HospitalInspections.org

The facility failed to provide a building construction type per code. Findings include:

During the survey, the following are examples of what was observed:
The two hour seperation between the Type I (443) structure is not provided on the first floor
1. The Annex Corridor going to the single story building has type II (000) construction
2. The corridor in front of the elevator for the "two story building" has a type II (111) construction on all three floors

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.

Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
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The facility failed to provide corridor walls that would provide at least a 30 minute fire resistance rating. Findings include: During the survey, the following are examples of what was observed:

Unsealed penetrations around a section of condiut, in the corridor wall, by Patient Room 211.


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.

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

During the survey, the following are examples of what was observed:
1. The following doors had penetrations at the door knob:
a. Housekeeping Storage Room by the Maintenance Hall
b. Annex Hall "Conference Room"
2. The following doors were not positive latching:
a. Housekeeping Closet on the Maintenance Hall
b. Medical Records om Annex Hall North

2000 NFPA 101, 19.3.6.3.1 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.
2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
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The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include: During the survey, the following are examples of what was observed:


1. Unsealed penetrations at the end of a sleeve, in the Smoke Barrier, at the ER Entrance.

2. Unsealed penetrations around a sprinkler line, and conduit, also at the end of a sleeve, in the Smoke Barrier, in the OR Director Office # 251.


2000 NFPA 101, 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.
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.

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

During the survey, the following are examples of what was found:
The following doors were located in a smoke barrier and were not self-closing:
1. Case Management Office
2. Medical Records on Annex Hall North

2000 NFPA 101, 19.3.7.6 Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6.
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The facility failed to maintain separation of hazardous areas in non sprinklered areas. Findings include: During the survey, the following are examples of what was observed:

A) The Biohazard Room across from Patient Room 209, had unsealed penetrations in the wall around conduit, above the door. The self-closing device for the door was disconnected.


NFPA 101, 19.3.2.1 Hazardous areas shall be safeguarded by a fire barrier of a one-hour fire resistance rating or provided with an automatic sprinkler system.


27382

B) During the survey, the following are examples of what was observed:
First Floor
1. The wall separarting the Boiler Room from the Janitor's Room had an unsealed hole in the wall.
2. The Storage Room by Materials Management Director's Office was over 50 sq. ft., combustibles stored in it, not sprinklered - the door was not 45 minute rated and did not have a self-closing device
3. Central Supply was over 50 sq. ft., had combustibles stored in it, not sprinklered - the door was not 45 minute rated


2000 NFPA 101, 8.4.1.1 Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means: (1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2. (2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42.
2000 NFPA 101, 8.4.1.3 Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.
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The facility failed to maintain the hazardous areas per code. Findings include:

During the survey, the following are examples of what was observed:
The following rooms were being used for storage of combustible materials, were over 50 sq. ft. and the doors did not have self-closing devices:
1. Both Home Health Rooms on the Annex Hall North
2. Medical Records Storage on the Annex Hall North

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 maintain stairways with at least 1 hour fire resistance rating. During the survey, the following are examples of what was observed:


1. Unsealed penetrations around a sprinkler line in the Stairwell by Mop Closet # 253.

2. Unsealed penetrations around a sprinkler line in the stairwell by patient Room 202.


NFPA 101, 19.3.1.1, 8.2.3.2.4, and 7.1.3.2.1 requires a fire resistance rating.

The facility failed to maintain the fire alarm system in proper working order.

A) Findings include: During the survey, the following are examples of what was observed:

While testing the fire alarm system, the alarm could not be heard, in the Materials Management offices, located on the First floor.

NFPA 101, 9.6.1.4 The fire alarm system to be installed, tested, and maintained in accordance with the requirements of NFPA 70 and NFPA 72.


27382


B) During the survey, the following are examples of what was observed:
1. The fire alarm annual inspection dated 06/28-30/2011 did not indicate that the kitchen hood was connected to the fire alarm
Third Floor
2. The fire alarm strobe between rooms 303 and 305 did not flash when the fire alarm was tested



1999 NFPA 72, 7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer ' s recommendations, and shall verify correct operation of the fire alarm system.
1999 NFPA 72, 7-2.2 Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2.
1999 NFPA 72, 4-4.2 Light Pulse Characteristics. The flash rate shall not exceed two flashes per second (2 Hz) nor be less than one flash every second (1 Hz) throughout the listed voltage range of the appliance.

1999 NFPA 72, 4-4.2.1 A maximum pulse duration shall be 0.2 seconds with a maximum duty cycle of 40 percent. The pulse duration shall be defined as the time interval between initial and final points of 10 percent of maximum signal.

1999 NFPA 72, 4-4.2.2* The light source color shall be clear or nominal white and shall not exceed 1000 cd (effective intensity).

1999 NFPA 72, 4-4.3.1 Visible notification appliances used in the public mode shall be located and shall be of a type, size, intensity, and number so that the operating effect of the appliance is seen by the intended viewers regardless of the viewer ' s orientation.

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

During the survey, the following is an example of what was observed:
While testing the fire alarm onthe second floor it was observed that the fire alarm devices could not seen or heard in the two O.R.s .


2000 NFPA 101, 9.6.1.3 The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.
2000 NFPA 101, 9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
2000 NFPA 101, 9.6.1.5 All systems and components shall be approved for the purpose for which they are installed.
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The facility failed to provide complete sprinkler coverage to all parts of the facility.
Findings include: During the survey, the following are examples of what was observed:

1. Missing escutcheon plate on a sprinkler Elevator Lobby Second Floor.

2. Loose escutcheon plate on two sprinklers in the corridor Second Floor.

3. Missing escutcheon plate on a sprinkler in Recovery Room.

4. Missing escutcheon plate on two sprinklers in OR # 2.

5. Missing escutcheon plate on a sprinkler in the corridor in front of OR # 2.

6. Loose escutcheon plate on two sprinklers in OR # 1.

7. Missing escutcheon plate on a sprinkler in the Restroom in ER.


2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

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

During the survey, the following is an example of what was observed:

The Second Floor fire extinguisher's (at the O.R.s) last monthly documented inspection was 01/2011

1998 NFPA 10, 4-3.4.3 Records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or in an electronic system (e.g., bar coding) that provides a permanent record.

1998 NFPA 10, 4-3.1 Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.

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The facility failed to maintain the cooking facilities per code. Findings include:

During the survey, the following are examples of what was observed:
1. Per documentation and interview the facility was not conducting monthly inspections on the kitchen hood suppression system
2. The facility did not have a sign for the K type fire extinguisher, noting it was a secondary device



1998 NFPA 17A, 5-2.1 Inspection shall be conducted on a monthly basis in accordance with the manufacturer ' s listed installation and maintenance manual or the 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) No obvious physical damage or condition exists that might prevent operation. (f) The pressure gauge(s), if provided, is in operable range. (g) The nozzle blowoff caps are intact and undamaged. (h) The hood, duct, and protected cooking appliances have not been replaced, modified, or relocated.
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 had improper heating devices. Findings include: During the survey, the following are examples of what was observed:


Electrical heater was observed in the Doctor's Lounge/Sleeping Room in ER.

NFPA 101, 19.7.8, prohibits the use of portable space heating devices.

The facility failed to maintain the O.R.s per code. Findings include:

During the survey, the following is an example of what was observed:

The two Second Floor O.R.s could not be verified if they had a smoke venting system or not, the facility staff did not know.

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 provide approved electrical utilities. Findings include: During the survey, the following are examples of what was observed:


A junction box was missing the cover above the ceiling by Patient Room 311.


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

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

During the survey, the following is an example of what was observed:
The Transcription Room had a refrigerator and 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.

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

During the survey, the following is an example of what was observed:
The "Passenger Elevator" pit had a pile of debris in the front corner

1996 ASME A17.1, Part XII, 1206.2a Hoistways and pits shall be kept clean and free of dirt and rubbish and shall not be used for storage purposes. Water shall not be allowed to accumulate in pits.

The facility failed to provide a building construction type per code. Findings include:

During the survey, the following are examples of what was observed:
The two hour seperation between the Type I (443) structure is not provided on the first floor
1. The Annex Corridor going to the single story building has type II (000) construction
2. The corridor in front of the elevator for the "two story building" has a type II (111) construction on all three floors

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.

Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
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The facility failed to provide corridor walls that would provide at least a 30 minute fire resistance rating. Findings include: During the survey, the following are examples of what was observed:

Unsealed penetrations around a section of condiut, in the corridor wall, by Patient Room 211.


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.

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

During the survey, the following are examples of what was observed:
1. The following doors had penetrations at the door knob:
a. Housekeeping Storage Room by the Maintenance Hall
b. Annex Hall "Conference Room"
2. The following doors were not positive latching:
a. Housekeeping Closet on the Maintenance Hall
b. Medical Records om Annex Hall North

2000 NFPA 101, 19.3.6.3.1 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.
2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
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The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include: During the survey, the following are examples of what was observed:


1. Unsealed penetrations at the end of a sleeve, in the Smoke Barrier, at the ER Entrance.

2. Unsealed penetrations around a sprinkler line, and conduit, also at the end of a sleeve, in the Smoke Barrier, in the OR Director Office # 251.


2000 NFPA 101, 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.
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.

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

During the survey, the following are examples of what was found:
The following doors were located in a smoke barrier and were not self-closing:
1. Case Management Office
2. Medical Records on Annex Hall North

2000 NFPA 101, 19.3.7.6 Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6.
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The facility failed to maintain separation of hazardous areas in non sprinklered areas. Findings include: During the survey, the following are examples of what was observed:

A) The Biohazard Room across from Patient Room 209, had unsealed penetrations in the wall around conduit, above the door. The self-closing device for the door was disconnected.


NFPA 101, 19.3.2.1 Hazardous areas shall be safeguarded by a fire barrier of a one-hour fire resistance rating or provided with an automatic sprinkler system.


27382

B) During the survey, the following are examples of what was observed:
First Floor
1. The wall separarting the Boiler Room from the Janitor's Room had an unsealed hole in the wall.
2. The Storage Room by Materials Management Director's Office was over 50 sq. ft., combustibles stored in it, not sprinklered - the door was not 45 minute rated and did not have a self-closing device
3. Central Supply was over 50 sq. ft., had combustibles stored in it, not sprinklered - the door was not 45 minute rated


2000 NFPA 101, 8.4.1.1 Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means: (1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2. (2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42.
2000 NFPA 101, 8.4.1.3 Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.
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The facility failed to maintain the hazardous areas per code. Findings include:

During the survey, the following are examples of what was observed:
The following rooms were being used for storage of combustible materials, were over 50 sq. ft. and the doors did not have self-closing devices:
1. Both Home Health Rooms on the Annex Hall North
2. Medical Records Storage on the Annex Hall North

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 maintain stairways with at least 1 hour fire resistance rating. During the survey, the following are examples of what was observed:


1. Unsealed penetrations around a sprinkler line in the Stairwell by Mop Closet # 253.

2. Unsealed penetrations around a sprinkler line in the stairwell by patient Room 202.


NFPA 101, 19.3.1.1, 8.2.3.2.4, and 7.1.3.2.1 requires a fire resistance rating.

The facility failed to maintain the fire alarm system in proper working order.

A) Findings include: During the survey, the following are examples of what was observed:

While testing the fire alarm system, the alarm could not be heard, in the Materials Management offices, located on the First floor.

NFPA 101, 9.6.1.4 The fire alarm system to be installed, tested, and maintained in accordance with the requirements of NFPA 70 and NFPA 72.


27382


B) During the survey, the following are examples of what was observed:
1. The fire alarm annual inspection dated 06/28-30/2011 did not indicate that the kitchen hood was connected to the fire alarm
Third Floor
2. The fire alarm strobe between rooms 303 and 305 did not flash when the fire alarm was tested



1999 NFPA 72, 7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer ' s recommendations, and shall verify correct operation of the fire alarm system.
1999 NFPA 72, 7-2.2 Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2.
1999 NFPA 72, 4-4.2 Light Pulse Characteristics. The flash rate shall not exceed two flashes per second (2 Hz) nor be less than one flash every second (1 Hz) throughout the listed voltage range of the appliance.

1999 NFPA 72, 4-4.2.1 A maximum pulse duration shall be 0.2 seconds with a maximum duty cycle of 40 percent. The pulse duration shall be defined as the time interval between initial and final points of 10 percent of maximum signal.

1999 NFPA 72, 4-4.2.2* The light source color shall be clear or nominal white and shall not exceed 1000 cd (effective intensity).

1999 NFPA 72, 4-4.3.1 Visible notification appliances used in the public mode shall be located and shall be of a type, size, intensity, and number so that the operating effect of the appliance is seen by the intended viewers regardless of the viewer ' s orientation.

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

During the survey, the following is an example of what was observed:
While testing the fire alarm onthe second floor it was observed that the fire alarm devices could not seen or heard in the two O.R.s .


2000 NFPA 101, 9.6.1.3 The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.
2000 NFPA 101, 9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
2000 NFPA 101, 9.6.1.5 All systems and components shall be approved for the purpose for which they are installed.
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The facility failed to provide complete sprinkler coverage to all parts of the facility.
Findings include: During the survey, the following are examples of what was observed:

1. Missing escutcheon plate on a sprinkler Elevator Lobby Second Floor.

2. Loose escutcheon plate on two sprinklers in the corridor Second Floor.

3. Missing escutcheon plate on a sprinkler in Recovery Room.

4. Missing escutcheon plate on two sprinklers in OR # 2.

5. Missing escutcheon plate on a sprinkler in the corridor in front of OR # 2.

6. Loose escutcheon plate on two sprinklers in OR # 1.

7. Missing escutcheon plate on a sprinkler in the Restroom in ER.


2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

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

During the survey, the following is an example of what was observed:

The Second Floor fire extinguisher's (at the O.R.s) last monthly documented inspection was 01/2011

1998 NFPA 10, 4-3.4.3 Records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or in an electronic system (e.g., bar coding) that provides a permanent record.

1998 NFPA 10, 4-3.1 Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.

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The facility failed to maintain the cooking facilities per code. Findings include:

During the survey, the following are examples of what was observed:
1. Per documentation and interview the facility was not conducting monthly inspections on the kitchen hood suppression system
2. The facility did not have a sign for the K type fire extinguisher, noting it was a secondary device



1998 NFPA 17A, 5-2.1 Inspection shall be conducted on a monthly basis in accordance with the manufacturer ' s listed installation and maintenance manual or the 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) No obvious physical damage or condition exists that might prevent operation. (f) The pressure gauge(s), if provided, is in operable range. (g) The nozzle blowoff caps are intact and undamaged. (h) The hood, duct, and protected cooking appliances have not been replaced, modified, or relocated.
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 had improper heating devices. Findings include: During the survey, the following are examples of what was observed:


Electrical heater was observed in the Doctor's Lounge/Sleeping Room in ER.

NFPA 101, 19.7.8, prohibits the use of portable space heating devices.

The facility failed to maintain the O.R.s per code. Findings include:

During the survey, the following is an example of what was observed:

The two Second Floor O.R.s could not be verified if they had a smoke venting system or not, the facility staff did not know.

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 provide approved electrical utilities. Findings include: During the survey, the following are examples of what was observed:


A junction box was missing the cover above the ceiling by Patient Room 311.


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

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

During the survey, the following is an example of what was observed:
The Transcription Room had a refrigerator and 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.

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

During the survey, the following is an example of what was observed:
The "Passenger Elevator" pit had a pile of debris in the front corner

1996 ASME A17.1, Part XII, 1206.2a Hoistways and pits shall be kept clean and free of dirt and rubbish and shall not be used for storage purposes. Water shall not be allowed to accumulate in pits.