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1) Verification of the building construction type is required. Findings include:
a) Type V (000) Biohazard (red bag) Storage Area attached to the Type II (222) structure without a 2 hour separation.
b) Type V (000) (Biohazard Storage Room) without sprinkler system
c) Type II (000) one story without completion sprinkler coverage
d) The two hour separation between the Type II (000) and Type II (222) was not maintained.


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

During the survey, an unsprinklered Type V (000) Biohazard (red bag) Storage Area was observed attached to the two story Type II (222) building.

2000 NFPA 101, 8.2.1 Buildings or structures occupied or used in accordance with the individual occupancy chapters (Chapters 12 through 42) shall meet the minimum construction requirements of those chapters. NFPA 220, Standard on Types of Building Construction, shall be used to determine the requirements for the construction classification. Where the building or facility includes additions or connected structures of different construction types, the rating and classification of the structure shall be based on either of the following: (1) Separate buildings, if a 2-hour or greater vertically-aligned fire barrier wall in accordance with NFPA 221, Standard for Fire Walls and Fire Barrier Walls, exists between the portions of the building.
Exception: The requirement of 8.2.1(1) shall not apply to previously approved separations between buildings. (2) The least fire-resistive type of construction of the connected portions, if no such separation is provided
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
LimitationsConstruction Type Stories
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 provide corridor walls that would provide at least a 30 minute fire resistance rating in the unsprinklered smoke compartment. Findings include:

1) Unsealed penetrations/openings were observed above the ceiling in corridor walls at the following locations:
a) Over the door entering X-Ray Room
b) Over the door entering the old X-Ray Room near the Chapel
c) Rear wall of the Business Office
d) Solid ceiling above drop-in ceiling inside room 106 (Hard ceiling forms corridor separation)
e) Rear wall of First Floor Nursing Station

2) The corridor wall at the Quality Management Office was observed consisting of OSB board and plexi-glass with openings.

NFPA 101, 19.3.6.1 Corridors in unsprinklered smoke compartments shall be separated from all other areas by partitions having a fire resistance rating of at least
30 minutes.

The facility failed to provide/maintain corridor doors which would close and resist the passage of smoke. Findings include:

1) A toe-stop hold-open device was observed on the door entering the Business Manager's Office.

Form CMS-2786R (06/07) Survey Book. There shall be no impediment to closing corridor doors.

2) The door entering the X-Ray Supervisor's Office was observed without positive latching.


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3) During the survey, in the Basement the corridor door to the Storage Room outside of the Laundry at the main elevator was observed not to be positive latching.

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.

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The facility failed to maintain the elevator shaft per code. Findings include:

During the survey, on the Second Floor the main elevator shaft was observed with an unsealed penetration on the left wall.

2000 NFPA 101, 19.3.1.1 Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.
2000 NFPA 101, 8.2.5.2 Openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier.
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The facility failed to provide/maintain smoke barriers that would provide at least a half hour fire resistance rating and restrict the movement of smoke. Findings include:

Unsealed penetrations/openings were observed in smoke barriers as follows:
a) Unsealed pipe over the smoke doors at ER
b) Unsealed pipe penetration over the smoke door at ER-11
c) Unsealed penetration on left side of smoke door entering ER Expansion near the Doctors' Parking Lot
d) Over the smoke door entering ER near the Doctors' Lounge
e) Over the smoke door entering ER near X-Ray 2

NFPA 101, 19.3.7.3 and 8.3.1 Smoke walls shall have a fire resistance rating of at least half hour and to be continuous from floor-to-deck and from outside-to-outside.

1) The facility failed to provide separation of hazardous areas by either at least a one-hour fire resistance rating or to provide protection by an automatic sprinkler system. Findings include:

The following hazardous areas without sprinkler coverage were observed without the hour seperation required, as follows:
a) Administration Janitor Closet, unsealed top of wall to deck
b) Unsealed wall opening in Medical Records
c) Data Processing Office/Storage Room, unsealed top of wall to deck
d) Pharmacy walls with unsealed penetrations
e) OR Two used as a storage room without a closing device on the door entering the room
f) OR Two rear door unsealed between the door and frame
g) Two doors in OR Sterile Storage Room without latching hardware
h) ER's Soiled Linen Room, unsealed top of wall to deck
i) ER's Storage Room, unsealed top of wall to deck
j) Twenty minute doors were observed in hazardous areas in ER
k) The door entering Medical Records was observed held in the open position with a wedge


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

A) During the survey, the following was observed:
a) Second Floor - the I.C.U. Storage Room 1 (used to be a patient room) is over 50 sq. ft. and sprinklered the corridor door did not have a self-closing device.
B) Outside - the Med. Gas (compressed air) Room had four unsealed pipe penetrations in the right wall.

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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The facility failed to provide readily accessible exit access. Findings include:

1) A hasp/lock was observed on the closet door located in the Endoscopy Room which would prevent exit from within the closet.

2) The exit doors to the exterior near OR-3 were observed hanging/binding in the door frame requiring excessive force from facility staff to open.

3) The exit to the exterior from near room 106 as observed failed to provide an all weather surface to the public way.

NFPA 101, 19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.

NFPA 101, 7.1.10 and 7.5.1.1 Exit access shall be arranged so that exits are readily accessible at all times.

NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments for full instant use in case of fire or other emergencies.

The facility failed to maintain the horizontal exits per code. Findings include:

During the survey, the following was observed in the Basement:
1. The two hour fire barrier at the fire doors at the Employee Elevator - the left corner was not sealed.
2. The two hour fire barrier separating the Physical Therapy Office from Payroll had an unsealed hole around an electrical or I.T. tray/trough.
3. The Physical Therapy Office had unsealed penetrations in the concrete fire barrier separating the Basement from the First Floor above the lay-in ceiling tile.

2000 NFPA 101, 8.2.3.2.4.2 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows: (1) The space between the penetrating item and the fire barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire 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 fire barrier, the sleeve shall be solidly set in the fire 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 fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met: a. The material shall be capable of maintaining the fire resistance of the fire barrier. b. The material shall be protected by an approved device that is designed for the specific purpose. (4) 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 fire barrier. b. It shall be made by an approved device that is designed for the specific purpose.
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The facility failed to provide continuous lighting for means of egress. Findings include:

1) The facility was observed with a single, one bulb light fixture at the exterior exit area from the stairs near Elevator One.


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2) During the survey, the exit discharge of the stairwell on James St. was observed with a single bulb/single fixture.

2000 NFPA 101, 7.8.1.2 Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use. Artificial lighting shall be employed at such locations and for such periods of time as required to maintain the illumination to the minimum criteria values herein specified.
2000 NFPA 101, 7.8.1.4 Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2 lux) in any designated area.
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The facility failed to provide documentation of fire drills per code. Findings include:

During the survey, the documentation provided by the facility was observed not having the following:
1. Documention for fire drills on the First or Second Shift in the last quarter of 2009 was not provided, the documention indicted an in-service was performed.
2. Only Department Heads or the signature of the person in charge was observed on the documention provided for the last twelve months fire drills.

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 maintain the fire alarm system in proper working order. Findings include:

1) It was observed, while testing the fire alarm system, during the loss of AC power to the fire alarm system, and the system operated on battery backup power, exit egress doors with magnetic locking devices failed to release in ER.

1999 NFPA 72 National Fire Alarm Code 3-9.7.3 All exits connected in accordance with 3-9.7.1 shall unlock upon loss of the primary power to the fire alarm system serving the protected premises. The secondary power supply shall not be utilized to maintain these doors in the locked condition.

2) A manual pull station was not observed in the exit egress path of the Cath Lab. (Mobile Unit which has been on location for years per interview and observation with facility staff).

NFPA 101, 9.6.2.3 A manual fire alarm box shall be provided in the natural exit access path near each required exit from an area, unless modified by another section of this Code.

The facility failed to provide sprinkler protection per code. Findings include:

During the survey, the "B1" exit was observed with a combustible porch/covered walkway over 4'-0" in width that did not have sprinkler coverage.

1999 NFPA 13, 5-13.8.1 Sprinklers shall be installed under exterior roofs or canopies exceeding 4 ft (1.2 m) in width.
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The facility failed to maintain the sprinkler system. Findings include:

A tamper device was not observed on the cut-off valve located above the ceiling in the corridor near the Lab/X-Ray Waiting Room.

NFPA 101, 19.3.5.1 and 9.7.2.1; 1999 NFPA 13, 5-14.1.1.3; and 1999 NFPA 72, 2-9.1 Sprinkler control valves shall be electrically supervised so that at least a local alarm will sound at a constantly attended location when the valve is turned.

The facility failed to maintain the automatic sprinkler system per code. Findings include:

During the survey, per documentation provided by the facility and interview with the staff, the automatic sprinkler system gauges have not been calibrated or replaced in 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.
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The facility failed to provide signage for the fire extinguisher(s) in the Kitchen per code. Findings include:

During the survey, the fire extinguisher(s) in the Kitchen was observed without code required signage.

1998 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.
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The facility failed to provide a readily accessible means of egress pathway at all times.
Findings include:

1) Storage of a table and trash can was observed in the alcove of the exit near OR-3 partially blocking egress, preventing the left exit door to the alcove from fully opening.


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During the survey, on the Second Floor, the following was observed:
2) In the I.C.U., the following items were in the corridor: a copy machine, (2) paper shredder boxes, a trash can, (2) stools and a computer stand.
3) In the patient corridor, the following items were in the corridor: (3) stools and (3) computer stands.

2000 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.
2000 NFPA 101, 7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.
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The facility failed to maintain the medical gas storage per code. Findings include:

During the survey, the following was observed:
1. The outside Med. Gas Room (compressed air) - the cylinders were not secured.
2. Med. gas cylinders were being stored at the Maintenance Exit discharge.

1999 NFPA 99, 4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) * Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
1999 NFPA 99, 4-3.5.2.1 Gases in Cylinders and Liquefied Gases in Containers - Level 1.
13. Oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device. Such cylinders shall not be stored near elevators, gangways, or in locations where heavy moving objects will strike them or fall on them.
15. Cylinders shall be protected from the tampering of unauthorized individuals.

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The facility failed to provide a smoke venting system per code. Findings include:

During the survey, O.R. 1 (windowless) , per interview with staff and observation , did not have a smoke venting system.

1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.
1999 NFPA 99, 5-4.1.3 Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.
1999 NFPA 99, 5-4.1.4 The electric supply to the ventilating system shall be served by the equipment system of the essential electrical system specified in Chapter 3," Electrical Systems."
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The facility failed to maintain the smoke barrier per code. Findings include:

During the survey, on the Second Floor, the smoke barrier in I.C.U., at the electrical panels on the right side just inside the smoke doors, was observed with an unsealed hole.

2000 NFPA 101, 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.
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The facility failed to provide a Type 1 Essential Electrical System (EES) per code. Findings include:

During the survey, per documentation provided by the facility, generator #1 was installed in 2006 - the EES was not divided into the separate branches.

1999 NFPA 99, 3-4.2.2.2 Emergency System. (a) General. Those functions of patient care depending on lighting or appliances that are permitted to be connected to the emergency system are divided into two mandatory branches, described in 3-4.2.2.2(b) and (c). +All ac-powered support and accessory equipment necessary to the operation of the EPS shall be supplied from the load side of the automatic transfer switch(es), or the output terminals of the EPS, ahead of the main EPS overcurrent protection, as necessary, to ensure continuity of the EPSS operation and performance. (NFPA 110: 5-12.5) (b) Life Safety Branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment: 1. Illumination of means of egress as required in NFPA 101,? Life Safety Code? 2. Exit signs and exit direction signs required in NFPA 101, Life Safety Code 3. Alarm and alerting systems including the following: a. Fire alarms b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems" 4. * Hospital communication systems, where used for issuing instruction during emergency conditions 5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location 6. Elevator cab lighting, control, communication, and signal systems 7. Automatically operated doors used for building egress. No function other than those listed above in items 1 through 7 shall be connected to the life safety branch. Exception: The auxiliary functions of fire alarm combination systems complying with NAPA 72, National Fire Alarm Code, shall be permitted to be connected to the life safety branch. (c) * Critical Branch. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and selected power circuits serving the following areas and functions related to patient care. It shall be permitted to subdivide the critical branch into two or more branches. 1. Critical care areas that utilize anesthetizing gases, task illumination, selected receptacles, and fixed equipment 2. The isolated power systems in special environments 3. Patient care areas - task illumination and selected receptacles in the following: a. Infant nurseries b. Medication preparation areas c. Pharmacy dispensing areas d. Selected acute nursing areas e. Psychiatric bed areas (omit receptacles) f. Ward treatment rooms g. Nurses' stations (unless adequately lighted by corridor luminaires) 4. Additional specialized patient care task illumination and receptacles, where needed 5. Nurse call systems 6. Blood, bone, and tissue banks 7. * Telephone equipment rooms and closets 8. Task illumination, selected receptacles, and selected power circuits for the following: a. General care beds (at least one duplex receptacle per patient bedroom) b. Angiographic labs c. Cardiac catheterization labs d. Coronary care units e. Hemodialysis rooms or areas f. Emergency Room treatment areas (selected) g. Human Physiology Labs h. Intensive Care Units i. Postoperative Recovery Rooms (selected) 9. Additional task illumination, receptacles, and selected power circuits needed for effective facility operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch.
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The facility failed to provide approved electrical utilities. Findings include:

1) Extension cords without overcurrent protection were observed in the following areas:
a) Nursing Supervisor Office
b) A three-way adapter in the X-Ray Office
c) CEO's Office
d)Two in Nuclear Medicine
e) Television Cart in room ER-11

1999 NFPA 70, Article 240-4, and HFCA Transmittal Notice 22-99 prohibits the use of extension cords without overcurrent protection.

2) Overcurrent protected cords were observed piggybacked, plugged together, in the following locations:
a) DON Office
b) Business Office, front desk
d) Business Office Manager

NFPA 101, 19-5.1 Utilities shall comply with NFPA 101, 9-1 Electrical shall comply with the NFPA 70 National Electrical Code. NEC 400-7(b) Requires each flexible cord to "be energized from a receptacle outlet."

3) A refrigerator was observed plugged into an overcurrent protected cord in the CEO Office.

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

4) Junction boxes without covers were observed above the ceiling in the following locations:
a) Corridor at Doctor's Lounge
b) Waiting Room near room 100
c) Gift Shop

1999 NFPA 70, 370-25 and 410-12 Each box in completed installations to have a cover, face plate, or fixture canopy.

5) Exposed electrical wires were observed spliced together without being in a junction box near the X-Ray File Room.

1999 NFPA 70, 343-12 Splices and taps shall be made in junction boxes or other enclosures.

6) A television cord was observed extending to the area above the ceiling plugged into a pigtail cord wired into a junction box in the Front Lobby.

NFPA 70, 400-8 Flexible cords and cables shall not be used where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.

7) A loose receptacle was observed in the rear wall of the GXT Room.

1999 NFPA 70, 410-56(f); 370-23. Supports Enclosures to be fastened securely upon which they are mounted.


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8) During the survey, the O.R's emergency outlets were observed without a distinctive color or marking indicating they were on an emergency circuit.

1999 NFPA 70, 517-33 (c) Receptacle Identification. The receptacles or the faceplates for receptacles supplied by the critical branch shall have a distinctive color or marking so as to be readily recognizable.

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1) Verification of the building construction type is required. Findings include:
a) Type V (000) Biohazard (red bag) Storage Area attached to the Type II (222) structure without a 2 hour separation.
b) Type V (000) (Biohazard Storage Room) without sprinkler system
c) Type II (000) one story without completion sprinkler coverage
d) The two hour separation between the Type II (000) and Type II (222) was not maintained.


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

During the survey, an unsprinklered Type V (000) Biohazard (red bag) Storage Area was observed attached to the two story Type II (222) building.

2000 NFPA 101, 8.2.1 Buildings or structures occupied or used in accordance with the individual occupancy chapters (Chapters 12 through 42) shall meet the minimum construction requirements of those chapters. NFPA 220, Standard on Types of Building Construction, shall be used to determine the requirements for the construction classification. Where the building or facility includes additions or connected structures of different construction types, the rating and classification of the structure shall be based on either of the following: (1) Separate buildings, if a 2-hour or greater vertically-aligned fire barrier wall in accordance with NFPA 221, Standard for Fire Walls and Fire Barrier Walls, exists between the portions of the building.
Exception: The requirement of 8.2.1(1) shall not apply to previously approved separations between buildings. (2) The least fire-resistive type of construction of the connected portions, if no such separation is provided
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
LimitationsConstruction Type Stories
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 provide corridor walls that would provide at least a 30 minute fire resistance rating in the unsprinklered smoke compartment. Findings include:

1) Unsealed penetrations/openings were observed above the ceiling in corridor walls at the following locations:
a) Over the door entering X-Ray Room
b) Over the door entering the old X-Ray Room near the Chapel
c) Rear wall of the Business Office
d) Solid ceiling above drop-in ceiling inside room 106 (Hard ceiling forms corridor separation)
e) Rear wall of First Floor Nursing Station

2) The corridor wall at the Quality Management Office was observed consisting of OSB board and plexi-glass with openings.

NFPA 101, 19.3.6.1 Corridors in unsprinklered smoke compartments shall be separated from all other areas by partitions having a fire resistance rating of at least
30 minutes.

The facility failed to provide/maintain corridor doors which would close and resist the passage of smoke. Findings include:

1) A toe-stop hold-open device was observed on the door entering the Business Manager's Office.

Form CMS-2786R (06/07) Survey Book. There shall be no impediment to closing corridor doors.

2) The door entering the X-Ray Supervisor's Office was observed without positive latching.


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3) During the survey, in the Basement the corridor door to the Storage Room outside of the Laundry at the main elevator was observed not to be positive latching.

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.

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The facility failed to maintain the elevator shaft per code. Findings include:

During the survey, on the Second Floor the main elevator shaft was observed with an unsealed penetration on the left wall.

2000 NFPA 101, 19.3.1.1 Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.
2000 NFPA 101, 8.2.5.2 Openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier.
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The facility failed to provide/maintain smoke barriers that would provide at least a half hour fire resistance rating and restrict the movement of smoke. Findings include:

Unsealed penetrations/openings were observed in smoke barriers as follows:
a) Unsealed pipe over the smoke doors at ER
b) Unsealed pipe penetration over the smoke door at ER-11
c) Unsealed penetration on left side of smoke door entering ER Expansion near the Doctors' Parking Lot
d) Over the smoke door entering ER near the Doctors' Lounge
e) Over the smoke door entering ER near X-Ray 2

NFPA 101, 19.3.7.3 and 8.3.1 Smoke walls shall have a fire resistance rating of at least half hour and to be continuous from floor-to-deck and from outside-to-outside.

1) The facility failed to provide separation of hazardous areas by either at least a one-hour fire resistance rating or to provide protection by an automatic sprinkler system. Findings include:

The following hazardous areas without sprinkler coverage were observed without the hour seperation required, as follows:
a) Administration Janitor Closet, unsealed top of wall to deck
b) Unsealed wall opening in Medical Records
c) Data Processing Office/Storage Room, unsealed top of wall to deck
d) Pharmacy walls with unsealed penetrations
e) OR Two used as a storage room without a closing device on the door entering the room
f) OR Two rear door unsealed between the door and frame
g) Two doors in OR Sterile Storage Room without latching hardware
h) ER's Soiled Linen Room, unsealed top of wall to deck
i) ER's Storage Room, unsealed top of wall to deck
j) Twenty minute doors were observed in hazardous areas in ER
k) The door entering Medical Records was observed held in the open position with a wedge


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

A) During the survey, the following was observed:
a) Second Floor - the I.C.U. Storage Room 1 (used to be a patient room) is over 50 sq. ft. and sprinklered the corridor door did not have a self-closing device.
B) Outside - the Med. Gas (compressed air) Room had four unsealed pipe penetrations in the right wall.

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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The facility failed to provide readily accessible exit access. Findings include:

1) A hasp/lock was observed on the closet door located in the Endoscopy Room which would prevent exit from within the closet.

2) The exit doors to the exterior near OR-3 were observed hanging/binding in the door frame requiring excessive force from facility staff to open.

3) The exit to the exterior from near room 106 as observed failed to provide an all weather surface to the public way.

NFPA 101, 19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.

NFPA 101, 7.1.10 and 7.5.1.1 Exit access shall be arranged so that exits are readily accessible at all times.

NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments for full instant use in case of fire or other emergencies.

The facility failed to maintain the horizontal exits per code. Findings include:

During the survey, the following was observed in the Basement:
1. The two hour fire barrier at the fire doors at the Employee Elevator - the left corner was not sealed.
2. The two hour fire barrier separating the Physical Therapy Office from Payroll had an unsealed hole around an electrical or I.T. tray/trough.
3. The Physical Therapy Office had unsealed penetrations in the concrete fire barrier separating the Basement from the First Floor above the lay-in ceiling tile.

2000 NFPA 101, 8.2.3.2.4.2 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows: (1) The space between the penetrating item and the fire barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire 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 fire barrier, the sleeve shall be solidly set in the fire 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 fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met: a. The material shall be capable of maintaining the fire resistance of the fire barrier. b. The material shall be protected by an approved device that is designed for the specific purpose. (4) 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 fire barrier. b. It shall be made by an approved device that is designed for the specific purpose.
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The facility failed to provide continuous lighting for means of egress. Findings include:

1) The facility was observed with a single, one bulb light fixture at the exterior exit area from the stairs near Elevator One.


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2) During the survey, the exit discharge of the stairwell on James St. was observed with a single bulb/single fixture.

2000 NFPA 101, 7.8.1.2 Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use. Artificial lighting shall be employed at such locations and for such periods of time as required to maintain the illumination to the minimum criteria values herein specified.
2000 NFPA 101, 7.8.1.4 Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2 lux) in any designated area.
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The facility failed to provide documentation of fire drills per code. Findings include:

During the survey, the documentation provided by the facility was observed not having the following:
1. Documention for fire drills on the First or Second Shift in the last quarter of 2009 was not provided, the documention indicted an in-service was performed.
2. Only Department Heads or the signature of the person in charge was observed on the documention provided for the last twelve months fire drills.

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 maintain the fire alarm system in proper working order. Findings include:

1) It was observed, while testing the fire alarm system, during the loss of AC power to the fire alarm system, and the system operated on battery backup power, exit egress doors with magnetic locking devices failed to release in ER.

1999 NFPA 72 National Fire Alarm Code 3-9.7.3 All exits connected in accordance with 3-9.7.1 shall unlock upon loss of the primary power to the fire alarm system serving the protected premises. The secondary power supply shall not be utilized to maintain these doors in the locked condition.

2) A manual pull station was not observed in the exit egress path of the Cath Lab. (Mobile Unit which has been on location for years per interview and observation with facility staff).

NFPA 101, 9.6.2.3 A manual fire alarm box shall be provided in the natural exit access path near each required exit from an area, unless modified by another section of this Code.

The facility failed to provide sprinkler protection per code. Findings include:

During the survey, the "B1" exit was observed with a combustible porch/covered walkway over 4'-0" in width that did not have sprinkler coverage.

1999 NFPA 13, 5-13.8.1 Sprinklers shall be installed under exterior roofs or canopies exceeding 4 ft (1.2 m) in width.
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The facility failed to maintain the sprinkler system. Findings include:

A tamper device was not observed on the cut-off valve located above the ceiling in the corridor near the Lab/X-Ray Waiting Room.

NFPA 101, 19.3.5.1 and 9.7.2.1; 1999 NFPA 13, 5-14.1.1.3; and 1999 NFPA 72, 2-9.1 Sprinkler control valves shall be electrically supervised so that at least a local alarm will sound at a constantly attended location when the valve is turned.

The facility failed to maintain the automatic sprinkler system per code. Findings include:

During the survey, per documentation provided by the facility and interview with the staff, the automatic sprinkler system gauges have not been calibrated or replaced in 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.
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The facility failed to provide signage for the fire extinguisher(s) in the Kitchen per code. Findings include:

During the survey, the fire extinguisher(s) in the Kitchen was observed without code required signage.

1998 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.
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The facility failed to provide a readily accessible means of egress pathway at all times.
Findings include:

1) Storage of a table and trash can was observed in the alcove of the exit near OR-3 partially blocking egress, preventing the left exit door to the alcove from fully opening.


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During the survey, on the Second Floor, the following was observed:
2) In the I.C.U., the following items were in the corridor: a copy machine, (2) paper shredder boxes, a trash can, (2) stools and a computer stand.
3) In the patient corridor, the following items were in the corridor: (3) stools and (3) computer stands.

2000 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.
2000 NFPA 101, 7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.
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The facility failed to maintain the medical gas storage per code. Findings include:

During the survey, the following was observed:
1. The outside Med. Gas Room (compressed air) - the cylinders were not secured.
2. Med. gas cylinders were being stored at the Maintenance Exit discharge.

1999 NFPA 99, 4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) * Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
1999 NFPA 99, 4-3.5.2.1 Gases in Cylinders and Liquefied Gases in Containers - Level 1.
13. Oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device. Such cylinders shall not be stored near elevators, gangways, or in locations where heavy moving objects will strike them or fall on them.
15. Cylinders shall be protected from the tampering of unauthorized individuals.

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The facility failed to provide a smoke venting system per code. Findings include:

During the survey, O.R. 1 (windowless) , per interview with staff and observation , did not have a smoke venting system.

1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.
1999 NFPA 99, 5-4.1.3 Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.
1999 NFPA 99, 5-4.1.4 The electric supply to the ventilating system shall be served by the equipment system of the essential electrical system specified in Chapter 3," Electrical Systems."
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The facility failed to maintain the smoke barrier per code. Findings include:

During the survey, on the Second Floor, the smoke barrier in I.C.U., at the electrical panels on the right side just inside the smoke doors, was observed with an unsealed hole.

2000 NFPA 101, 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.
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The facility failed to provide a Type 1 Essential Electrical System (EES) per code. Findings include:

During the survey, per documentation provided by the facility, generator #1 was installed in 2006 - the EES was not divided into the separate branches.

1999 NFPA 99, 3-4.2.2.2 Emergency System. (a) General. Those functions of patient care depending on lighting or appliances that are permitted to be connected to the emergency system are divided into two mandatory branches, described in 3-4.2.2.2(b) and (c). +All ac-powered support and accessory equipment necessary to the operation of the EPS shall be supplied from the load side of the automatic transfer switch(es), or the output terminals of the EPS, ahead of the main EPS overcurrent protection, as necessary, to ensure continuity of the EPSS operation and performance. (NFPA 110: 5-12.5) (b) Life Safety Branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment: 1. Illumination of means of egress as required in NFPA 101,? Life Safety Code? 2. Exit signs and exit direction signs required in NFPA 101, Life Safety Code 3. Alarm and alerting systems including the following: a. Fire alarms b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems" 4. * Hospital communication systems, where used for issuing instruction during emergency conditions 5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location 6. Elevator cab lighting, control, communication, and signal systems 7. Automatically operated doors used for building egress. No function other than those listed above in items 1 through 7 shall be connected to the life safety branch. Exception: The auxiliary functions of fire alarm combination systems complying with NAPA 72, National Fire Alarm Code, shall be permitted to be connected to the life safety branch. (c) * Critical Branch. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and selected power circuits serving the following areas and functions related to patient care. It shall be permitted to subdivide the critical branch into two or more branches. 1. Critical care areas that utilize anesthetizing gases, task illumination, selected receptacles, and fixed equipment 2. The isolated power systems in special environments 3. Patient care areas - task illumination and selected receptacles in the following: a. Infant nurseries b. Medication preparation areas c. Pharmacy dispensing areas d. Selected acute nursing areas e. Psychiatric bed areas (omit receptacles) f. Ward treatment rooms g. Nurses' stations (unless adequately lighted by corridor luminaires) 4. Additional specialized patient care task illumination and receptacles, where needed 5. Nurse call systems 6. Blood, bone, and tissue banks 7. * Telephone equipment rooms and closets 8. Task illumination, selected receptacles, and selected power circuits for the following: a. General care beds (at least one duplex receptacle per patient bedroom) b. Angiographic labs c. Cardiac catheterization labs d. Coronary care units e. Hemodialysis rooms or areas f. Emergency Room treatment areas (selected) g. Human Physiology Labs h. Intensive Care Units i. Postoperative Recovery Rooms (selected) 9. Additional task illumination, receptacles, and selected power circuits needed for effective facility operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch.
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The facility failed to provide approved electrical utilities. Findings include:

1) Extension cords without overcurrent protection were observed in the following areas:
a) Nursing Supervisor Office
b) A three-way adapter in the X-Ray Office
c) CEO's Office
d)Two in Nuclear Medicine
e) Television Cart in room ER-11

1999 NFPA 70, Article 240-4, and HFCA Transmittal Notice 22-99 prohibits the use of extension cords without overcurrent protection.

2) Overcurrent protected cords were observed piggybacked, plugged together, in the following locations:
a) DON Office
b) Business Office, front desk
d) Business Office Manager

NFPA 101, 19-5.1 Utilities shall comply with NFPA 101, 9-1 Electrical shall comply with the NFPA 70 National Electrical Code. NEC 400-7(b) Requires each flexible cord to "be energized from a receptacle outlet."

3) A refrigerator was observed plugged into an overcurrent protected cord in the CEO Office.

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

4) Junction boxes without covers were observed above the ceiling in the following locations:
a) Corridor at Doctor's Lounge
b) Waiting Room near room 100
c) Gift Shop

1999 NFPA 70, 370-25 and 410-12 Each box in completed installations to have a cover, face plate, or fixture canopy.

5) Exposed electrical wires were observed spliced together without being in a junction box near the X-Ray File Room.

1999 NFPA 70, 343-12 Splices and taps shall be made in junction boxes or other enclosures.

6) A television cord was observed extending to the area above the ceiling plugged into a pigtail cord wired into a junction box in the Front Lobby.

NFPA 70, 400-8 Flexible cords and cables shall not be used where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.

7) A loose receptacle was observed in the rear wall of the GXT Room.

1999 NFPA 70, 410-56(f); 370-23. Supports Enclosures to be fastened securely upon which they are mounted.


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8) During the survey, the O.R's emergency outlets were observed without a distinctive color or marking indicating they were on an emergency circuit.

1999 NFPA 70, 517-33 (c) Receptacle Identification. The receptacles or the faceplates for receptacles supplied by the critical branch shall have a distinctive color or marking so as to be readily recognizable.

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