HospitalInspections.org

Based on observation and interview, the facility failed to separate corridors from use areas by at least ?-hour fire resistance rating. This deficient practice affects patients, staff and visitors that use fifth floor. The facility census was 13 patients.

Findings are:
Observations on 5-7-14 at 12:13 pm revealed an unsealed penetration around the water pipe in the fire extinguisher cabinet next to Office 523.

During an interview on 5-7-14 at 12:13 pm, Maintenance A confirmed the unsealed penetration.

NFPA Standard:
19.3.6.2 Construction of Corridor Walls.
19.3.6.2.1*

Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.

Exception No. 1*: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, a corridor shall be permitted to be separated from all other areas by non-fire-rated partitions and shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke.

Exception No. 2: Existing corridor partitions shall be permitted to terminate at ceilings that are not an integral part of a floor construction if 5 ft (1.5 m) or more of space exists between the top of the ceiling subsystem and the bottom of the floor or roof above, provided that the following criteria are met:

(a) The ceiling shall be part of a fire-rated assembly tested to have a fire resistance rating of not less than 1 hour in compliance with the provisions of 8.2.3.1.
(b) The corridor partitions form smoke tight joints with the ceilings (joint filler, if used, shall be noncombustible).
(c) Each compartment of interstitial space that constitutes a separate smoke area is vented, in a smoke emergency, to the outside by mechanical means having sufficient capacity to provide not less than two air changes per hour but, in no case, a capacity less than 5000 ft3/min (2.36 m3/s).
(d) The interstitial space shall not be used for storage.
(e) The space shall not be used as a plenum for supply, exhaust, or return air, except as noted in 19.3.6.2.1(3).

Exception No. 3*: Existing corridor partitions shall be permitted to terminate at monolithic ceilings that resist the passage of smoke where there is a smoke tight joint between the top of the partition and the bottom of the ceiling.

Based on observation and interview, the facility failed to ensure that doors to the corridor would resist the passage of smoke into exit corridor. This deficient practice would allow smoke to migrate into the exit corridor and delay egress. The facility census was 13 patients.

Findings are:
Observations on 5/7/14 between 12:01pm and 12:42pm revealed:
5th Floor-
1. Room 528 door failed to latch into door frame.
2. Training Room door 522 failed to latch within the door frame.
4th Floor-
3. Nuclear Radiation Materials Room door held open with a wood chock.
4. " Big Treadmill Room " door held open with a wood chock.
5. Dictating Room door with a self-closing device failed to latch within the door frame.
6. Exam Room 9 door held open with a wood chock.
3rd Floor-
7. Room 324 door held open with a wood chock.

During an interview on 5/7/14 between 12:11pm and 12:42pm, Maintenance A confirmed all findings.

NFPA Standard:
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. Hold-open devices that release when the door is pushed or pulled shall be permitted. 2000 NFPA 101, 19.3.6.3

Based on observation and interview, the facility failed to maintain smoke barrier doors that would resist the passage of smoke and failed to latch within the door frame. This deficient practice would allow smoke to migrate from one smoke compartment to adjoining smoke compartment and affects all patients. The facility census was 13 patients.

Findings are:
Observations on 5/7/14 at 12:25pm revealed the smoke door equipped with latching devices, located near 4th floor Soiled Utility Room failed to resist the passage of smoke.

During an interview on 5/7/14 at 12:25pm, Maintenance A confirmed the smoke door did not latch when closed.

Based on observation and interview, the facility failed to ensure that doors to hazard areas would close and latch within the door frame. This deficient practice would allow smoke, fire and gasses to migrate from hazardous areas into areas occupied by patients. The facility census was 13 patients.

Findings are:
Observations on 5-7-14 between 12:02 pm and 12:40pm revealed:
1. Storage room door 529 failed to close and latch within the door frame.
2. Storage room door next to Room 402 failed to latch within the door frame.
3. Oxygen storage room door in the Nuclear Medicine area failed to close and latch within the door frame.
4. The door to the South Medical Records Room did not latch when closed.

During an interview on 5/7/14 between 12:40pm, Maintenance A, confirmed the findings.

NFPA Standard:
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. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 square feet
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 square feet, including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard. 2000 NFPA 101, 19.3.2.1

Based on observation and interview, the facility failed to provide a protected enclosure that would resist smoke or fire from migrating into the enclosure. The deficient practice would affect all patients. The facility census was 13 patients.

Findings are:
Observation on 5/7/14 at 12:29pm revealed the door to the East 4th Floor Stair Tower failed to latch when closed.

During an interview on 5/7/14, Maintenance A confirmed the door failed to latch.

NFPA Standard:
Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating. The separation shall have not less than a 2-hour fire resistance rating where the exit connects four or more stories. The separation shall be constructed of an assembly of noncombustible or limited-combustible materials and shall be supported by construction having not less than a 2-hour fire resistance rating. Openings in the separation shall be protected by fire door assemblies equipped with door closers complying with 7.2.1.8. Openings 2000 NFPA 101, 19.3.1.1, 8.2.5.2 and 8.2.5.4

Based on observation and interview, the facility failed to ensure that powered exit doors were accessible at all times and exit doors failed to open with 15 pounds of force. These deficient practices would delay or prohibit all patients from exiting building in event of emergency. The facility census was 13 patients.

Findings are:
Observation on 5/7/14 between 1:30pm and 2:00pm revealed:
2nd Floor
1. The exit door from North Stair failed to open with 15 pounds of pressure.
1st Floor
2. Access-controlled doors at the emergency lobby were equipped with a thumb turn locks.
3. Switch to turn off power to the doors was not secured, so that the doors could be inadvertently turned off.
4. The controlled access doors when locked could not be opened manually.

During an interview on 4-30-14 at 2:27 pm, Administration A confirmed the findings.

NFPA Standard:
7.2.1.6.2 Access-Controlled Egress Doors.
Where permitted in Chapters 11 through 42, doors in the means of egress shall be permitted to be equipped with an approved entrance and egress access control system, provided that the following criteria are met.
a) A sensor shall be provided on the egress side and arranged to detect an occupant approaching the doors, and the doors shall be arranged to unlock in the direction of egress upon detection of an approaching occupant or loss of power to the sensor.
b) Loss of power to the part of the access control system that locks the doors shall automatically unlock the doors in the direction of egress.
c) The doors shall be arranged to unlock in the direction of egress from a manual release device located 40 in. to 48 in. (102 cm to 122 cm) vertically above the floor and within 5 ft (1.5 m) of the secured doors. The manual release device shall be readily accessible and clearly identified by a sign that reads as follows: PUSH TO EXIT
d) When operated, the manual release device shall result in direct interruption of power to the lock - independent of the access control system electronics - and the doors shall remain unlocked for not less than 30 seconds.
e) Activation of the building fire-protective signaling system, if provided, shall automatically unlock the doors in the direction of egress, and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.
f) Activation of the building automatic sprinkler or fire detection system, if provided, shall automatically unlock the doors in the direction of egress and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.


The forces required to fully open any door manually in a means of egress shall not exceed 15 lbf (67 N) to release the latch, 30 lbf (133 N) to set the door in motion, and 15 lbf (67 N) to open the door to the minimum required width. Opening forces for interior side-hinged or pivoted-swinging doors without closers shall not exceed 5 lbf (22 N). These forces shall be applied at the latch stile. 2000 NFPA 101, 19.2.1 and 7.2.1.4.5
Where means of egress doors are operated by power upon the approach of a person or doors with power-assisted manual operation, the design shall be such that, in the event of power failure, the door opens manually to allow egress travel or closes where necessary to safeguard the means of egress. The forces required to open such doors manually shall not exceed those required in 7.2.1.4.5, except that the force required to set the door in motion shall not exceed 50 lbf (222 N). The door shall be designed and installed so that when a force is applied to the door on the side from which egress is made, it shall be capable of swinging from any position to the full use of the required width of the opening in which it is installed (see 7.2.1.4). On the egress side of each door, there shall be a readily visible, durable sign that reads as follows: IN EMERGENCY, SLIDE TO OPEN. 2000 NFPA 101, 19.2.1 and 7.2.1.9.1

Based on record review and interview, the facility failed to ensure that all exits were marked with exit signage. The deficient practice would delay egress during an emergency to the nearest exit by patients. The facility census was 13 patients.

Findings are:
Observation on 5/7/14 at 1:47pm revealed that at the corridor outside the Laboratory, the corridor was not marked with a directional exit sign.

During an interview on 5/7/14 at 1:47pm, Maintenance B confirmed no directional exit sign was present outside the Laboratory to corridor.

NFPA Standard:
Means of egress shall have signs. A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent. 2000 NFPA 101, 19.2.10.1 and 7.10.2

Based on record review and interview, the facility failed to ensure that fire drills were conducted at varying times. The deficient practice would allow staff to become familiar with the evacuation procedures of facility in the event of an emergency, which would affect all patients. The facility census was 13.

Findings are:
Record review on 5/7/14 revealed:
1. Fire drills failed to be conducted at varying times during the 2nd and 3rd nursing shifts for the first, second, third and fourth quarters of 2013.
Fire drills were conducted for the 2nd or 3-11pm shift at 3:20pm for the month of March, 3:35pm for the month of June, 3:20pm for the month of August and 3:20pm for the month of November. Fire drills were conducted for the 3rd or 11-7am shift at 11:30pm for the months of January, May, September and December.
2. No documentation of fire drills for the months of March and April

During an interview on 5/7/14 at 2:51pm, Maintenance B confirmed all findings.

NFPA Standard
NFPA Standard: Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms. 2000 NFPA 101, 19.7.1.2

Based on observation and interview, the facility failed to provide total sprinkler protection throughout a smoke compartments throughout the facility. This deficient practice could allow a fire in the non-sprinklered compartment to exceed the working capabilities of the fire sprinkler system in the adjoining area and allow fire to spread. The facility census was 13 patients.

Findings are:
Observation on 5/7/14 between 11:57 am to 1:59pm revealed that areas throughout smoke compartments on several floors were not fully sprinkled.

During an interview on 5/7/14 at 12:59pm, Maintenance A confirmed the findings.

NFPA Standard:
NFPA Standard: Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. 2000 NPFA 101, 19.3.5 and 1999 NFPA 13

Based on observation and interview, the facility failed to ensure sprinkler head in closets were not obstructed. The deficient practice would prevent sprinklers from activating properly in the event of fire. The facility census was 13 patients.

Findings are:
Observation on 5/7/14 at 11:59am revealed, that the sprinkler head located in the Closet of Room 508 was obstructed by a cardboard box.

During interview on 5/7/14 at 11:59am, Maintenance A confirmed that the sprinkler head in closet was obstructed.

NFPA Standard:
The clearance between the deflector and the top of storage shall be 18 inch or greater. 1999 NFPA 13, 5.5.6

Based on observation and interview, the facility failed to ensure that a fire extinguisher had been inspected. The deficient practice has the potential to lead to a delay in containing a fire. The facility census was 13 patients.

Findings are:
Observation on 5/7/14 at 1:13pm revealed, that the fire extinguisher in the Surgery Area had not been inspected since 1/21/14.

During interview on 5/7/14 at 1:13pm, Maintenance A confirmed that the fire extinguisher had not been inspected.

NFPA Standard:
Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 2000 NFPA 101, 19.3.5.6 and 9.7.4.1

Based on documentation review and interview the facility failed to provide documentation that kitchen hood had been cleaned. The facility failed to provide documentation that the kitchen suppression system had been inspected semi-annually. These deficient practices increase the potential for a grease fire. The facility census was 13 patients.

Findings are:
Record review on 5-7-14 revealed:
1. The facility failed to provide documentation for the kitchen hood cleaning.
2. The last inspections for the hood system were dated 2-10-14 and 4-13-10.

During an interview on 5-7-14 at 1:49 pm, Maintenance B confirmed the lack of documentation.

NFPA Standard:
Require inspection and servicing at least every six months by properly trained and qualified persons. 1998 NFPA 17, 9-3 and 1998 NFPA 17(a), 5-3.

NFPA Standard:
1998, NFPA 96
Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1.

Table 8-3.1 Exhaust System Inspection Schedule
Type or Volume of Cooking Frequency Frequency
Systems serving solid fuel cooking operations Monthly

Systems serving high-volume cooking operations
such as 24-hour cooking, charbroiling or wok cooking Quarterly

Systems serving moderate-volume cooking operations Semiannually

Systems serving low-volume cooking operations, such as churches,
day camps, seasonal businesses, or senior centers Annually

8-3.1.1
Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Section 8-3.

8-3.1.2
When a vent cleaning service is used, a certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company. It shall also indicate areas not cleaned.

Based on observation and interview, the facility failed to ensure that exit corridors were free of obstructions. This deficient practice has the potential to delay patients in the means of egress on the first floor and basement. The facility census was 13 patients.

Findings are:
Observations on 5/7/14 between 2:12pm and 2:35pm revealed:
1st Floor-
1. Two operating room tables, a couch, four chairs and two pallets of medical supplies stored in corridor near Clean and Soiled laundry areas.
Basement -
2. Three pallets of boxes, a wheel chair and a hospital bed stored in corridor outside of Housekeeping Room.

During interview on 5/7/14 between 2:12pm and 2:35pm, Maintenance B confirmed all findings

NFPA Standard:
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10

Based on observation and interview, the facility failed to provide labeling readily identifying the name and direction of medical gases. The deficient practice has the potential to delay shut-off to appropriate medical gas in the event of emergency. The facility census was 13 patients.

Findings are:
Observation on 5/7/14 at 1:11pm revealed that the medical gas zone valve between the two operating rooms was not labeled as to which operating room was controlled by the valves.

During an interview on 5/7/14 at 1:11pm, Maintenance A confirmed that the medical gas zone valve was not labeled.

NFPA Standard:
Anesthetizing locations, medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities. The gas content of medical gas piping systems shall be readily identifiable by appropriate labeling with the name and pressure of the gas contained. Such labeling shall be by means of metal tags, stenciling, stamping, or adhesive markers, in a manner that is not readily removable. Labeling shall appear on the piping at intervals of not more than 20 ft (6 m) and at least once in each room and each story traversed by the piping system. Where supplementary color identification of piping is used, it shall be in accordance with the gases and colors indicated in CGA Pamphlet C-9, Standard Color-Marking of Compressed Gas Cylinders Intended for Medical Use. Only those systems operating at nonstandard pressures shall be labeled with the name of the gas and the operating pressure. 2000 NFPA101, 19.3.2.3, 19.3.2.4 and 1999 NFPA 99, 4.3.1.2.13

Based on interview and documentation review, the facility failed to ensure that the relative humidity was being maintained for the operating room. The deficient practice has the potential to create patient complications during operating procedures. The facility census was 13 patients.

Findings are:
Documentation review on 5/7/14 revealed that from 3/24/14 to 5/7/14, 9 of 23 days indicated the relative humidity in the Operating Room was below 35 percent.

During an interview on 5/7/14 at 2:21pm Maintenance B confirmed the findings.

NFPA Standard:
The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater. 2000 NFPA 101, 19.3.2.3 and 1999 NFPA 99, 5.4.1.1

Based on observation and interview, the facility failed to restrict burning candles in Chapel and failed to provide documentation of prior approval for the use of burning candles in the Chapel during non-religious ceremonies. The deficient practice has the potential to cause a fire if candles were knocked over. The facility census was 13 patients.

Findings are:
Observation on 5/7/14 at 12:47pm revealed three candles burning on alter of Chapel.
The facility failed to provide flame protection.

During an interview on 5/7/14 at 12:47pm Maintenance A confirmed the candles and did not provide documentation indicating prior approval to have burning candles in the Chapel.

Regulation:
Nebraska State Fire Marshal Official Interpretation 03-03
Open flame devices are allowed in assembly occupancies under the following circumstances. 1) when used for a ceremonial or religious purposes other than handheld candles by occupants in seating areas; 2) on stage and platforms as a necessary part of a performance; 3) on tables where the candle is securely supported on a substantial noncombustible base and the candle flame is protected; 4) food preparation operations, or as noted in section 12/13 pateints.7.2
The use of candles in all other occupancies is deemed hazardous to life and property. The authority having jurisdiction shall maintain safe conditions and shall have candles removed.
Candle burning will NOT be allowed in health care, residential board and care, assisted living, day care center, home care, hotel, motel or dormitories, rooming and lodging, education, business, mercantile, industrial, detention or storage occupancies unless specifically approved by the authority having jurisdiction.

Based on interview and observation, the facility failed to provide a remote audible annunciator panel in an attended location. This deficient practice affects all smoke compartments of the building and all patients, as it would delay the response to maintain the generator in the event of failure. The facility census was 13 residents.

Findings are:
Observations on 5-7-14 at 1:45 pm revealed that the facility failed to provide an alarm annunciator panel for the generator in an attended location.

During an interview on 5-7-14 at 1:45 pm, Maintenance A confirmed the facility failed to provide an annunciator panel.

NFPA Standard
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 (see NFPA 70, National Electrical Code, Section 700-12.)
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] 1999 NFPA 99, 3-4.1.1.15

Based on observation and interview, the facility failed to provide a cover for electrical junction box, failed to maintain proper clearance around electrical panel box and failed to ensure that a power strip was not being used as permanent wiring which the potential to cause electrical shock or a an electrical fire. The facility census was 13 patients.

Findings are:
Observations on 5/7/14 between 12:44pm to 2:59pm revealed:
3rd Floor-
1. In Room 324, a power strip was being used as a substitute for permanent wiring to the window air conditioning unit.
Basement-
2. An open junction box In Housekeeping Room above desk.
3. Storage in front of electrical panels along rear wall in Maintenance Office.
4. An extension cord used as permanent wiring for a remote ice machine in Air Handler 12 and 13 Room.

During an interview on 5/7/14 between 12:44pm to 2:59pm, Maintenance B confirmed all findings.

NFPA Standard:
Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors; run through doorways, windows, or similar openings; and attached to building surfaces. 2000 NFPA 101, 9.1.2 and 1999 NFPA 70, 400.8

All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. 2000 NFPA 101, 9.1.2 and 1999 NFPA 70, 328.70 (C)

The depth of the working space in the direction of access to live parts shall not be less than 3 feet. Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed. 2000 NFPA 101, 9.1.2 and 1999 NFPA 70, 110.26(A) (1)

Based on observation and interview, the facility failed to separate corridors from use areas by at least ?-hour fire resistance rating. This deficient practice affects patients, staff and visitors that use fifth floor. The facility census was 13 patients.

Findings are:
Observations on 5-7-14 at 12:13 pm revealed an unsealed penetration around the water pipe in the fire extinguisher cabinet next to Office 523.

During an interview on 5-7-14 at 12:13 pm, Maintenance A confirmed the unsealed penetration.

NFPA Standard:
19.3.6.2 Construction of Corridor Walls.
19.3.6.2.1*

Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.

Exception No. 1*: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, a corridor shall be permitted to be separated from all other areas by non-fire-rated partitions and shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke.

Exception No. 2: Existing corridor partitions shall be permitted to terminate at ceilings that are not an integral part of a floor construction if 5 ft (1.5 m) or more of space exists between the top of the ceiling subsystem and the bottom of the floor or roof above, provided that the following criteria are met:

(a) The ceiling shall be part of a fire-rated assembly tested to have a fire resistance rating of not less than 1 hour in compliance with the provisions of 8.2.3.1.
(b) The corridor partitions form smoke tight joints with the ceilings (joint filler, if used, shall be noncombustible).
(c) Each compartment of interstitial space that constitutes a separate smoke area is vented, in a smoke emergency, to the outside by mechanical means having sufficient capacity to provide not less than two air changes per hour but, in no case, a capacity less than 5000 ft3/min (2.36 m3/s).
(d) The interstitial space shall not be used for storage.
(e) The space shall not be used as a plenum for supply, exhaust, or return air, except as noted in 19.3.6.2.1(3).

Exception No. 3*: Existing corridor partitions shall be permitted to terminate at monolithic ceilings that resist the passage of smoke where there is a smoke tight joint between the top of the partition and the bottom of the ceiling.

Based on observation and interview, the facility failed to ensure that doors to the corridor would resist the passage of smoke into exit corridor. This deficient practice would allow smoke to migrate into the exit corridor and delay egress. The facility census was 13 patients.

Findings are:
Observations on 5/7/14 between 12:01pm and 12:42pm revealed:
5th Floor-
1. Room 528 door failed to latch into door frame.
2. Training Room door 522 failed to latch within the door frame.
4th Floor-
3. Nuclear Radiation Materials Room door held open with a wood chock.
4. " Big Treadmill Room " door held open with a wood chock.
5. Dictating Room door with a self-closing device failed to latch within the door frame.
6. Exam Room 9 door held open with a wood chock.
3rd Floor-
7. Room 324 door held open with a wood chock.

During an interview on 5/7/14 between 12:11pm and 12:42pm, Maintenance A confirmed all findings.

NFPA Standard:
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. Hold-open devices that release when the door is pushed or pulled shall be permitted. 2000 NFPA 101, 19.3.6.3

Based on observation and interview, the facility failed to maintain smoke barrier doors that would resist the passage of smoke and failed to latch within the door frame. This deficient practice would allow smoke to migrate from one smoke compartment to adjoining smoke compartment and affects all patients. The facility census was 13 patients.

Findings are:
Observations on 5/7/14 at 12:25pm revealed the smoke door equipped with latching devices, located near 4th floor Soiled Utility Room failed to resist the passage of smoke.

During an interview on 5/7/14 at 12:25pm, Maintenance A confirmed the smoke door did not latch when closed.

Based on observation and interview, the facility failed to ensure that doors to hazard areas would close and latch within the door frame. This deficient practice would allow smoke, fire and gasses to migrate from hazardous areas into areas occupied by patients. The facility census was 13 patients.

Findings are:
Observations on 5-7-14 between 12:02 pm and 12:40pm revealed:
1. Storage room door 529 failed to close and latch within the door frame.
2. Storage room door next to Room 402 failed to latch within the door frame.
3. Oxygen storage room door in the Nuclear Medicine area failed to close and latch within the door frame.
4. The door to the South Medical Records Room did not latch when closed.

During an interview on 5/7/14 between 12:40pm, Maintenance A, confirmed the findings.

NFPA Standard:
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. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 square feet
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 square feet, including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard. 2000 NFPA 101, 19.3.2.1

Based on observation and interview, the facility failed to provide a protected enclosure that would resist smoke or fire from migrating into the enclosure. The deficient practice would affect all patients. The facility census was 13 patients.

Findings are:
Observation on 5/7/14 at 12:29pm revealed the door to the East 4th Floor Stair Tower failed to latch when closed.

During an interview on 5/7/14, Maintenance A confirmed the door failed to latch.

NFPA Standard:
Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating. The separation shall have not less than a 2-hour fire resistance rating where the exit connects four or more stories. The separation shall be constructed of an assembly of noncombustible or limited-combustible materials and shall be supported by construction having not less than a 2-hour fire resistance rating. Openings in the separation shall be protected by fire door assemblies equipped with door closers complying with 7.2.1.8. Openings 2000 NFPA 101, 19.3.1.1, 8.2.5.2 and 8.2.5.4

Based on observation and interview, the facility failed to ensure that powered exit doors were accessible at all times and exit doors failed to open with 15 pounds of force. These deficient practices would delay or prohibit all patients from exiting building in event of emergency. The facility census was 13 patients.

Findings are:
Observation on 5/7/14 between 1:30pm and 2:00pm revealed:
2nd Floor
1. The exit door from North Stair failed to open with 15 pounds of pressure.
1st Floor
2. Access-controlled doors at the emergency lobby were equipped with a thumb turn locks.
3. Switch to turn off power to the doors was not secured, so that the doors could be inadvertently turned off.
4. The controlled access doors when locked could not be opened manually.

During an interview on 4-30-14 at 2:27 pm, Administration A confirmed the findings.

NFPA Standard:
7.2.1.6.2 Access-Controlled Egress Doors.
Where permitted in Chapters 11 through 42, doors in the means of egress shall be permitted to be equipped with an approved entrance and egress access control system, provided that the following criteria are met.
a) A sensor shall be provided on the egress side and arranged to detect an occupant approaching the doors, and the doors shall be arranged to unlock in the direction of egress upon detection of an approaching occupant or loss of power to the sensor.
b) Loss of power to the part of the access control system that locks the doors shall automatically unlock the doors in the direction of egress.
c) The doors shall be arranged to unlock in the direction of egress from a manual release device located 40 in. to 48 in. (102 cm to 122 cm) vertically above the floor and within 5 ft (1.5 m) of the secured doors. The manual release device shall be readily accessible and clearly identified by a sign that reads as follows: PUSH TO EXIT
d) When operated, the manual release device shall result in direct interruption of power to the lock - independent of the access control system electronics - and the doors shall remain unlocked for not less than 30 seconds.
e) Activation of the building fire-protective signaling system, if provided, shall automatically unlock the doors in the direction of egress, and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.
f) Activation of the building automatic sprinkler or fire detection system, if provided, shall automatically unlock the doors in the direction of egress and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.


The forces required to fully open any door manually in a means of egress shall not exceed 15 lbf (67 N) to release the latch, 30 lbf (133 N) to set the door in motion, and 15 lbf (67 N) to open the door to the minimum required width. Opening forces for interior side-hinged or pivoted-swinging doors without closers shall not exceed 5 lbf (22 N). These forces shall be applied at the latch stile. 2000 NFPA 101, 19.2.1 and 7.2.1.4.5
Where means of egress doors are operated by power upon the approach of a person or doors with power-assisted manual operation, the design shall be such that, in the event of power failure, the door opens manually to allow egress travel or closes where necessary to safeguard the means of egress. The forces required to open such doors manually shall not exceed those required in 7.2.1.4.5, except that the force required to set the door in motion shall not exceed 50 lbf (222 N). The door shall be designed and installed so that when a force is applied to the door on the side from which egress is made, it shall be capable of swinging from any position to the full use of the required width of the opening in which it is installed (see 7.2.1.4). On the egress side of each door, there shall be a readily visible, durable sign that reads as follows: IN EMERGENCY, SLIDE TO OPEN. 2000 NFPA 101, 19.2.1 and 7.2.1.9.1

Based on record review and interview, the facility failed to ensure that all exits were marked with exit signage. The deficient practice would delay egress during an emergency to the nearest exit by patients. The facility census was 13 patients.

Findings are:
Observation on 5/7/14 at 1:47pm revealed that at the corridor outside the Laboratory, the corridor was not marked with a directional exit sign.

During an interview on 5/7/14 at 1:47pm, Maintenance B confirmed no directional exit sign was present outside the Laboratory to corridor.

NFPA Standard:
Means of egress shall have signs. A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent. 2000 NFPA 101, 19.2.10.1 and 7.10.2

Based on record review and interview, the facility failed to ensure that fire drills were conducted at varying times. The deficient practice would allow staff to become familiar with the evacuation procedures of facility in the event of an emergency, which would affect all patients. The facility census was 13.

Findings are:
Record review on 5/7/14 revealed:
1. Fire drills failed to be conducted at varying times during the 2nd and 3rd nursing shifts for the first, second, third and fourth quarters of 2013.
Fire drills were conducted for the 2nd or 3-11pm shift at 3:20pm for the month of March, 3:35pm for the month of June, 3:20pm for the month of August and 3:20pm for the month of November. Fire drills were conducted for the 3rd or 11-7am shift at 11:30pm for the months of January, May, September and December.
2. No documentation of fire drills for the months of March and April

During an interview on 5/7/14 at 2:51pm, Maintenance B confirmed all findings.

NFPA Standard
NFPA Standard: Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms. 2000 NFPA 101, 19.7.1.2

Based on observation and interview, the facility failed to provide total sprinkler protection throughout a smoke compartments throughout the facility. This deficient practice could allow a fire in the non-sprinklered compartment to exceed the working capabilities of the fire sprinkler system in the adjoining area and allow fire to spread. The facility census was 13 patients.

Findings are:
Observation on 5/7/14 between 11:57 am to 1:59pm revealed that areas throughout smoke compartments on several floors were not fully sprinkled.

During an interview on 5/7/14 at 12:59pm, Maintenance A confirmed the findings.

NFPA Standard:
NFPA Standard: Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. 2000 NPFA 101, 19.3.5 and 1999 NFPA 13

Based on observation and interview, the facility failed to ensure sprinkler head in closets were not obstructed. The deficient practice would prevent sprinklers from activating properly in the event of fire. The facility census was 13 patients.

Findings are:
Observation on 5/7/14 at 11:59am revealed, that the sprinkler head located in the Closet of Room 508 was obstructed by a cardboard box.

During interview on 5/7/14 at 11:59am, Maintenance A confirmed that the sprinkler head in closet was obstructed.

NFPA Standard:
The clearance between the deflector and the top of storage shall be 18 inch or greater. 1999 NFPA 13, 5.5.6

Based on observation and interview, the facility failed to ensure that a fire extinguisher had been inspected. The deficient practice has the potential to lead to a delay in containing a fire. The facility census was 13 patients.

Findings are:
Observation on 5/7/14 at 1:13pm revealed, that the fire extinguisher in the Surgery Area had not been inspected since 1/21/14.

During interview on 5/7/14 at 1:13pm, Maintenance A confirmed that the fire extinguisher had not been inspected.

NFPA Standard:
Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 2000 NFPA 101, 19.3.5.6 and 9.7.4.1

Based on documentation review and interview the facility failed to provide documentation that kitchen hood had been cleaned. The facility failed to provide documentation that the kitchen suppression system had been inspected semi-annually. These deficient practices increase the potential for a grease fire. The facility census was 13 patients.

Findings are:
Record review on 5-7-14 revealed:
1. The facility failed to provide documentation for the kitchen hood cleaning.
2. The last inspections for the hood system were dated 2-10-14 and 4-13-10.

During an interview on 5-7-14 at 1:49 pm, Maintenance B confirmed the lack of documentation.

NFPA Standard:
Require inspection and servicing at least every six months by properly trained and qualified persons. 1998 NFPA 17, 9-3 and 1998 NFPA 17(a), 5-3.

NFPA Standard:
1998, NFPA 96
Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1.

Table 8-3.1 Exhaust System Inspection Schedule
Type or Volume of Cooking Frequency Frequency
Systems serving solid fuel cooking operations Monthly

Systems serving high-volume cooking operations
such as 24-hour cooking, charbroiling or wok cooking Quarterly

Systems serving moderate-volume cooking operations Semiannually

Systems serving low-volume cooking operations, such as churches,
day camps, seasonal businesses, or senior centers Annually

8-3.1.1
Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Section 8-3.

8-3.1.2
When a vent cleaning service is used, a certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company. It shall also indicate areas not cleaned.

Based on observation and interview, the facility failed to ensure that exit corridors were free of obstructions. This deficient practice has the potential to delay patients in the means of egress on the first floor and basement. The facility census was 13 patients.

Findings are:
Observations on 5/7/14 between 2:12pm and 2:35pm revealed:
1st Floor-
1. Two operating room tables, a couch, four chairs and two pallets of medical supplies stored in corridor near Clean and Soiled laundry areas.
Basement -
2. Three pallets of boxes, a wheel chair and a hospital bed stored in corridor outside of Housekeeping Room.

During interview on 5/7/14 between 2:12pm and 2:35pm, Maintenance B confirmed all findings

NFPA Standard:
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10

Based on observation and interview, the facility failed to provide labeling readily identifying the name and direction of medical gases. The deficient practice has the potential to delay shut-off to appropriate medical gas in the event of emergency. The facility census was 13 patients.

Findings are:
Observation on 5/7/14 at 1:11pm revealed that the medical gas zone valve between the two operating rooms was not labeled as to which operating room was controlled by the valves.

During an interview on 5/7/14 at 1:11pm, Maintenance A confirmed that the medical gas zone valve was not labeled.

NFPA Standard:
Anesthetizing locations, medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities. The gas content of medical gas piping systems shall be readily identifiable by appropriate labeling with the name and pressure of the gas contained. Such labeling shall be by means of metal tags, stenciling, stamping, or adhesive markers, in a manner that is not readily removable. Labeling shall appear on the piping at intervals of not more than 20 ft (6 m) and at least once in each room and each story traversed by the piping system. Where supplementary color identification of piping is used, it shall be in accordance with the gases and colors indicated in CGA Pamphlet C-9, Standard Color-Marking of Compressed Gas Cylinders Intended for Medical Use. Only those systems operating at nonstandard pressures shall be labeled with the name of the gas and the operating pressure. 2000 NFPA101, 19.3.2.3, 19.3.2.4 and 1999 NFPA 99, 4.3.1.2.13

Based on interview and documentation review, the facility failed to ensure that the relative humidity was being maintained for the operating room. The deficient practice has the potential to create patient complications during operating procedures. The facility census was 13 patients.

Findings are:
Documentation review on 5/7/14 revealed that from 3/24/14 to 5/7/14, 9 of 23 days indicated the relative humidity in the Operating Room was below 35 percent.

During an interview on 5/7/14 at 2:21pm Maintenance B confirmed the findings.

NFPA Standard:
The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater. 2000 NFPA 101, 19.3.2.3 and 1999 NFPA 99, 5.4.1.1

Based on observation and interview, the facility failed to restrict burning candles in Chapel and failed to provide documentation of prior approval for the use of burning candles in the Chapel during non-religious ceremonies. The deficient practice has the potential to cause a fire if candles were knocked over. The facility census was 13 patients.

Findings are:
Observation on 5/7/14 at 12:47pm revealed three candles burning on alter of Chapel.
The facility failed to provide flame protection.

During an interview on 5/7/14 at 12:47pm Maintenance A confirmed the candles and did not provide documentation indicating prior approval to have burning candles in the Chapel.

Regulation:
Nebraska State Fire Marshal Official Interpretation 03-03
Open flame devices are allowed in assembly occupancies under the following circumstances. 1) when used for a ceremonial or religious purposes other than handheld candles by occupants in seating areas; 2) on stage and platforms as a necessary part of a performance; 3) on tables where the candle is securely supported on a substantial noncombustible base and the candle flame is protected; 4) food preparation operations, or as noted in section 12/13 pateints.7.2
The use of candles in all other occupancies is deemed hazardous to life and property. The authority having jurisdiction shall maintain safe conditions and shall have candles removed.
Candle burning will NOT be allowed in health care, residential board and care, assisted living, day care center, home care, hotel, motel or dormitories, rooming and lodging, education, business, mercantile, industrial, detention or storage occupancies unless specifically approved by the authority having jurisdiction.

Based on interview and observation, the facility failed to provide a remote audible annunciator panel in an attended location. This deficient practice affects all smoke compartments of the building and all patients, as it would delay the response to maintain the generator in the event of failure. The facility census was 13 residents.

Findings are:
Observations on 5-7-14 at 1:45 pm revealed that the facility failed to provide an alarm annunciator panel for the generator in an attended location.

During an interview on 5-7-14 at 1:45 pm, Maintenance A confirmed the facility failed to provide an annunciator panel.

NFPA Standard
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 (see NFPA 70, National Electrical Code, Section 700-12.)
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] 1999 NFPA 99, 3-4.1.1.15

Based on observation and interview, the facility failed to provide a cover for electrical junction box, failed to maintain proper clearance around electrical panel box and failed to ensure that a power strip was not being used as permanent wiring which the potential to cause electrical shock or a an electrical fire. The facility census was 13 patients.

Findings are:
Observations on 5/7/14 between 12:44pm to 2:59pm revealed:
3rd Floor-
1. In Room 324, a power strip was being used as a substitute for permanent wiring to the window air conditioning unit.
Basement-
2. An open junction box In Housekeeping Room above desk.
3. Storage in front of electrical panels along rear wall in Maintenance Office.
4. An extension cord used as permanent wiring for a remote ice machine in Air Handler 12 and 13 Room.

During an interview on 5/7/14 between 12:44pm to 2:59pm, Maintenance B confirmed all findings.

NFPA Standard:
Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors; run through doorways, windows, or similar openings; and attached to building surfaces. 2000 NFPA 101, 9.1.2 and 1999 NFPA 70, 400.8

All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. 2000 NFPA 101, 9.1.2 and 1999 NFPA 70, 328.70 (C)

The depth of the working space in the direction of access to live parts shall not be less than 3 feet. Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed. 2000 NFPA 101, 9.1.2 and 1999 NFPA 70, 110.26(A) (1)