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The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include: During the survey, the following are examples of what was observed:

1. The shower room door failed to close tight and positive latch by Patient Room 170 in the Special Care Unit. This door opens into the corridor, and is equipped with positive latching hardware just failed to latch.

2. The supply room door which is a dutch door, when this surveyor advised maintenance to close and latch the top of door this surveyor was able to see into the room from the corridor. Room is located across from Patient Room 170 in Special Care Unit.

3. Patient Room 161 door failed to positive latch.

4. The electrical room door had a hole approximately the size of a quarter above the handle, located by OutPatient Services Office.
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NFPA 101, 19.3.6.3.1 Exception No.2. In the smoke compartments protected throughout by an approved, supervised automatic sprinkler system, doors in corridor walls shall be constructed to resist the passage of smoke and be provided with suitable means of keeping the doors closed.

NFPA 19.3.6.3.6 Dutch doors shall be permitted where they conform to 19.3.6.3. In addition, both the upper leaf and lower leaf shall be equipped with a latching device, and the meeting edges of the upper and lower leaves shall be equipped with an astragal, a rabbet, or a bevel.

NFPA 19.3.6.3.6 Dutch doors shall be permitted where they conform to 19.3.6.3. In addition, both the upper leaf and lower leaf shall be equipped with a latching device, and the meeting edges of the upper and lower leaves shall be equipped with an astragal, a rabbet, or a bevel.

The facility failed to provide protection of openings in fire barriers to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. During the survey, the following are examples of what was observed:

1. Unsealed penetrations around a group of wiring, and at the end of a sleeve in the fire barrier at Labor/Delivery by the Nurses Station.

2. Unsealed penetrations at the deck of the fire barrier by Patient Room 120.
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NFPA 101, 19.2.2.5 and 7.2.4.3 Openings in fire barriers shall be constructed to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other.

The facility failed to provide proper emergency lighting: Findings include: During the survey, the following is an example of what was observed:

The maintenance director was not able to verify if the exit discharge lighting was on the generator.
---------------------------------------
NFPA 101, 7.9.2.3 Emergency generators providing power to emergency lighting systems to be installed per NFPA 110.

7.9.1.1* Emergency lighting facilities for means of egress shall be provided in accordance with Section 7.9 for the following:
(1) Buildings or structures where required in Chapters 11 through 42
(2) Underground and windowless structures as addressed in Section 11.7
(3) High-rise buildings as required by other sections of this Code
(4) Doors equipped with delayed egress locks
(5) The stair shaft and vestibule of smokeproof enclosures, which shall be permitted to include a standby generator that is installed for the smokeproof enclosure mechanical ventilation equipment and used for the stair shaft and vestibule emergency lighting power supply
For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, ramps, aisles, walkways, and escalators leading to a public way.

The facility failed to provide proper emergency lighting: Findings include: During the survey, the following is an example of what was observed:

The maintenance director was not able to verify if the exit discharge lighting was on the generator.
------------------------------------------
NFPA 101, 7.9.2.3 Emergency generators providing power to emergency lighting systems to be installed per NFPA 110.

7.9.1.1* Emergency lighting facilities for means of egress shall be provided in accordance with Section 7.9 for the following:
(1) Buildings or structures where required in Chapters 11 through 42
(2) Underground and windowless structures as addressed in Section 11.7
(3) High-rise buildings as required by other sections of this Code
(4) Doors equipped with delayed egress locks
(5) The stair shaft and vestibule of smokeproof enclosures, which shall be permitted to include a standby generator that is installed for the smokeproof enclosure mechanical ventilation equipment and used for the stair shaft and vestibule emergency lighting power supply
For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, ramps, aisles, walkways, and escalators leading to a public way.

The facility failed to perform sensitivity testing of the smoke detectors. Findings include:


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 perform sensitivity testing of the smoke detectors. Findings include:

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).

Sprinkler coverage was observed during the survey not adequately provided. Findings include: During the survey, the following is an example of what was observed:

A storage room located in Housekeeping was not provided with sprinkler coverage.
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NFPA 19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.

The facility failed to provide a sprinkler system which meets code requirements. Findings include: During the survey, the following is an example of what was observed:


The fire department connection was not provided with an identification sign.
---------------------------------------
NFPA 101,2000 Edition, 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this code shall be inspected, tested, and maintained in accordance with NFPA 25, Standards for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

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.

The facility failed to provide a sprinkler system which meets code requirements. Findings include: During the survey, the following is an example of what was observed:

The fire department connection was not provided with an identification sign.
---------------------------------------
NFPA 101,2000 Edition, 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this code shall be inspected, tested, and maintained in accordance with NFPA 25, Standards for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

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.

The facility failed to maintain required height for fire extinguishers. Findings include: During the survey, the following are examples of what was observed:


1. Two fire extinguishers mounted in cabinets in the Special Care Unit were measured by maintenance, one was 64"and the other one was 68" from the floor to the top of the gauge of the extinguisher.

2. Several other fire extinguishers were measured by maintenance all mounted in cabinets, throughout the facility these were approximately 68" in height from floor to top of the gauge of the extinguisher.
------------------------------------------------
1998 NFPA 10, 1-6.10 Fire extinguishers weighting not more than 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).

At the time of the survey, it was observed that the Generator Remote Annunciator for generators one and two did not indicate EPS supplying load when generators were transferred.
--------------------------------------
1999 NFPA 999, 3-4.1.1.15 + Alarm Annunciator. 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]

At the time of the survey, it was observed that the Generator Remote Annunciator for generators one and two did not indicate EPS supplying load when generators were transferred.
---------------------------------------
NFPA 99, 3-4. 1.1.15, + Alarm Annunciator.
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 refrigerator and microwave was plugged into a circuit breaker protected power strip in Radiologist.
------------------------------------------------

Appliances, such as air conditioners and refrigerators, microwaves, shall plug directly into a receptacle. 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99.

The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include: During the survey, the following are examples of what was observed:

1. The shower room door failed to close tight and positive latch by Patient Room 170 in the Special Care Unit. This door opens into the corridor, and is equipped with positive latching hardware just failed to latch.

2. The supply room door which is a dutch door, when this surveyor advised maintenance to close and latch the top of door this surveyor was able to see into the room from the corridor. Room is located across from Patient Room 170 in Special Care Unit.

3. Patient Room 161 door failed to positive latch.

4. The electrical room door had a hole approximately the size of a quarter above the handle, located by OutPatient Services Office.
---------------------------------------------
NFPA 101, 19.3.6.3.1 Exception No.2. In the smoke compartments protected throughout by an approved, supervised automatic sprinkler system, doors in corridor walls shall be constructed to resist the passage of smoke and be provided with suitable means of keeping the doors closed.

NFPA 19.3.6.3.6 Dutch doors shall be permitted where they conform to 19.3.6.3. In addition, both the upper leaf and lower leaf shall be equipped with a latching device, and the meeting edges of the upper and lower leaves shall be equipped with an astragal, a rabbet, or a bevel.

NFPA 19.3.6.3.6 Dutch doors shall be permitted where they conform to 19.3.6.3. In addition, both the upper leaf and lower leaf shall be equipped with a latching device, and the meeting edges of the upper and lower leaves shall be equipped with an astragal, a rabbet, or a bevel.

The facility failed to provide protection of openings in fire barriers to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. During the survey, the following are examples of what was observed:

1. Unsealed penetrations around a group of wiring, and at the end of a sleeve in the fire barrier at Labor/Delivery by the Nurses Station.

2. Unsealed penetrations at the deck of the fire barrier by Patient Room 120.
-------------------------------------------------
NFPA 101, 19.2.2.5 and 7.2.4.3 Openings in fire barriers shall be constructed to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other.

The facility failed to provide proper emergency lighting: Findings include: During the survey, the following is an example of what was observed:

The maintenance director was not able to verify if the exit discharge lighting was on the generator.
---------------------------------------
NFPA 101, 7.9.2.3 Emergency generators providing power to emergency lighting systems to be installed per NFPA 110.

7.9.1.1* Emergency lighting facilities for means of egress shall be provided in accordance with Section 7.9 for the following:
(1) Buildings or structures where required in Chapters 11 through 42
(2) Underground and windowless structures as addressed in Section 11.7
(3) High-rise buildings as required by other sections of this Code
(4) Doors equipped with delayed egress locks
(5) The stair shaft and vestibule of smokeproof enclosures, which shall be permitted to include a standby generator that is installed for the smokeproof enclosure mechanical ventilation equipment and used for the stair shaft and vestibule emergency lighting power supply
For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, ramps, aisles, walkways, and escalators leading to a public way.

The facility failed to provide proper emergency lighting: Findings include: During the survey, the following is an example of what was observed:

The maintenance director was not able to verify if the exit discharge lighting was on the generator.
------------------------------------------
NFPA 101, 7.9.2.3 Emergency generators providing power to emergency lighting systems to be installed per NFPA 110.

7.9.1.1* Emergency lighting facilities for means of egress shall be provided in accordance with Section 7.9 for the following:
(1) Buildings or structures where required in Chapters 11 through 42
(2) Underground and windowless structures as addressed in Section 11.7
(3) High-rise buildings as required by other sections of this Code
(4) Doors equipped with delayed egress locks
(5) The stair shaft and vestibule of smokeproof enclosures, which shall be permitted to include a standby generator that is installed for the smokeproof enclosure mechanical ventilation equipment and used for the stair shaft and vestibule emergency lighting power supply
For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, ramps, aisles, walkways, and escalators leading to a public way.

The facility failed to perform sensitivity testing of the smoke detectors. Findings include:


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 perform sensitivity testing of the smoke detectors. Findings include:

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).

Sprinkler coverage was observed during the survey not adequately provided. Findings include: During the survey, the following is an example of what was observed:

A storage room located in Housekeeping was not provided with sprinkler coverage.
--------------------------------------------------
NFPA 19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.

The facility failed to provide a sprinkler system which meets code requirements. Findings include: During the survey, the following is an example of what was observed:


The fire department connection was not provided with an identification sign.
---------------------------------------
NFPA 101,2000 Edition, 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this code shall be inspected, tested, and maintained in accordance with NFPA 25, Standards for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

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.

The facility failed to provide a sprinkler system which meets code requirements. Findings include: During the survey, the following is an example of what was observed:

The fire department connection was not provided with an identification sign.
---------------------------------------
NFPA 101,2000 Edition, 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this code shall be inspected, tested, and maintained in accordance with NFPA 25, Standards for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

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.

The facility failed to maintain required height for fire extinguishers. Findings include: During the survey, the following are examples of what was observed:


1. Two fire extinguishers mounted in cabinets in the Special Care Unit were measured by maintenance, one was 64"and the other one was 68" from the floor to the top of the gauge of the extinguisher.

2. Several other fire extinguishers were measured by maintenance all mounted in cabinets, throughout the facility these were approximately 68" in height from floor to top of the gauge of the extinguisher.
------------------------------------------------
1998 NFPA 10, 1-6.10 Fire extinguishers weighting not more than 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).

At the time of the survey, it was observed that the Generator Remote Annunciator for generators one and two did not indicate EPS supplying load when generators were transferred.
--------------------------------------
1999 NFPA 999, 3-4.1.1.15 + Alarm Annunciator. 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]

At the time of the survey, it was observed that the Generator Remote Annunciator for generators one and two did not indicate EPS supplying load when generators were transferred.
---------------------------------------
NFPA 99, 3-4. 1.1.15, + Alarm Annunciator.
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 refrigerator and microwave was plugged into a circuit breaker protected power strip in Radiologist.
------------------------------------------------

Appliances, such as air conditioners and refrigerators, microwaves, shall plug directly into a receptacle. 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99.