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Based on observation, the facility failed to maintain the integrity of the building construction as evidenced by unsealed wall and ceiling penetrations. This affected two of three smoke compartments, and could result in the passage of smoke in the event of a fire.

During a tour of the facility with the Engineering Supervisor on 2/27/13, the walls and ceilings were observed.

1. At 11:57 a.m., a telephone faceplate was detached from the wall leaving an approximately 3 inch by 4 inch penetration, in the Laboratory.

2. At 12:15 p.m., there was an approximately 1/8 inch circular penetration in the ceiling around a telephone wire, in the Medicine room located in the Operations room.

Based on observation, the facility failed to maintain its corridor doors. This was evidenced by a corridor door that was obstructed from closing. This could result in the passage of smoke in the event of a fire, and affected one of three smoke compartments.

Findings:

During a tour of the facility with the Engineering Supervisor on 2/27/13, the corridor doors were observed.

At 12:05 p.m., a food cart tray obstructed the door to Room 102 from closing.

Based on observation, the facility failed to maintain its fire doors, as evidenced by a fire door with a gap between both the doors. This could result in the passage of smoke in the event of a fire, and affected one of three smoke compartments.

Findings:

During a tour of the facility with the Engineering Supervisor on 2/27/13, the fire doors were observed.

At 12:34 p.m., both of the fire doors to the Emergency Room Registration did not form a seal when closed. There was an approximately 1/4 inch gap in the middle between both doors when the doors closed.

Based on record review, the facility failed to maintain their smoke detectors. This was evidenced by the failure to provide the sensitivity testing range for the smoke detectors in the smoke detector sensitivity testing report. This affected three of three smoke compartments, and could result in delayed notification of a fire due to a malfunctioning or dirty smoke detector.

NFPA 72, 1999 edition
Table 7-3.2 Testing Frequencies
Item 15. Initiating Devices
(h) All Smoke Detectors - Functional (Annually)
7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Findings:

During record review with the Engineering Supervisor on 2/27/13, the facility's smoke detector test and inspection records were reviewed.

On 11:05 a.m., the facility's smoke detector sensitivity test records were reviewed. The facility had a smoke detector sensitivity test completed on 3/27/12. The report did not indicate the sensitivity range for the smoke detectors that were tested.

Based on observation and interview, the facility failed to maintain its automatic sprinkler system. This was evidenced by debris on a sprinkler head, and by items stored less than 18 inches below a sprinkler deflector. The sprinkler deflector diverts the water to create a spray pattern when the sprinkler is activated. This could result in an obstruction to the sprinkler spray pattern, and a delay in extinguishing a fire. This affected two of three smoke compartments.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

Exception No. 1: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.

Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

5-5.6 Clearance to Storage. The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

Findings:

During a tour of the facility with the Engineering Supervisor on 2/27/13, the automatic sprinkler system was observed.

1. At 12:03 p.m., there was white foreign material on the sprinkler head, in the corridor bathroom.

During interview, staff confirmed that there was white foreign material on the sprinkler head.

2. At 12:09 p.m., the sprinkler head had an accumulation of dust, in the Housekeeping Office.

3. At 12:16 p.m., pillows were stored directly below the sprinkler deflector, in the Material Storage room located in Operations room.

Based on observation and interview, the facility failed to maintain their kitchen hood fire suppression system. This was evidenced by the facility's failure to have a current semi-annual inspection on their kitchen hood fire suppression system. This affected one of three smoke compartments, and could result in a fire to build and spread due to a malfunctioning kitchen hood fire suppression system.

NFPA 96, 1998 edition
8-2 Inspection
An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shell be made at least every 6 months by properly trained and qualified persons.

Findings:

During record review with the Engineering Supervisor on 2/27/13, the semi-annual inspections for the kitchen hood fire suppression system were requested.

At 11:48 a.m., the facility's kitchen hood fire suppression system inspection records were requested. The kitchen hood fire suppression system was last serviced and inspected on 8/23/12. Engineering Supervisor was interviewed, and staff acknowledged that they were due for an inspection in February, 2013.

Based on record review and interview, the facility failed to maintain their piped-in medical gas system. This was evidenced by the facility's failure to correct discrepancies noted on their most recent piped-in medical gas system inspection report. This affected two of three smoke compartments, and could result in a piped-in medical gas system malfunction.

Findings:

During record review with the Engineering Supervisor on 2/27/13 at 11:00 a.m., the facility's most recent piped-in medical gas system inspection report was requested. The facility had a piped-in medical gas system inspection on 1/22/13. The inspection report indicated that medical gas alarm set point adjustment was required in the area alarm panel located in the Emergency room by room 4, the zone valve in the Physical Therapy room had improper/missing label for Area served, outlet in Emergency room 2 had a leak with an adapter and damaged/missing parts, and final line regulators not duplexed/Pressure Relief Valve Setting not properly vented outside and screened at the North Wall Manifold Closet.

During interview, Engineering Supervisor confirmed that the repairs have not yet been made. They got quotes and ordering parts for the repairs.

Based on document review and interview, the facility failed to maintain their emergency generator. This was evidenced by missing weekly inspections for 49 of 52 weeks. This could result in a delayed notification of a malfunctioning emergency generator. This affected four of four smoke compartments.

NFPA 110, 1999 Edition
6-3 Maintenance and Operational Testing.
6-3.3 A written schedule for routine maintenance and operational testing of the EPSS shall be established.
6-3.4 A written record for the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises. The written record shall include the following:
(a) The date of the maintenance report
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer.
6-4 Operational Inspection and Testing.
6-4.1* Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.
Findings:
During document review with the Engineering Supervisor on 2/27/13, the emergency generator weekly inspection records were requested.
At 12:05 p.m., the documentation provided for the weekly inspections for the generator had 49 of 52 weeks missing.

Upon interview, staff stated that they did the weekly inspections, and confirmed that they started a documentation log on 2/14/13.

Based on observation, the facility failed to maintain electrical wiring and equipment. This was evidenced by the use of a surge protector, extension cords, a multi-plug adapter, and by a missing faceplate. This deficient practice affected three of three smoke compartments, and could result in the ignition of an electrical fire.

NFPA 70, 1999 edition
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.
400-8 Unless specifically permitted in Section 400-7, flexible cord and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code

410-56(e) After installation, receptacle faces shall be flush with or project from faceplates of insulating material and shall project a minimum of 0.015 in. (0.381 mm) from metal faceplates. Faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.

Findings:

During a tour of the facility with the Engineering Supervisor on 2/27/13, the electrical outlets and utilities were observed.

1. At 11:58 p.m., a blanket warmer and an electric stimulation machine were plugged into a surge protector, in the Therapy room.

2. At 12:00 p.m., a blanket warmer was plugged into a multi-plug adapter, in the Treatment room located in the Therapy room.

3. At 12:06 p.m., a telephone faceplate was missing between Bed C and Bed D, in room 109.

4. At 12:15 p.m., a sterilizer machine and charger were plugged into a green three plug extension cord, that was plugged into an orange extension cord, in the Material Central room located in the Operations room

Based on observation, the facility failed to maintain the integrity of the building construction as evidenced by unsealed wall and ceiling penetrations. This affected two of three smoke compartments, and could result in the passage of smoke in the event of a fire.

During a tour of the facility with the Engineering Supervisor on 2/27/13, the walls and ceilings were observed.

1. At 11:57 a.m., a telephone faceplate was detached from the wall leaving an approximately 3 inch by 4 inch penetration, in the Laboratory.

2. At 12:15 p.m., there was an approximately 1/8 inch circular penetration in the ceiling around a telephone wire, in the Medicine room located in the Operations room.

Based on observation, the facility failed to maintain its corridor doors. This was evidenced by a corridor door that was obstructed from closing. This could result in the passage of smoke in the event of a fire, and affected one of three smoke compartments.

Findings:

During a tour of the facility with the Engineering Supervisor on 2/27/13, the corridor doors were observed.

At 12:05 p.m., a food cart tray obstructed the door to Room 102 from closing.

Based on observation, the facility failed to maintain its fire doors, as evidenced by a fire door with a gap between both the doors. This could result in the passage of smoke in the event of a fire, and affected one of three smoke compartments.

Findings:

During a tour of the facility with the Engineering Supervisor on 2/27/13, the fire doors were observed.

At 12:34 p.m., both of the fire doors to the Emergency Room Registration did not form a seal when closed. There was an approximately 1/4 inch gap in the middle between both doors when the doors closed.

Based on record review, the facility failed to maintain their smoke detectors. This was evidenced by the failure to provide the sensitivity testing range for the smoke detectors in the smoke detector sensitivity testing report. This affected three of three smoke compartments, and could result in delayed notification of a fire due to a malfunctioning or dirty smoke detector.

NFPA 72, 1999 edition
Table 7-3.2 Testing Frequencies
Item 15. Initiating Devices
(h) All Smoke Detectors - Functional (Annually)
7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Findings:

During record review with the Engineering Supervisor on 2/27/13, the facility's smoke detector test and inspection records were reviewed.

On 11:05 a.m., the facility's smoke detector sensitivity test records were reviewed. The facility had a smoke detector sensitivity test completed on 3/27/12. The report did not indicate the sensitivity range for the smoke detectors that were tested.

Based on observation and interview, the facility failed to maintain its automatic sprinkler system. This was evidenced by debris on a sprinkler head, and by items stored less than 18 inches below a sprinkler deflector. The sprinkler deflector diverts the water to create a spray pattern when the sprinkler is activated. This could result in an obstruction to the sprinkler spray pattern, and a delay in extinguishing a fire. This affected two of three smoke compartments.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

Exception No. 1: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.

Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

5-5.6 Clearance to Storage. The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

Findings:

During a tour of the facility with the Engineering Supervisor on 2/27/13, the automatic sprinkler system was observed.

1. At 12:03 p.m., there was white foreign material on the sprinkler head, in the corridor bathroom.

During interview, staff confirmed that there was white foreign material on the sprinkler head.

2. At 12:09 p.m., the sprinkler head had an accumulation of dust, in the Housekeeping Office.

3. At 12:16 p.m., pillows were stored directly below the sprinkler deflector, in the Material Storage room located in Operations room.

Based on observation and interview, the facility failed to maintain their kitchen hood fire suppression system. This was evidenced by the facility's failure to have a current semi-annual inspection on their kitchen hood fire suppression system. This affected one of three smoke compartments, and could result in a fire to build and spread due to a malfunctioning kitchen hood fire suppression system.

NFPA 96, 1998 edition
8-2 Inspection
An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shell be made at least every 6 months by properly trained and qualified persons.

Findings:

During record review with the Engineering Supervisor on 2/27/13, the semi-annual inspections for the kitchen hood fire suppression system were requested.

At 11:48 a.m., the facility's kitchen hood fire suppression system inspection records were requested. The kitchen hood fire suppression system was last serviced and inspected on 8/23/12. Engineering Supervisor was interviewed, and staff acknowledged that they were due for an inspection in February, 2013.

Based on record review and interview, the facility failed to maintain their piped-in medical gas system. This was evidenced by the facility's failure to correct discrepancies noted on their most recent piped-in medical gas system inspection report. This affected two of three smoke compartments, and could result in a piped-in medical gas system malfunction.

Findings:

During record review with the Engineering Supervisor on 2/27/13 at 11:00 a.m., the facility's most recent piped-in medical gas system inspection report was requested. The facility had a piped-in medical gas system inspection on 1/22/13. The inspection report indicated that medical gas alarm set point adjustment was required in the area alarm panel located in the Emergency room by room 4, the zone valve in the Physical Therapy room had improper/missing label for Area served, outlet in Emergency room 2 had a leak with an adapter and damaged/missing parts, and final line regulators not duplexed/Pressure Relief Valve Setting not properly vented outside and screened at the North Wall Manifold Closet.

During interview, Engineering Supervisor confirmed that the repairs have not yet been made. They got quotes and ordering parts for the repairs.

Based on document review and interview, the facility failed to maintain their emergency generator. This was evidenced by missing weekly inspections for 49 of 52 weeks. This could result in a delayed notification of a malfunctioning emergency generator. This affected four of four smoke compartments.

NFPA 110, 1999 Edition
6-3 Maintenance and Operational Testing.
6-3.3 A written schedule for routine maintenance and operational testing of the EPSS shall be established.
6-3.4 A written record for the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises. The written record shall include the following:
(a) The date of the maintenance report
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer.
6-4 Operational Inspection and Testing.
6-4.1* Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.
Findings:
During document review with the Engineering Supervisor on 2/27/13, the emergency generator weekly inspection records were requested.
At 12:05 p.m., the documentation provided for the weekly inspections for the generator had 49 of 52 weeks missing.

Upon interview, staff stated that they did the weekly inspections, and confirmed that they started a documentation log on 2/14/13.

Based on observation, the facility failed to maintain electrical wiring and equipment. This was evidenced by the use of a surge protector, extension cords, a multi-plug adapter, and by a missing faceplate. This deficient practice affected three of three smoke compartments, and could result in the ignition of an electrical fire.

NFPA 70, 1999 edition
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.
400-8 Unless specifically permitted in Section 400-7, flexible cord and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code

410-56(e) After installation, receptacle faces shall be flush with or project from faceplates of insulating material and shall project a minimum of 0.015 in. (0.381 mm) from metal faceplates. Faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.

Findings:

During a tour of the facility with the Engineering Supervisor on 2/27/13, the electrical outlets and utilities were observed.

1. At 11:58 p.m., a blanket warmer and an electric stimulation machine were plugged into a surge protector, in the Therapy room.

2. At 12:00 p.m., a blanket warmer was plugged into a multi-plug adapter, in the Treatment room located in the Therapy room.

3. At 12:06 p.m., a telephone faceplate was missing between Bed C and Bed D, in room 109.

4. At 12:15 p.m., a sterilizer machine and charger were plugged into a green three plug extension cord, that was plugged into an orange extension cord, in the Material Central room located in the Operations room