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Based on observation, the facility failed to provide automatically closing doors to protect its hazardous area enclosures. This was evidenced by rooms that posed a degree of hazard greater than that normal to the general occupancy of the building, that were not equipped with door closures, whose doors were being held open and/or were not designed to automatically close upon activation of the fire alarm system.
This was also evidenced by a fire barrier door that was being held open and was not arranged to automatically close upon activation of the fire alarm system.
This deficient practice affected all staff and patients in two of two smoke compartments within the general acute care portion of the hospital and could potentially result in the spread of smoke and/or fire.

Findings:

During a tour of the facility with the Maintenance Staff, smoke barrier doors were inspected.

Main Hospital
1. On 5/15/12, at 2:35 p.m., the corridor door to the Laboratory was being held open by friction at the door closure. This door was not equipped with a device arranged to automatically close upon activation of the fire alarm system.

2. On 5/15/12, at 3:25 p.m., the Business Office had approximately 35 percent of walls and surface area of the office furniture that were covered with attached and hanging loose papers. Outside of the Business Office corridor door was an approximately four foot by four foot paper organizer that was approximately 50 percent full of standard size sheet paper.
The corridor door to the Business Office was being held fully open by friction at the door closure. This room had a wall separating it from the Accounting Office that had a standard glass window in it that was in the open position making it a communicating opening between the two rooms. The Accounting Office corridor door was open and did not have a door closure on it.
The two above-mentioned corridor doors to the Business Office and Accounting Office were not arranged to close automatically upon activation of the fire alarm system. These doors were open to the corridor throughout the survey.

3. On 5/16/12, at 9:18 a.m., the door identified on the facility evacuation diagram as a fire door near the Emergency Room was being held open by friction at the door closure. This door was not equipped with a device that would automatically close the door upon activation of the fire alarm system.
This door was held open throughout the survey.

Based on observation, the facility failed to maintain the one and one-half hour fire-rated construction of its smoke barrier walls in accordance with 2000 NFPA 101. This was evidenced by unsealed penetrations observed in the smoke/fire barrier wall. This affected one of two smoke compartments within the facility and could potentially result in smoke and/or fire spreading from one smoke compartment to another.

8.3.6.1: Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
1. The space between the penetrating item and the smoke barrier shall meet one following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
2. Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b It shall be protected by an approved device that is designed for the specific purpose.
3. Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with Maintenance Staff, smoke/fire barrier walls were inspected.

Main Hospital
1. On 5/16/12, at 9:05 a.m., the one and one-half hour fire-rated wall in the attic above Patient Room 4 had a metal sleeve that was not sealed on the end. This sleeve was approximately one inch in diameter and had data cables traveling through it.

Based on observation and interview, the facility failed to ensure that exits are readily accessible at all times in accordance with 2000 NFPA 101. This was evidenced by an exit door that could be locked against egress which had latching mechanisms located higher than 48 inches above the finished floor. This was also evidenced by an exit door that was equipped with a double-action locking device requiring more that one motion to open the door when locked. This affected all staff and patients in two of two smoke compartments and could potentially result in a delayed egress in the event of an emergency.

3.3.121* Means of Egress. A continuous and unobstructed way of travel from any point in a building or structure to a public way consisting of three separate and distinct parts: (1) the exit access, (2) the exit, and (3) the exit discharge.

7.2.1.5 Locks and Latches.
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.

7.2.1.5.4* A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.

19.2.2.2.4 Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.
Exception No. 1: Door-locking arrangements without delayed egress shall be permitted in health care occupancies, or portions of health care occupancies, where the clinical needs of the patients require specialized
security measures for their safety, provided that staff can readily unlock such doors at all times. (See 19.1.1.1.5 and 19.2.2.2.5.)
Exception No. 2:* Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path.
Exception No. 3: Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted.

19.2.2.2.5 Doors located in the means of egress that are permitted to be locked under other provisions of this chapter shall have adequate provisions made for the rapid removal of occupants by means such as remote control of locks, keying of all locks to keys carried by staff at all times, or other such reliable means available to the staff at all times. Only one such locking device shall be permitted on each door.
Exception No. 1: Locks in accordance with Exception Nos. 2 and 3 to
19.2.2.2.4.
Exception No. 2: More than one lock shall be permitted on each door
subject to approval of the authority having jurisdiction.

Findings:

Clinic Building
During a tour of the facility with Maintenance Staff on 5/15/12, exit doors were inspected.

1. At 2:22 p.m., the corridor door leading to the front lobby exit was equipped with double-action latching/locking hardware requiring two distinct motions to open the door from the egress side.

Main Hospital Building
During a tour of the facility with Maintenance Staff on 5/16/12, exit doors were inspected.

2. At 11:05 a.m., the glass Front Lobby exit door had a deadbolt type lock that was 52 inches above the floor. This dead bolt lock had a key in it on the egress side allowing the front door to be locked from the inside. When Staff A1 was asked about the key, Staff stated that the door was locked at night for security reasons to keep people from entering the building. Staff also stated that the key could not be removed because it was stuck in the door. This surveyor noted that the panic hardware and lock on the door were no long working.

Based on observation, the facility failed to provide illumination of means of egress in accordance with 2000 NFPA 101. This was evidenced by the failure to provide emergency lights in the corridors of its health clinic. This affected one of two buildings and could potentially result in injury or a delayed evacuation in the event of an emergency


39.2.8 Illumination of Means of Egress. Means of egress shall be illuminated in accordance with Section 7.8.

7.8.1.2 Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use. Artificial lighting shall
be employed at such locations and for such periods of time as required to maintain the illumination to the minimum criteria values herein specified.
Exception: Automatic, motion sensor-type lighting switches shall be permitted within the means of egress, provided that the switch controllers are equipped for fail-safe operation, the illumination timers are set for a minimum 15-minute duration, and the motion sensor is activated by any occupant movement in the area served by the lighting units.
7.8.1.3* The floors and other walking surfaces within an exit and within the portions of the exit access and exit discharge designated in 7.8.1.1 shall be illuminated to values of at least
1 ft-candle (10 lux) measured at the floor.
Exception No. 1: In assembly occupancies, the illumination of the floors of exit access shall be at least 0.2 ft-candle (2 lux) during periods of performances or projections involving directed light.
Exception No. 2:* This requirement shall not apply where operations or processes require low lighting levels.
7.8.1.4* Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2 lux) in any designated area.
7.8.1.5 The equipment or units installed to meet the requirements of Section 7.10 also shall be permitted to serve the function of illumination of means of egress, provided that all requirements of Section 7.8 for such illumination are met.
7.8.2 Sources of Illumination.
7.8.2.1* Illumination of means of egress shall be from a source considered reliable by the authority having jurisdiction.
7.8.2.2 Battery-operated electric lights and other types of portable lamps or lanterns shall not be used for primary illumination of means of egress. Battery-operated electric lights shall be permitted to be used as an emergency source to the extent permitted under Section 7.9.

Findings:

Clinic Building
During a tour of the facility with Maintenance Staff on 5/15/12, egress was inspected throughout the facility.

1. At 2:20 p.m., the Health Clinic did not have emergency egress lights in the corridors.
During an interview with Staff A4, Staff stated that the hours of operation for the clinic were between 8:00 a.m., and 5:00 p.m., and that during some winter months it was dark outside by that time.
This family clinic is a business occupancy, but is still required to have emergency egress lights in areas that may be dark during a power outage. This building does not have emergency back-up power supplied by a UPS or Generator.

Based on observation and document review, the facility failed to provide emergency illumination in accordance with 2000 NFPA 101. This was evidenced by the facility's failure to test its battery-powered emergency lighting units on a monthly and annual schedule. This affected all staff and patients in one of two smoke compartments within the general acute care portion of the hospital and could potentially result in injury or a delayed evacuation in the event of an emergency.

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

Main Hospital building
During document review, the facility failed to provide documentation for the testing of its battery-powered emergency lighting equipment. Documentation provided indicated that the testing was being done bi-annually. Documentation did not indicate the duration of the monthly or annual tests. Staff A1 stated that the testing was done bi-annually but was unsure of the testing duration requirements.

Based on observation, the facility failed to maintain all exit and directional signs in accordance with 2000 NFPA 101. This was evidenced by exit signs which were not illuminated. It is essential that all exit signs are properly illuminated in order to identify the location of exits in an emergency situation. This deficient practice affected all patient in one of two buildings and could potentially result in a delayed evacuation in the event of an emergency.

Findings:

Clinic Building
During a tour of the facility with Maintenance Staff on 5/15/12, exit signs were inspected throughout the facility.

At 2:20 p.m., five of five exit signs in the clinic were not illuminated. Staff A1 stated that he thought that they were designed to come on when it was dark outside.

During an interview on 5/16/12, at 8:48 a.m., Staff A1 stated that they had found a breaker that was in the off position and that that was the reason that the exit lights were not on.
During a reinspection of the clinic between 8:45 a.m. and 9:00 a.m., this surveyor noted that five of five exit signs were illuminated.

Based on record review and staff interview, the facility failed to hold disaster drills twice per year in accordance with 2000 NFPA 101 and 1999 NFPA 99. This was evidenced by a lack of documentation provided for one of two required disaster drills in a twelve month period. This deficient practice affected all staff and patients within the facility and could potentially result in staff not being well trained and familiar with disaster response procedures.


NFPA 99 11-5.3.9 "Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually...."

Findings:

Main Hospital Building
1. During record review with on 5/15/12, at 10:45 a.m., the facility failed to provide documentation for one of two required disaster drills for a twelve month period. Documentation provided for the disaster drill was dated 5/5/12. This documentation did not have a critique of the drill. Administrative Staff AS 3 stated that this was the only disaster drill that had been documented in a 12 month period and that they had not had time to critique the drill yet.

The facility's policy for disaster drills stated that an external drill would be done annually and that internal drills would be done quarterly.

Based on record review and staff interview, the facility failed to periodically test and maintain its automatic sprinkler system in accordance with NFPA 101, 4.6.12 and NFPA 25. This was evidenced by a lack of documentation provided for the annual sprinkler inspection by a qualified person, sprinkler escutcheons that were not flush to the ceiling creating a penetration around the sprinkler pipe, and item placement that would prevent the spray pattern from providing complete coverage This affected two of two smoke compartments within the facility and could potentially result in the spread of smoke and/or fire if the sprinkler system failed to function as required.

NFPA 101
4.6.12 Maintenance and Testing.
4.6.12.3 Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.

1998 NFPA 25
Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance
Item Activity Frequency Reference
Gauges (dry, preaction deluge systems) Inspection Weekly/monthly 2-2.4.2
Control valves Inspection Weekly/monthly Table 9-1
Alarm devices Inspection Quarterly 2-2.6
Gauges (wet pipe systems) Inspection Monthly 2-2.4.1
Hydraulic nameplate Inspection Quarterly 2-2.7
Buildings Inspection Annually (prior to freezing weather) 2-2.5
Hanger/seismic bracing Inspection Annually 2-2.3
Pipe and fittings Inspection Annually 2-2.2
Sprinklers Inspection Annually 2-2.1.1
Spare sprinklers Inspection Annually 2-2.1.3
Fire department connections Inspection Table 9-1
Valves (all types) Inspection Table 9-1
Alarm devices Test Quarterly 2-3.3
Main drain Test Annually Table 9-1
Antifreeze solution Test Annually 2-3.4
Gauges Test 5 years 2-3.2
Obstruction investigation Maintenance 5 years or as needed Chapter 10


Findings:

During record review on 5/15/12 at 10:45 a.m., documentation for automatic sprinkler system testing and inspection was reviewed:

Main Hospital Building
1. At 10:45 a.m., the facility failed to provide documentation for the Annual Sprinkler System inspection and Testing from a certified vendor.
During an interview with AS1 on 5/16/12, at 8:10 a.m., Staff stated that they had been performing the annual inspection of the sprinkler system in-house.

2. At 3:39 p.m., the sprinkler escutcheon located in the Janitor's Closet in the Dining Room was not flush to the ceiling creating an approximately one-half inch unsealed penetration around the pipe.

3. At 3:41 p.m., the sprinkler escutcheon in Medical Records Room was not flush to the ceiling creating an approximately one-half inch unsealed penetration around the pipe.

4. At 3:46 p.m., the sprinkler escutcheon located in the Kitchen walk-in freezer had slipped down creating an approximately one-half inch unsealed penetration.

5. At 3:46 p.m., the sidewall sprinkler located in the walk-in freezer had boxes stored within approximally ten inches in front of it.

Based on observation, the facility failed to maintain its portable fire extinguishers in accordance with 1998 NFPA 10. This was evidenced by fire extinguishers that were mounted greater than 60 inches above the floor. This deficient practice affected staff and patients in two of two smoke compartments at the Main Hospital and one of one smoke compartments at the Clinic building and could potentially cause a delay in access to the fire extinguishers resulting in the spread of smoke and/or fire.

NFPA 10, 1998 edition
1-6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.
1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

Findings:

During a tour of the facility with Maintenance Staff on 5/15/12, fire extinguishers were inspected

Clinic Building
1. At 2:33 p.m., the fire extinguisher located in the Main Corridor was mounted to the wall approximately 70 inches above the floor.

Main Hospital Building
2. At 3:57 p.m., the K type fire extinguisher located in the Kitchen was mounted to the wall approximately 64 inches above the floor.

3. At 4:00 p.m., the fire extinguisher located in the entry into the Conference Room was mounted to the wall approximately 64 inches above the floor.

Based on observation, the facility failed to maintain its heating, ventilation, and air conditioning system (HVAC), in accordance with NFPA 90A. This was evidenced by an exhaust duct which vented directly into the attic. This deficient practice affected one of two smoke compartments within the Main Hospital Building and could potentially result in the spread of smoke and/or fire.

1-1 Introduction. An air duct system has the potential to convey smoke, hot gases, and flame from area to area and to supply air to aid combustion in the fire area. For these reasons, fire protection of an air duct system is essential to safety to life and the protection of property. However, an air duct system ' s fire integrity also enables it to be used as part of a building ' s fire protection system. (See Section 1-4.)

2-3.1 Air Ducts.
2-3.1.1 Air ducts shall be permitted to be rigid or flexible and shall be constructed of materials that are reinforced and sealed to satisfy the requirements for the use of the air duct system, such as the supply air system, the return or exhaust air system, and the variable volume/pressure air system.

Findings:

Main Hospital Building
During a tour of the facility with Maintenance Staff on 5/16/12, at 9:13 a.m., the ceiling vent and twelve inch vent pipe in the Administrator's Office was fully open to the attic. The vent pipe terminated at approximately twelve inches above the floor of the attic.

Based on observation, the facility failed to ensure that all means of egress are continuously maintained free of obstructions to full, instant use in the case of fire or other emergency in accordance with 2000 NFPA 101. This was evidenced by items stored in the exit discharge. This deficient practice affected all staff and patients in one of four smoke compartments within the facility and could potentially result in injury or a delayed evacuation in the event of an emergency.

Findings:

During a tour of the facility on 5/15/12, exit discharge was inspected throughout the facility.

1. At 3:45 p.m., there were three Gerry chairs located in the exit discharge area at the South Entrance of the building.

Based on observation, the facility failed to protect its medical compressed gas cylinders in accordance with 1999 NFPA 99. This was evidenced by cylinders which were stored free standing unsecured on the floor. This deficient practice affected one of two buildings and could potentially result in injury or damage to the cylinders if they were to fall.

4-3.1.1.1 "Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over."

Findings:

During a tour of the facility with Maintenance Staff on 5/15/12, compressed gas cylinders were observed.

Clinic Building
1. At 2:22 p.m., the Dental Lab had two E-size oxygen cylinders and two E-size nitrogen cylinders that were sitting on the floor unsecured.

2. At 2:36 p.m., the northeast Exam Room had two 45 pound nitrous oxide tanks sitting unsecured on the floor.

Based on document review and interview, the facility failed to provide continuing safety education in accordance with 1999 NFPA 99. This was evidenced by the facility's failure to provide documentation for laboratory safety education for all laboratory personnel. This affected one of two smoke compartments within the facility and could potentially result in accidents occurring in the laboratory.

10-2.1.4 Orientation and Training.
safety practices for the laboratory and specific safety practices for the equipment and procedures they will use.

Findings:

During document review with Maintenance Staff on 5/15/12, at 10:45 a.m., the facility failed to provide documentation of laboratory-specific safety training. Staff A5 stated that the three laboratory staff did review the policy and procedures and discuss laboratory safety, but that it was not documented.

Based on observation, the facility failed to comply with the regulations regarding electrical wiring and utilities in accordance with 1999 NFPA 70 and 1999 NFPA 99. This was evidenced by the permanent use of extension cords and power strips that were plugged into each other. This deficient practice affected staff and residents in one of two smoke compartments and could potentially result in the ignition of fire.

NFPA 70
400.8 Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors.

400-10 Flexible cords and cables shall be connected to devices and to fittings so that tension will not be transmitted to joints or terminals.

NFPA 99 3-3.2.1.2, All patient care areas.
(d)(2) Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.


Findings:

Main Hospital Building
During a tour of the facility on 5/15/12, electrical wiring and equipment were inspected.

1. At 4:00 p.m., the Conference Room had two flexible cords that were approximately four feet long with a single gang junction box and outlet plugged into the wall outlet. This outlet had a power strip plugged into it.

2. At 4:00 p.m., the Emergency Room had a flexible cord that was approximately four feet long with a single gang junction box and outlet plugged into the wall outlet. This outlet had a power strip plugged into it. The power strip had a medical device plugged into it.

Based on observation, the facility failed to provide automatically closing doors to protect its hazardous area enclosures. This was evidenced by rooms that posed a degree of hazard greater than that normal to the general occupancy of the building, that were not equipped with door closures, whose doors were being held open and/or were not designed to automatically close upon activation of the fire alarm system.
This was also evidenced by a fire barrier door that was being held open and was not arranged to automatically close upon activation of the fire alarm system.
This deficient practice affected all staff and patients in two of two smoke compartments within the general acute care portion of the hospital and could potentially result in the spread of smoke and/or fire.

Findings:

During a tour of the facility with the Maintenance Staff, smoke barrier doors were inspected.

Main Hospital
1. On 5/15/12, at 2:35 p.m., the corridor door to the Laboratory was being held open by friction at the door closure. This door was not equipped with a device arranged to automatically close upon activation of the fire alarm system.

2. On 5/15/12, at 3:25 p.m., the Business Office had approximately 35 percent of walls and surface area of the office furniture that were covered with attached and hanging loose papers. Outside of the Business Office corridor door was an approximately four foot by four foot paper organizer that was approximately 50 percent full of standard size sheet paper.
The corridor door to the Business Office was being held fully open by friction at the door closure. This room had a wall separating it from the Accounting Office that had a standard glass window in it that was in the open position making it a communicating opening between the two rooms. The Accounting Office corridor door was open and did not have a door closure on it.
The two above-mentioned corridor doors to the Business Office and Accounting Office were not arranged to close automatically upon activation of the fire alarm system. These doors were open to the corridor throughout the survey.

3. On 5/16/12, at 9:18 a.m., the door identified on the facility evacuation diagram as a fire door near the Emergency Room was being held open by friction at the door closure. This door was not equipped with a device that would automatically close the door upon activation of the fire alarm system.
This door was held open throughout the survey.

Based on observation, the facility failed to maintain the one and one-half hour fire-rated construction of its smoke barrier walls in accordance with 2000 NFPA 101. This was evidenced by unsealed penetrations observed in the smoke/fire barrier wall. This affected one of two smoke compartments within the facility and could potentially result in smoke and/or fire spreading from one smoke compartment to another.

8.3.6.1: Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
1. The space between the penetrating item and the smoke barrier shall meet one following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
2. Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b It shall be protected by an approved device that is designed for the specific purpose.
3. Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with Maintenance Staff, smoke/fire barrier walls were inspected.

Main Hospital
1. On 5/16/12, at 9:05 a.m., the one and one-half hour fire-rated wall in the attic above Patient Room 4 had a metal sleeve that was not sealed on the end. This sleeve was approximately one inch in diameter and had data cables traveling through it.

Based on observation and interview, the facility failed to ensure that exits are readily accessible at all times in accordance with 2000 NFPA 101. This was evidenced by an exit door that could be locked against egress which had latching mechanisms located higher than 48 inches above the finished floor. This was also evidenced by an exit door that was equipped with a double-action locking device requiring more that one motion to open the door when locked. This affected all staff and patients in two of two smoke compartments and could potentially result in a delayed egress in the event of an emergency.

3.3.121* Means of Egress. A continuous and unobstructed way of travel from any point in a building or structure to a public way consisting of three separate and distinct parts: (1) the exit access, (2) the exit, and (3) the exit discharge.

7.2.1.5 Locks and Latches.
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.

7.2.1.5.4* A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.

19.2.2.2.4 Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.
Exception No. 1: Door-locking arrangements without delayed egress shall be permitted in health care occupancies, or portions of health care occupancies, where the clinical needs of the patients require specialized
security measures for their safety, provided that staff can readily unlock such doors at all times. (See 19.1.1.1.5 and 19.2.2.2.5.)
Exception No. 2:* Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path.
Exception No. 3: Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted.

19.2.2.2.5 Doors located in the means of egress that are permitted to be locked under other provisions of this chapter shall have adequate provisions made for the rapid removal of occupants by means such as remote control of locks, keying of all locks to keys carried by staff at all times, or other such reliable means available to the staff at all times. Only one such locking device shall be permitted on each door.
Exception No. 1: Locks in accordance with Exception Nos. 2 and 3 to
19.2.2.2.4.
Exception No. 2: More than one lock shall be permitted on each door
subject to approval of the authority having jurisdiction.

Findings:

Clinic Building
During a tour of the facility with Maintenance Staff on 5/15/12, exit doors were inspected.

1. At 2:22 p.m., the corridor door leading to the front lobby exit was equipped with double-action latching/locking hardware requiring two distinct motions to open the door from the egress side.

Main Hospital Building
During a tour of the facility with Maintenance Staff on 5/16/12, exit doors were inspected.

2. At 11:05 a.m., the glass Front Lobby exit door had a deadbolt type lock that was 52 inches above the floor. This dead bolt lock had a key in it on the egress side allowing the front door to be locked from the inside. When Staff A1 was asked about the key, Staff stated that the door was locked at night for security reasons to keep people from entering the building. Staff also stated that the key could not be removed because it was stuck in the door. This surveyor noted that the panic hardware and lock on the door were no long working.

Based on observation, the facility failed to provide illumination of means of egress in accordance with 2000 NFPA 101. This was evidenced by the failure to provide emergency lights in the corridors of its health clinic. This affected one of two buildings and could potentially result in injury or a delayed evacuation in the event of an emergency


39.2.8 Illumination of Means of Egress. Means of egress shall be illuminated in accordance with Section 7.8.

7.8.1.2 Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use. Artificial lighting shall
be employed at such locations and for such periods of time as required to maintain the illumination to the minimum criteria values herein specified.
Exception: Automatic, motion sensor-type lighting switches shall be permitted within the means of egress, provided that the switch controllers are equipped for fail-safe operation, the illumination timers are set for a minimum 15-minute duration, and the motion sensor is activated by any occupant movement in the area served by the lighting units.
7.8.1.3* The floors and other walking surfaces within an exit and within the portions of the exit access and exit discharge designated in 7.8.1.1 shall be illuminated to values of at least
1 ft-candle (10 lux) measured at the floor.
Exception No. 1: In assembly occupancies, the illumination of the floors of exit access shall be at least 0.2 ft-candle (2 lux) during periods of performances or projections involving directed light.
Exception No. 2:* This requirement shall not apply where operations or processes require low lighting levels.
7.8.1.4* Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2 lux) in any designated area.
7.8.1.5 The equipment or units installed to meet the requirements of Section 7.10 also shall be permitted to serve the function of illumination of means of egress, provided that all requirements of Section 7.8 for such illumination are met.
7.8.2 Sources of Illumination.
7.8.2.1* Illumination of means of egress shall be from a source considered reliable by the authority having jurisdiction.
7.8.2.2 Battery-operated electric lights and other types of portable lamps or lanterns shall not be used for primary illumination of means of egress. Battery-operated electric lights shall be permitted to be used as an emergency source to the extent permitted under Section 7.9.

Findings:

Clinic Building
During a tour of the facility with Maintenance Staff on 5/15/12, egress was inspected throughout the facility.

1. At 2:20 p.m., the Health Clinic did not have emergency egress lights in the corridors.
During an interview with Staff A4, Staff stated that the hours of operation for the clinic were between 8:00 a.m., and 5:00 p.m., and that during some winter months it was dark outside by that time.
This family clinic is a business occupancy, but is still required to have emergency egress lights in areas that may be dark during a power outage. This building does not have emergency back-up power supplied by a UPS or Generator.

Based on observation and document review, the facility failed to provide emergency illumination in accordance with 2000 NFPA 101. This was evidenced by the facility's failure to test its battery-powered emergency lighting units on a monthly and annual schedule. This affected all staff and patients in one of two smoke compartments within the general acute care portion of the hospital and could potentially result in injury or a delayed evacuation in the event of an emergency.

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

Main Hospital building
During document review, the facility failed to provide documentation for the testing of its battery-powered emergency lighting equipment. Documentation provided indicated that the testing was being done bi-annually. Documentation did not indicate the duration of the monthly or annual tests. Staff A1 stated that the testing was done bi-annually but was unsure of the testing duration requirements.

Based on observation, the facility failed to maintain all exit and directional signs in accordance with 2000 NFPA 101. This was evidenced by exit signs which were not illuminated. It is essential that all exit signs are properly illuminated in order to identify the location of exits in an emergency situation. This deficient practice affected all patient in one of two buildings and could potentially result in a delayed evacuation in the event of an emergency.

Findings:

Clinic Building
During a tour of the facility with Maintenance Staff on 5/15/12, exit signs were inspected throughout the facility.

At 2:20 p.m., five of five exit signs in the clinic were not illuminated. Staff A1 stated that he thought that they were designed to come on when it was dark outside.

During an interview on 5/16/12, at 8:48 a.m., Staff A1 stated that they had found a breaker that was in the off position and that that was the reason that the exit lights were not on.
During a reinspection of the clinic between 8:45 a.m. and 9:00 a.m., this surveyor noted that five of five exit signs were illuminated.

Based on record review and staff interview, the facility failed to hold disaster drills twice per year in accordance with 2000 NFPA 101 and 1999 NFPA 99. This was evidenced by a lack of documentation provided for one of two required disaster drills in a twelve month period. This deficient practice affected all staff and patients within the facility and could potentially result in staff not being well trained and familiar with disaster response procedures.


NFPA 99 11-5.3.9 "Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually...."

Findings:

Main Hospital Building
1. During record review with on 5/15/12, at 10:45 a.m., the facility failed to provide documentation for one of two required disaster drills for a twelve month period. Documentation provided for the disaster drill was dated 5/5/12. This documentation did not have a critique of the drill. Administrative Staff AS 3 stated that this was the only disaster drill that had been documented in a 12 month period and that they had not had time to critique the drill yet.

The facility's policy for disaster drills stated that an external drill would be done annually and that internal drills would be done quarterly.

Based on record review and staff interview, the facility failed to periodically test and maintain its automatic sprinkler system in accordance with NFPA 101, 4.6.12 and NFPA 25. This was evidenced by a lack of documentation provided for the annual sprinkler inspection by a qualified person, sprinkler escutcheons that were not flush to the ceiling creating a penetration around the sprinkler pipe, and item placement that would prevent the spray pattern from providing complete coverage This affected two of two smoke compartments within the facility and could potentially result in the spread of smoke and/or fire if the sprinkler system failed to function as required.

NFPA 101
4.6.12 Maintenance and Testing.
4.6.12.3 Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.

1998 NFPA 25
Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance
Item Activity Frequency Reference
Gauges (dry, preaction deluge systems) Inspection Weekly/monthly 2-2.4.2
Control valves Inspection Weekly/monthly Table 9-1
Alarm devices Inspection Quarterly 2-2.6
Gauges (wet pipe systems) Inspection Monthly 2-2.4.1
Hydraulic nameplate Inspection Quarterly 2-2.7
Buildings Inspection Annually (prior to freezing weather) 2-2.5
Hanger/seismic bracing Inspection Annually 2-2.3
Pipe and fittings Inspection Annually 2-2.2
Sprinklers Inspection Annually 2-2.1.1
Spare sprinklers Inspection Annually 2-2.1.3
Fire department connections Inspection Table 9-1
Valves (all types) Inspection Table 9-1
Alarm devices Test Quarterly 2-3.3
Main drain Test Annually Table 9-1
Antifreeze solution Test Annually 2-3.4
Gauges Test 5 years 2-3.2
Obstruction investigation Maintenance 5 years or as needed Chapter 10


Findings:

During record review on 5/15/12 at 10:45 a.m., documentation for automatic sprinkler system testing and inspection was reviewed:

Main Hospital Building
1. At 10:45 a.m., the facility failed to provide documentation for the Annual Sprinkler System inspection and Testing from a certified vendor.
During an interview with AS1 on 5/16/12, at 8:10 a.m., Staff stated that they had been performing the annual inspection of the sprinkler system in-house.

2. At 3:39 p.m., the sprinkler escutcheon located in the Janitor's Closet in the Dining Room was not flush to the ceiling creating an approximately one-half inch unsealed penetration around the pipe.

3. At 3:41 p.m., the sprinkler escutcheon in Medical Records Room was not flush to the ceiling creating an approximately one-half inch unsealed penetration around the pipe.

4. At 3:46 p.m., the sprinkler escutcheon located in the Kitchen walk-in freezer had slipped down creating an approximately one-half inch unsealed penetration.

5. At 3:46 p.m., the sidewall sprinkler located in the walk-in freezer had boxes stored within approximally ten inches in front of it.

Based on observation, the facility failed to maintain its portable fire extinguishers in accordance with 1998 NFPA 10. This was evidenced by fire extinguishers that were mounted greater than 60 inches above the floor. This deficient practice affected staff and patients in two of two smoke compartments at the Main Hospital and one of one smoke compartments at the Clinic building and could potentially cause a delay in access to the fire extinguishers resulting in the spread of smoke and/or fire.

NFPA 10, 1998 edition
1-6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.
1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

Findings:

During a tour of the facility with Maintenance Staff on 5/15/12, fire extinguishers were inspected

Clinic Building
1. At 2:33 p.m., the fire extinguisher located in the Main Corridor was mounted to the wall approximately 70 inches above the floor.

Main Hospital Building
2. At 3:57 p.m., the K type fire extinguisher located in the Kitchen was mounted to the wall approximately 64 inches above the floor.

3. At 4:00 p.m., the fire extinguisher located in the entry into the Conference Room was mounted to the wall approximately 64 inches above the floor.

Based on observation, the facility failed to maintain its heating, ventilation, and air conditioning system (HVAC), in accordance with NFPA 90A. This was evidenced by an exhaust duct which vented directly into the attic. This deficient practice affected one of two smoke compartments within the Main Hospital Building and could potentially result in the spread of smoke and/or fire.

1-1 Introduction. An air duct system has the potential to convey smoke, hot gases, and flame from area to area and to supply air to aid combustion in the fire area. For these reasons, fire protection of an air duct system is essential to safety to life and the protection of property. However, an air duct system ' s fire integrity also enables it to be used as part of a building ' s fire protection system. (See Section 1-4.)

2-3.1 Air Ducts.
2-3.1.1 Air ducts shall be permitted to be rigid or flexible and shall be constructed of materials that are reinforced and sealed to satisfy the requirements for the use of the air duct system, such as the supply air system, the return or exhaust air system, and the variable volume/pressure air system.

Findings:

Main Hospital Building
During a tour of the facility with Maintenance Staff on 5/16/12, at 9:13 a.m., the ceiling vent and twelve inch vent pipe in the Administrator's Office was fully open to the attic. The vent pipe terminated at approximately twelve inches above the floor of the attic.

Based on observation, the facility failed to ensure that all means of egress are continuously maintained free of obstructions to full, instant use in the case of fire or other emergency in accordance with 2000 NFPA 101. This was evidenced by items stored in the exit discharge. This deficient practice affected all staff and patients in one of four smoke compartments within the facility and could potentially result in injury or a delayed evacuation in the event of an emergency.

Findings:

During a tour of the facility on 5/15/12, exit discharge was inspected throughout the facility.

1. At 3:45 p.m., there were three Gerry chairs located in the exit discharge area at the South Entrance of the building.

Based on observation, the facility failed to protect its medical compressed gas cylinders in accordance with 1999 NFPA 99. This was evidenced by cylinders which were stored free standing unsecured on the floor. This deficient practice affected one of two buildings and could potentially result in injury or damage to the cylinders if they were to fall.

4-3.1.1.1 "Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over."

Findings:

During a tour of the facility with Maintenance Staff on 5/15/12, compressed gas cylinders were observed.

Clinic Building
1. At 2:22 p.m., the Dental Lab had two E-size oxygen cylinders and two E-size nitrogen cylinders that were sitting on the floor unsecured.

2. At 2:36 p.m., the northeast Exam Room had two 45 pound nitrous oxide tanks sitting unsecured on the floor.

Based on observation, the facility failed to comply with the regulations regarding electrical wiring and utilities in accordance with 1999 NFPA 70 and 1999 NFPA 99. This was evidenced by the permanent use of extension cords and power strips that were plugged into each other. This deficient practice affected staff and residents in one of two smoke compartments and could potentially result in the ignition of fire.

NFPA 70
400.8 Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors.

400-10 Flexible cords and cables shall be connected to devices and to fittings so that tension will not be transmitted to joints or terminals.

NFPA 99 3-3.2.1.2, All patient care areas.
(d)(2) Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.


Findings:

Main Hospital Building
During a tour of the facility on 5/15/12, electrical wiring and equipment were inspected.

1. At 4:00 p.m., the Conference Room had two flexible cords that were approximately four feet long with a single gang junction box and outlet plugged into the wall outlet. This outlet had a power strip plugged into it.

2. At 4:00 p.m., the Emergency Room had a flexible cord that was approximately four feet long with a single gang junction box and outlet plugged into the wall outlet. This outlet had a power strip plugged into it. The power strip had a medical device plugged into it.