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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


During the revisit, the surveyor observed that the unsealed penetration of the smoke barrier over the smoke doors near the Lab. had not been sealed as per the POC. The facility sealed this penetration while the surveyor was on site.


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27382


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

5. The Old Delivery Room (now used as a Storage Room) the corridor door did not have a self-closing device

During the revisit, the surveyor observed that the Old Delivery Room (now used as a Storage Room) the corridor door did not have a self-closing device as per the POC. The facility installed a self-closing device while the surveyor was on site.

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27382


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

During the survey, the following are examples of what was observed:
2. The Waiting Room (Front Lobby) door has a full time magnetic lock that did not release under the following conditions:
b. Loss of the primary power to the fire alarm system serving the protected premises.

During the revisit, per a phone interview with the company maintaing this door, this door is connected to the batteries for the fire alarm system.

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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, 3-9.7.3 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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27382


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

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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27382


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

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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The facility failed to maintain the piped in medical gas system. See example:

2) The annunciator located at the nursing station for the piped in medical gas system was observed not working.

During the revisit, the surveyor observed that the facility had not corrected this item as per their POC.
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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]