surface to the public way.

2. The Exit Discharge for the Exit Hall 600, 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.

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


The sensitivity documentation dated 9/26/2011 for the smoke detectors noted the following:

1. Office in room 105 no access to test smoke detector.

2. Room 305 storage room no access to test smoke detector.

3. Room 306 storage no access to test smoke detector.

4. Room 306 no access to test smoke detector.

5. Room 710 storage closet # 2 no access to test smoke detector.

Upon interview with maintenance he could not understand why these detectors were not tested since all areas of the facility is always locked, and they have to provide access during the testing of detectors.

___________________________
Documentation provided by the facility during the survey did not indicate sensitivity testing of the smoke detectors. Detector sensitivity shall be checked with 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).

The facility failed to comply with the required maintenance of the facility sprinkler system. During the survey, the following are examples of what was observed:


1. The fire department connection was not provided with a identification sign.

___________________
NFPA 25, 1998 Edition, 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following: (a) The fire department connections are visible and accessible. (b) Couplings or swivels are not damaged and rotate smoothly. (c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good conition. (e) Identification signs are in place. (f) The check valve is not leaking. (g) The automatic drain valve is in place and operating properly.


27382


2. The facility failed to provide documentation of replacing or calibrating the sprinkler gauges within the last five years.

______________________

1998 NFPA 25, 2-3.2 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.
.

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 designated smoking are was not provided with a metal self-closing container for disposing of cigarette butts and ashes from ashtrays. Also an excessive amount of smoking materials were discarded on the ground in the designated smoking area.

______________________
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.

The facility failed to maintain the dietary hood. Findings include: During the survey, the following are examples of what was observed:

1. Loose/missing caulk in seams of the dietary hood.

2. The filters were not tight fitting or firmly held in place, three of the filters had approximately a 1/4 inch opening between them.

3. The card was blank where the monthly inspection and sign off should have been indicated.

4. The K-extinguisher was not provided with a placard identifying the use of extinguisher.


____________________
NFPA 96, 2-1.2 Internal hood joints, seams, filter support frames, and appendages attached inside the hood need not be welded but shall be sealed or otherwise made grease tight.


NFPA 96, 3-2.3 Grease filters shall be listed and constructed of steel or listed equivalent material and shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions. Filters shall be tight fitting and firmly held in place.


NFPA 17, 9-2.1- On a monthly basis, inspection shall be conducted in accordance with the manufacturer 's listed installation and maintenance manual or owner 's manual. As a minimum, this "quick check " or inspection shall include verification of the following:

(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) The system shows no physical damage or condition that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blow-off caps, where provided, are intact and undamaged.
(h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.


NFPA 96 7-2.1.1 A placard identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system shall be conspicuously placed near each portable fire extinguisher in the cooking area.

Battery-powered lighting at the generator equipment and controls was observed to be inoperable during the survey.

_______________________
1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting.

The facility failed to maintain the generator remote annunciator per code. Findings include:

During the survey, the following are examples of what was observed:
1. The generator remote annunciator's "lamp test" button did not work when tested
2. The generator remote annunciator did not indicate "switch not in auto" when tested
3. The generator remote annunciator did not indicate "EPS supply load" when tested

_____________________

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 maintain the electrical equipment per code. Findings include:

During the survey, the following is an example of what was observed:
The Doctor's Office in the Children's Section (ABS) - room 605 had a microwave plugged into a surge protector

____________________

1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip

The facility failed to maintain the smoke barriers per code. Findings include:

During the survey, the following are examples of what was observed:
1. Court Room corridor double doors:
a. The right leaf was not positive latching
b. Were not smoke resistive
2. The following corridor doors had holes in them at the door knobs:
a. Room 418 - Clean Supply Room
b. Room 513 - Group Room for the 500 Hall

____________________

2000 NFPA 101, 18.3.6.3.2 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.

2000 NFPA 101, 18.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.

.

The facility failed to maintain the smoke barriers per code. Findings include:

During the survey, the following are examples of what was observed:
1. The smoke barrier at room 701 (Library) had an approximately 3" hole all the way through both layers of sheetrock.
2. The smoke barrier by room 404 had an unsealed penetration of pink wires.
3. The smoke barrier by the Nurses' Station for 500 Hall had an unsealed penetration of pink wires.

___________________


2000 NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
2000 NFPA 101, 8.2.4.4.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through smoke partitions shall be protected as follows:
(1) The space between the penetrating item and the smoke partition shall meet one of the following conditions:
a. It shall be filled with a material that is capable of limiting the transfer of smoke.
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 partition, the sleeve shall be solidly set in the smoke partition, 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 limiting the transfer of smoke.b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibrations into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke partitions.
b. It shall be made by an approved device that is designed for the specific purpose

.

The facility failed to maintain the smoke doors per code. Findings include:

During the survey, the following are examples of what was observed:
The following smoke doors did not release under activation of the fire alarm:
1. The smoke doors by room 743
2. The smoke doors by room 710

__________________

2000 NFPA 101, 18.2.2.2.6 Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure (except boiler rooms, heater rooms, and mechanical equipment rooms) shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.
.

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

1. The Exit Discharge for the Exit by 600 Hall Dayroom, was not provided with an all weather surface to the public way.

2. The Exit Discharge for the Exit Hall 600, 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.

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


The sensitivity documentation dated 9/26/2011 for the smoke detectors noted the following:

1. Office in room 105 no access to test smoke detector.

2. Room 305 storage room no access to test smoke detector.

3. Room 306 storage no access to test smoke detector.

4. Room 306 no access to test smoke detector.

5. Room 710 storage closet # 2 no access to test smoke detector.

Upon interview with maintenance he could not understand why these detectors were not tested since all areas of the facility is always locked, and they have to provide access during the testing of detectors.

___________________________
Documentation provided by the facility during the survey did not indicate sensitivity testing of the smoke detectors. Detector sensitivity shall be checked with 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).

The facility failed to comply with the required maintenance of the facility sprinkler system. During the survey, the following are examples of what was observed:


1. The fire department connection was not provided with a identification sign.

___________________
NFPA 25, 1998 Edition, 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following: (a) The fire department connections are visible and accessible. (b) Couplings or swivels are not damaged and rotate smoothly. (c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good conition. (e) Identification signs are in place. (f) The check valve is not leaking. (g) The automatic drain valve is in place and operating properly.


27382


2. The facility failed to provide documentation of replacing or calibrating the sprinkler gauges within the last five years.

______________________

1998 NFPA 25, 2-3.2 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.
.

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 designated smoking are was not provided with a metal self-closing container for disposing of cigarette butts and ashes from ashtrays. Also an excessive amount of smoking materials were discarded on the ground in the designated smoking area.

______________________
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.

The facility failed to maintain the dietary hood. Findings include: During the survey, the following are examples of what was observed:

1. Loose/missing caulk in seams of the dietary hood.

2. The filters were not tight fitting or firmly held in place, three of the filters had approximately a 1/4 inch opening between them.

3. The card was blank where the monthly inspection and sign off should have been indicated.

4. The K-extinguisher was not provided with a placard identifying the use of extinguisher.


____________________
NFPA 96, 2-1.2 Internal hood joints, seams, filter support frames, and appendages attached inside the hood need not be welded but shall be sealed or otherwise made grease tight.


NFPA 96, 3-2.3 Grease filters shall be listed and constructed of steel or listed equivalent material and shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions. Filters shall be tight fitting and firmly held in place.


NFPA 17, 9-2.1- On a monthly basis, inspection shall be conducted in accordance with the manufacturer 's listed installation and maintenance manual or owner 's manual. As a minimum, this "quick check " or inspection shall include verification of the following:

(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) The system shows no physical damage or condition that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blow-off caps, where provided, are intact and undamaged.
(h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.


NFPA 96 7-2.1.1 A placard identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system shall be conspicuously placed near each portable fire extinguisher in the cooking area.

Battery-powered lighting at the generator equipment and controls was observed to be inoperable during the survey.

_______________________
1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting.

The facility failed to maintain the generator remote annunciator per code. Findings include:

During the survey, the following are examples of what was observed:
1. The generator remote annunciator's "lamp test" button did not work when tested
2. The generator remote annunciator did not indicate "switch not in auto" when tested
3. The generator remote annunciator did not indicate "EPS supply load" when tested

_____________________

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 maintain the electrical equipment per code. Findings include:

During the survey, the following is an example of what was observed:
The Doctor's Office in the Children's Section (ABS) - room 605 had a microwave plugged into a surge protector

____________________

1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip