HospitalInspections.org

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

During the survey, the following is an example of what was observed:
The Dishwash Room had a pass thru opening in the corridor wall for trays, approximately 2' x 4' located above the handrail - the door for this opening was operated manually.

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2000 NFPA 101, 19.3.6.1 Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5. (See also 19.2.5.9.)
2000 NFPA 101, 19.3.6.2.2 Corridor walls shall form a barrier to limit the transfer of smoke.

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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. Pantry (Clean Linen) Room corridor door was missing the positive latching hardware
2. Dishwash Room corridor door had been removed
3. Central Supply corridor door on X-ray side
a. Was not positive latching
b. Had holes in the corridor door

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

2000 NFPA 101, 19.3.6.3.1 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.
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The facility failed to maintain smoke barriers that would provide at least a half hour fire resistance rating and restrict the movement of smoke. See examples:

Small unsealed pipe and wire penetrations were observed in smoke barriers as follows:
a) Over the smoke doors near the Lab
b) Over the smoke doors near the Waiting Room

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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.

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The facility failed to maintain separation of hazardous areas. See example:

1. A self-closing device was not observed on the door to the Telephone Equipment/Storage Room.


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2. The Old Sanitizing Room in the Old Delivery Room (now used as a Storage Room) was missing part of the plaster ceiling
3. The Bathroom in the Old Delivery Room (now used as a Storage Room) had a penetration in the plaster ceiling
4. The Old Delivery Room (now used as a Storage Room) the following doors did not have positive latching hardware:
a. Corridor Door
b. Door to the Doctors' Lounge
5. The Old Delivery Room (now used as a Storage Room) the corridor door did not have a self-closing device
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2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

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A) The facility failed to provide readily accessible exit access. See examples:

The door to the Fire Alarm Control Panel Room opens into the exit access corridor with a projection of approximately 16 " or more from the wall without a self-closing device.

NFPA 101, 7.2.1.4.4 During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 in. (17.8 cm) into the required width of an aisle, corridor, passageway, or landing, when fully open.


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B) The facility failed to maintain the exit access per code. Findings include:

During the survey, the following are examples of what was observed:
1. The emergency door release button at the Nurses' Station did not have a sign
2. The E.R. exit door and the Waiting Room (Front Lobby) doors have full time magnetic locks and did not release under the following conditions:
a. Emergency door release button at the Nurses' Station
b. Loss of the primary power to the fire alarm system serving the protected premises.
3. The Waiting Room (Front Lobby) door did not release under activation of the fire alarm system

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Alabama Department of Public Health Memo "Exit Door Locking Arrangements in Health Care Facilities" revised 08/23/2011, as authority having jurisdiction: an "emergency release switch" or "kill switch" shall be provided at the nearest nurse's station.

2000 NFPA 101, 7.1.9 Any device or alarm installed to restrict the improper use of a means of egress shall be designed and installed so that it cannot, even in case of failure, impede or prevent emergency use of such means of egress unless otherwise provided in 7.2.1.6 and Chapters 18, 19, 22, and 23.

2000 NFPA 101, 7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.

1999 NFPA 72, 3-9.7.2 All exits connected in accordance with 3-9.7.1 shall unlock upon receipt of any fire alarm signal by means of the fire alarm system serving the protected premises.

1999 NFPA 72, 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.
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The facility failed to provide emergency lighting. See example:

Emergency lighting was not observed provided in the CT Scan Trailer which has been on site since 2010 per interview with Administrator.

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NFPA 101, 19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.

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The facility failed to maintain required exit signs. See example:

The exit sign in the CT Scan Trailer, which has been on site since 2010 per interview with Administrator, was observed without illumination of the bulbs.

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NFPA 101, 7.10.5.2* Continuous Illumination. Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.

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

1) The dedicated circuit for the Fire Alarm Control Panel could not be verified by facility staff during the survey.

2) Documentation provided by the facility during the survey did not include the Annual Fire Alarm Inspection Report for the Halon Fire Alarm Control Panel in the CT Scan Trailer which has been on site since 2010 per interview with Administrator.

3) The Halon Fire Alarm Control Panel in the CT Scan Trailer, which has been on site since 2010 per interview with Administrator, was observed not to be functional.

4) The Halon Fire Alarm Control Panel in the CT Scan Trailer, which has been on site since 2010 per interview with Administrator, was observed not connected to the Main Fire Alarm Control Panel in the Hospital.

5) The main Fire Alarm Control Panel in the Hospital indicated Normal while the Fire Alarm Control Panel in the Nursing Home was in alarm while testing. The Monitoring Company was indicating all normal, not receiving a fire alarm signal, during this time when contacted by facility staff, therefore, all panels not communicating with each other.

6) A primary power failure of the Halon Fire Alarm Control Panel in the CT Scan Trailer, which has been on site since 2010 per interview with Administrator, could not be conducted by facility staff.

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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.

1999 NFPA 72, 7-5.2.2 and Figure 7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be maintained which includes periodic tests and applicable information.

NFPA 72, 1-5.2.5.2 Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

NFPA 12A, 2-3.1 Detection, actuation, alarm, and control systems shall be installed, tested, and maintained in accordance with NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.

NFPA 12A, 4-1.1 At least semiannually, all systems shall be thoroughly inspected, tested, and documented for proper operation by trained competent personnel. Tests shall be in accordance with the appropriate NFPA or Canadian standards.

NFPA 12A, 4-7.2.4.4 Testing of the control panel primary power source shall include the following:
(a) Verify that the control panel is connected to a dedicated circuit and labeled properly. This panel shall be readily accessible, yet restricted to unauthorized personnel.
(b) A primary power failure shall be tested in accordance with the manufacturer ' s specification with the system fully operated on standby power for the required design period.

NFPA 72, 3-8.1* Fire Alarm Control Units. Fire alarm systems shall be permitted to be either integrated systems combining all detection, notification, and auxiliary functions in a single system or a combination of component subsystems. Fire alarm system components shall be permitted to share control equipment or shall be able to operate as stand alone subsystems, but, in any case, they shall be arranged to function as a single system. All component subsystems shall be capable of simultaneous, full load operation without degradation of the required, overall system performance.



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7. Per fire alarm inspection report dated 07/11/2011 provided by the facility the following two smoke detectors failed and the facility failed to provide documentation of correction:
a. One in the Lab. Room
b. One in the Enviromental Services Closet

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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.

1999 NFPA 72, 3-9.5.2 If connected to the fire alarm system serving the protected premises, all detection devices used to cause the operation of HVAC systems smoke dampers, fire dampers, fan control, smoke doors, and fire doors shall be monitored for integrity in accordance with 1-5.8.

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.

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The facility failed to provide required sprinkler system. See examples:

1) Sprinkler coverage was not provided in the following exterior areas with plywood ceilings over four feet wide:
a) Front Entrance
b) Two side entrances

2) Sprinkler coverage was not provided in the following exterior areas:
a) Fabric canopy at the ER Entrance (Over four feet wide)
b) Smoking area behind Dietary (Wood framing with metal roofing over four feet wide)

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NFPA 101, 9.7.1.1 Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

1999 NFPA 13, 5-13.8.1 Sprinklers shall be installed under exterior combustible roofs or canopies exceeding four feet in width, or over areas where combustibles are stored.




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3. The facility failed to provide documentation of conducting automatic sprinkler inspection/testing quarterly:
02/23/2012
11/ /2011 - MISSING
08/25/2011
05/16/2011

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2000 NFPA 101, 9.7.5 All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.
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The facility failed to maintain fire extinguishers. See example:

Tagging was not observed on two fire extinguishers in the CT Scan Trailer for monthly inspections.

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

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The facility failed to provide/maintain smoking areas. See examples:

1) Smoking materials were observed mixed with combustible trash in a plastic trash can with a plastic liner in the smoking area behind Dietary.

2) Metal containers with self-closing cover devices into which ashtrays can be emptied were not observed in the following smoking areas:
a) Behind Dietary
b) Two side exit areas


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3) Per documentation provided by the facility the Dirty Utility Room by the Nurses' Station is a designated smoking area, it did not have the following
a. Noncombustible ashtray
b. Metal container with self-closing cover

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NFPA 101, 19.7.4 Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
Exception: In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(2) Smoking by patients classified as not responsible shall be prohibited.
Exception: The requirement of 19.7.4(2) shall not apply where the patient is under direct supervision.
(3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.

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* The facility failed to provide a proper path for HVAC return air. See example:

The corridor in the facility serves as return air plenum to the air handling unit.
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NFPA 101, 9.2 and 1999 NFPA 90a, 2-3.11.1 Egress corridors in health care, detention and correctional and residential occupancies shall not be used as a portion of a supply, return, or exhaust air system serving adjoining areas. An air transfer opening(s) shall not be permitted in walls or in doors separating egress corridors from adjoining areas.

The facility failed to maintain the oxygen storage per code. Findings include:

During the survey, the following are examples of what was observed:
1. An oxygen cylinder in the E.R. was not secured
2. Two oxygen cylinders in the Old Delivery Room (Storage Room) were not secured
3. Oxygen cylinders were being stored with combustibles in the Old Delivery Room (Storage Room)

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1999 NFPA 99, 4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) * Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both) 1. Sources of heat in storage locations shall be protected or located so that cylinders or compressed gases shall not be heated to the activation point of integral safety devices. In no case shall the temperature of the cylinders exceed 130?F (54?C). Care shall be exercised when handling cylinders that have been exposed to freezing temperatures or containers that contain cryogenic liquids to prevent injury to the skin. 2. * Enclosures shall be provided for supply systems cylinder storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour and shall not communicate directly with anesthetizing locations. Other nonflammable (inert) medical gases may be stored in the enclosure. Flammable gases shall not be stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose. 3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
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The facility failed to maintain the piped in medical gas system. See example:

1) Oxygen cylinders were observed unsecured in the piped-in oxygen bank area.

2) The annunciator located at the nursing station for the piped in medical gas system was observed not working.
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1999 NFPA 99, 4-3.1.1.1 Cylinder and Container Management Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.


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3) Per documentation and interview the facility has not had the piped oxygen system inspected in over five years
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1999 NFPA 99, 4-3.4.1.1* General. Inspection and testing shall be performed on all new piped gas systems, additions, renovations, temporary installations, or repaired systems, to assure the facility, by a documented procedure, that all applicable provisions of this document have been adhered to and system integrity has been achieved or maintained.
1999 NFPA 99, 4-3.5.2.3 Patient Gas Systems - Level 1.
(a) * Piping systems shall not be used for the distribution of flammable anesthetic gases.
(b) Nonflammable medical gas systems used to supply gases for respiratory therapy shall be installed in accordance with 4-3.1 of this chapter.
(c) Maintenance programs in accordance with the manufacturers ' recommendations shall be established for the medical air compressor supply system as connected in each individual installation.
(d) * The responsible authority of the facility shall establish procedures to ensure that all signal warnings are promptly evaluated and that all necessary measures are taken to reestablish the proper functions of the medical gas system.
(e) Piping systems for gases shall not be used as a grounding electrode.
(f) The facility shall have the capability and organization to implement a plan to cope with a complete loss of any medical gas system.
(g) A periodic testing procedure for nonflammable medical gas and related alarm systems shall be implemented.
(h) The test specified in 4-3.4.1.3(i) shall be conducted on the downstream portions of the medical gas piping system whenever a system is breached or whenever modifications are made or maintenance performed.
(i) * Periodic retesting of audible and visual alarm indicators shall be performed to determine that they are functioning properly, and records of the test shall be maintained until the next test.

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The facility failed to provide an emergency generator annunciator. See example:

A remote annunciator was not observed provided at any location within the facility for the emergency generator.
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1999 NFPA 99, 3-6.1.1 Generators shall conform to 3-4.1.1 1999 NFPA 99, 3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the Generating Room in a location readily observed by operating personnel at a regular work station.

The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed

Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]

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The facility failed to provide approved electrical utilities. See examples:


1) A junction box without a cover was observed above the ceiling in the Large Dietary Storage Room.
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NFPA 101, 18.5.1 Utilities shall comply with NFPA 101, 9.1.

NFPA 101, 9.1.2 Electrical utilities shall comply with 1999 NFPA 70, National Electrical Code.

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


2) Exposed electrical wires spliced with wire nuts, not in a junction box, were observed above the ceiling in the Large Dietary Storage Room.
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1999 NFPA 70, 343-12 Splices and taps shall be made in junction boxes or other enclosures.


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3. Storage Room next to General Supply Room - an electrical outlet had exposed wires, was not secure in the wall and was missing its cover plate
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2000 NFPA 101, 9.1.2 Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.
1999 NFPA 70, 410-3. Live Part Fixtures, lampholders, lamps, and receptacles shall have no live parts normally exposed to contact. Exposed accessible terminals in lampholders, receptacles, and switches shall not be installed in metal fixture canopies or in open bases of portable table or floor lamps.
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The facility failed to provide a fire watch policy per code. Findings include:

During the survey, the following is an example of what was observed:
Per observation and interview the facility was not notifying the authority having jurisdiction, ADPH, of the fire watch
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2000 NFPA 101, 9.7.6.1 Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.
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The facility failed to provide a fire watch policy per code. Findings include:

During the survey, the following is an example of what was observed:
Per observation and interview the facility was not notifying the authority having jurisdiction, ADPH, of the fire watch
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2000 NFPA 101, 9.6.1.8 Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

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

During the survey, the following is an example of what was observed:
The Dishwash Room had a pass thru opening in the corridor wall for trays, approximately 2' x 4' located above the handrail - the door for this opening was operated manually.

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2000 NFPA 101, 19.3.6.1 Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5. (See also 19.2.5.9.)
2000 NFPA 101, 19.3.6.2.2 Corridor walls shall form a barrier to limit the transfer of smoke.

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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. Pantry (Clean Linen) Room corridor door was missing the positive latching hardware
2. Dishwash Room corridor door had been removed
3. Central Supply corridor door on X-ray side
a. Was not positive latching
b. Had holes in the corridor door

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

2000 NFPA 101, 19.3.6.3.1 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.
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The facility failed to maintain smoke barriers that would provide at least a half hour fire resistance rating and restrict the movement of smoke. See examples:

Small unsealed pipe and wire penetrations were observed in smoke barriers as follows:
a) Over the smoke doors near the Lab
b) Over the smoke doors near the Waiting Room

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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.

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The facility failed to maintain separation of hazardous areas. See example:

1. A self-closing device was not observed on the door to the Telephone Equipment/Storage Room.


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2. The Old Sanitizing Room in the Old Delivery Room (now used as a Storage Room) was missing part of the plaster ceiling
3. The Bathroom in the Old Delivery Room (now used as a Storage Room) had a penetration in the plaster ceiling
4. The Old Delivery Room (now used as a Storage Room) the following doors did not have positive latching hardware:
a. Corridor Door
b. Door to the Doctors' Lounge
5. The Old Delivery Room (now used as a Storage Room) the corridor door did not have a self-closing device
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2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

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A) The facility failed to provide readily accessible exit access. See examples:

The door to the Fire Alarm Control Panel Room opens into the exit access corridor with a projection of approximately 16 " or more from the wall without a self-closing device.

NFPA 101, 7.2.1.4.4 During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 in. (17.8 cm) into the required width of an aisle, corridor, passageway, or landing, when fully open.


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B) The facility failed to maintain the exit access per code. Findings include:

During the survey, the following are examples of what was observed:
1. The emergency door release button at the Nurses' Station did not have a sign
2. The E.R. exit door and the Waiting Room (Front Lobby) doors have full time magnetic locks and did not release under the following conditions:
a. Emergency door release button at the Nurses' Station
b. Loss of the primary power to the fire alarm system serving the protected premises.
3. The Waiting Room (Front Lobby) door did not release under activation of the fire alarm system

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Alabama Department of Public Health Memo "Exit Door Locking Arrangements in Health Care Facilities" revised 08/23/2011, as authority having jurisdiction: an "emergency release switch" or "kill switch" shall be provided at the nearest nurse's station.

2000 NFPA 101, 7.1.9 Any device or alarm installed to restrict the improper use of a means of egress shall be designed and installed so that it cannot, even in case of failure, impede or prevent emergency use of such means of egress unless otherwise provided in 7.2.1.6 and Chapters 18, 19, 22, and 23.

2000 NFPA 101, 7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.

1999 NFPA 72, 3-9.7.2 All exits connected in accordance with 3-9.7.1 shall unlock upon receipt of any fire alarm signal by means of the fire alarm system serving the protected premises.

1999 NFPA 72, 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.
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The facility failed to provide emergency lighting. See example:

Emergency lighting was not observed provided in the CT Scan Trailer which has been on site since 2010 per interview with Administrator.

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NFPA 101, 19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.

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The facility failed to maintain required exit signs. See example:

The exit sign in the CT Scan Trailer, which has been on site since 2010 per interview with Administrator, was observed without illumination of the bulbs.

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NFPA 101, 7.10.5.2* Continuous Illumination. Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.

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

1) The dedicated circuit for the Fire Alarm Control Panel could not be verified by facility staff during the survey.

2) Documentation provided by the facility during the survey did not include the Annual Fire Alarm Inspection Report for the Halon Fire Alarm Control Panel in the CT Scan Trailer which has been on site since 2010 per interview with Administrator.

3) The Halon Fire Alarm Control Panel in the CT Scan Trailer, which has been on site since 2010 per interview with Administrator, was observed not to be functional.

4) The Halon Fire Alarm Control Panel in the CT Scan Trailer, which has been on site since 2010 per interview with Administrator, was observed not connected to the Main Fire Alarm Control Panel in the Hospital.

5) The main Fire Alarm Control Panel in the Hospital indicated Normal while the Fire Alarm Control Panel in the Nursing Home was in alarm while testing. The Monitoring Company was indicating all normal, not receiving a fire alarm signal, during this time when contacted by facility staff, therefore, all panels not communicating with each other.

6) A primary power failure of the Halon Fire Alarm Control Panel in the CT Scan Trailer, which has been on site since 2010 per interview with Administrator, could not be conducted by facility staff.

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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.

1999 NFPA 72, 7-5.2.2 and Figure 7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be maintained which includes periodic tests and applicable information.

NFPA 72, 1-5.2.5.2 Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

NFPA 12A, 2-3.1 Detection, actuation, alarm, and control systems shall be installed, tested, and maintained in accordance with NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.

NFPA 12A, 4-1.1 At least semiannually, all systems shall be thoroughly inspected, tested, and documented for proper operation by trained competent personnel. Tests shall be in accordance with the appropriate NFPA or Canadian standards.

NFPA 12A, 4-7.2.4.4 Testing of the control panel primary power source shall include the following:
(a) Verify that the control panel is connected to a dedicated circuit and labeled properly. This panel shall be readily accessible, yet restricted to unauthorized personnel.
(b) A primary power failure shall be tested in accordance with the manufacturer ' s specification with the system fully operated on standby power for the required design period.

NFPA 72, 3-8.1* Fire Alarm Control Units. Fire alarm systems shall be permitted to be either integrated systems combining all detection, notification, and auxiliary functions in a single system or a combination of component subsystems. Fire alarm system components shall be permitted to share control equipment or shall be able to operate as stand alone subsystems, but, in any case, they shall be arranged to function as a single system. All component subsystems shall be capable of simultaneous, full load operation without degradation of the required, overall system performance.



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7. Per fire alarm inspection report dated 07/11/2011 provided by the facility the following two smoke detectors failed and the facility failed to provide documentation of correction:
a. One in the Lab. Room
b. One in the Enviromental Services Closet

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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.

1999 NFPA 72, 3-9.5.2 If connected to the fire alarm system serving the protected premises, all detection devices used to cause the operation of HVAC systems smoke dampers, fire dampers, fan control, smoke doors, and fire doors shall be monitored for integrity in accordance with 1-5.8.

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.

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The facility failed to provide required sprinkler system. See examples:

1) Sprinkler coverage was not provided in the following exterior areas with plywood ceilings over four feet wide:
a) Front Entrance
b) Two side entrances

2) Sprinkler coverage was not provided in the following exterior areas:
a) Fabric canopy at the ER Entrance (Over four feet wide)
b) Smoking area behind Dietary (Wood framing with metal roofing over four feet wide)

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NFPA 101, 9.7.1.1 Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

1999 NFPA 13, 5-13.8.1 Sprinklers shall be installed under exterior combustible roofs or canopies exceeding four feet in width, or over areas where combustibles are stored.




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3. The facility failed to provide documentation of conducting automatic sprinkler inspection/testing quarterly:
02/23/2012
11/ /2011 - MISSING
08/25/2011
05/16/2011

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2000 NFPA 101, 9.7.5 All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.
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The facility failed to maintain fire extinguishers. See example:

Tagging was not observed on two fire extinguishers in the CT Scan Trailer for monthly inspections.

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

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The facility failed to provide/maintain smoking areas. See examples:

1) Smoking materials were observed mixed with combustible trash in a plastic trash can with a plastic liner in the smoking area behind Dietary.

2) Metal containers with self-closing cover devices into which ashtrays can be emptied were not observed in the following smoking areas:
a) Behind Dietary
b) Two side exit areas


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3) Per documentation provided by the facility the Dirty Utility Room by the Nurses' Station is a designated smoking area, it did not have the following
a. Noncombustible ashtray
b. Metal container with self-closing cover

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NFPA 101, 19.7.4 Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
Exception: In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(2) Smoking by patients classified as not responsible shall be prohibited.
Exception: The requirement of 19.7.4(2) shall not apply where the patient is under direct supervision.
(3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.

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* The facility failed to provide a proper path for HVAC return air. See example:

The corridor in the facility serves as return air plenum to the air handling unit.
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NFPA 101, 9.2 and 1999 NFPA 90a, 2-3.11.1 Egress corridors in health care, detention and correctional and residential occupancies shall not be used as a portion of a supply, return, or exhaust air system serving adjoining areas. An air transfer opening(s) shall not be permitted in walls or in doors separating egress corridors from adjoining areas.

The facility failed to maintain the oxygen storage per code. Findings include:

During the survey, the following are examples of what was observed:
1. An oxygen cylinder in the E.R. was not secured
2. Two oxygen cylinders in the Old Delivery Room (Storage Room) were not secured
3. Oxygen cylinders were being stored with combustibles in the Old Delivery Room (Storage Room)

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1999 NFPA 99, 4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) * Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both) 1. Sources of heat in storage locations shall be protected or located so that cylinders or compressed gases shall not be heated to the activation point of integral safety devices. In no case shall the temperature of the cylinders exceed 130?F (54?C). Care shall be exercised when handling cylinders that have been exposed to freezing temperatures or containers that contain cryogenic liquids to prevent injury to the skin. 2. * Enclosures shall be provided for supply systems cylinder storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour and shall not communicate directly with anesthetizing locations. Other nonflammable (inert) medical gases may be stored in the enclosure. Flammable gases shall not be stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose. 3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
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The facility failed to maintain the piped in medical gas system. See example:

1) Oxygen cylinders were observed unsecured in the piped-in oxygen bank area.

2) The annunciator located at the nursing station for the piped in medical gas system was observed not working.
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1999 NFPA 99, 4-3.1.1.1 Cylinder and Container Management Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.


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3) Per documentation and interview the facility has not had the piped oxygen system inspected in over five years
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1999 NFPA 99, 4-3.4.1.1* General. Inspection and testing shall be performed on all new piped gas systems, additions, renovations, temporary installations, or repaired systems, to assure the facility, by a documented procedure, that all applicable provisions of this document have been adhered to and system integrity has been achieved or maintained.
1999 NFPA 99, 4-3.5.2.3 Patient Gas Systems - Level 1.
(a) * Piping systems shall not be used for the distribution of flammable anesthetic gases.
(b) Nonflammable medical gas systems used to supply gases for respiratory therapy shall be installed in accordance with 4-3.1 of this chapter.
(c) Maintenance programs in accordance with the manufacturers ' recommendations shall be established for the medical air compressor supply system as connected in each individual installation.
(d) * The responsible authority of the facility shall establish procedures to ensure that all signal warnings are promptly evaluated and that all necessary measures are taken to reestablish the proper functions of the medical gas system.
(e) Piping systems for gases shall not be used as a grounding electrode.
(f) The facility shall have the capability and organization to implement a plan to cope with a complete loss of any medical gas system.
(g) A periodic testing procedure for nonflammable medical gas and related alarm systems shall be implemented.
(h) The test specified in 4-3.4.1.3(i) shall be conducted on the downstream portions of the medical gas piping system whenever a system is breached or whenever modifications are made or maintenance performed.
(i) * Periodic retesting of audible and visual alarm indicators shall be performed to determine that they are functioning properly, and records of the test shall be maintained until the next test.

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The facility failed to provide an emergency generator annunciator. See example:

A remote annunciator was not observed provided at any location within the facility for the emergency generator.
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1999 NFPA 99, 3-6.1.1 Generators shall conform to 3-4.1.1 1999 NFPA 99, 3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the Generating Room in a location readily observed by operating personnel at a regular work station.

The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed

Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]

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The facility failed to provide approved electrical utilities. See examples:


1) A junction box without a cover was observed above the ceiling in the Large Dietary Storage Room.
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NFPA 101, 18.5.1 Utilities shall comply with NFPA 101, 9.1.

NFPA 101, 9.1.2 Electrical utilities shall comply with 1999 NFPA 70, National Electrical Code.

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


2) Exposed electrical wires spliced with wire nuts, not in a junction box, were observed above the ceiling in the Large Dietary Storage Room.
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1999 NFPA 70, 343-12 Splices and taps shall be made in junction boxes or other enclosures.


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3. Storage Room next to General Supply Room - an electrical outlet had exposed wires, was not secure in the wall and was missing its cover plate
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2000 NFPA 101, 9.1.2 Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.
1999 NFPA 70, 410-3. Live Part Fixtures, lampholders, lamps, and receptacles shall have no live parts normally exposed to contact. Exposed accessible terminals in lampholders, receptacles, and switches shall not be installed in metal fixture canopies or in open bases of portable table or floor lamps.
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The facility failed to provide a fire watch policy per code. Findings include:

During the survey, the following is an example of what was observed:
Per observation and interview the facility was not notifying the authority having jurisdiction, ADPH, of the fire watch
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2000 NFPA 101, 9.7.6.1 Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.
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The facility failed to provide a fire watch policy per code. Findings include:

During the survey, the following is an example of what was observed:
Per observation and interview the facility was not notifying the authority having jurisdiction, ADPH, of the fire watch
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2000 NFPA 101, 9.6.1.8 Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.