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Based on observations of 9/14/10 in the basement, the surveyor determined the facility failed to maintain a fire separation between the basement and the floor above.

Findings include:

In accordance with Section 8.4.1.1 of NFPA 101, protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42.

Between 9:00 a.m. and 9:30 a.m., it was determined by the surveyor the basement is not separated from the upstairs with fire rated construction. Due to the furnaces in the basement and the the combustible storage in the basement, the basement is considered a severe hazardous storage area. The clinic is not separated from the basement with at least one hour fire rated construction.

Based on observations which were made on 9/14/10, it was determined that the facility did not ensure that all exit signs were properly illuminated.

Findings include:

Between 9:00 a.m. and 9:30 a.m., the exit lights in the clinic were examined. At least four of the exit lights located at two exit doors and two hallway locations were not illuminated.

Based on surveyor observations made on 9/14/10, the facility failed to maintain the sprinkler system and all its components in accordance with the standards of NFPA 25, 1998 Edition and NFPA 13, 1999 Edition.

The findings include:

In accordance with Chapter 2-2.1.2 of NFPA 25 (1998 Edition), storage of materials shall not block the discharge spray pattern of the sprinklers in the event the system is activated. Surveyor made observations between 9:00 a.m. and 9:30 a.m. in the basement. This code requirement is not being followed for the sprinkler heads located at basement ceiling. Boxes, medical record materials and other combustible items had been placed in storage at some locations in a manner to cause the discharge pattern of the sprinklers to be blocked.

Based on observations of 9/13/010, it was determined that the facility did not ensure that portable fire extinguishers are always maintained in accordance with all the standards of NFPA 10.

Findings include:

In accordance with 1-6.7 and 1-6.10 of NFPA 10, 1998 edition, portable extinguishers other than wheeled types shall be securely installed on the hanger or bracket supplied with them or placed in cabinets or wall recesses. In no case shall the clearance between the bottom of the supported extinguisher and the floor be less than 4 inches. Extinguishers weighing less than or equal to 40 lb shall be installed so that the top of the extinguisher is not more than 5 feet above the floor. Those extinguishers with a weight more than 40 lb shall be installed so that the top of the extinguisher is not more than 3 1/2 feet above the floor.

During an afternoon tour of the "Old Medical Clinic", the surveyor observed a "free standing" fire extinguisher on one of the counters of an office space. The extinguisher was not equipped with a bracket or other means to secure it in a fixed position per the code requirements of NFPA 10.

Based on surveyor observations on 9/14/10, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 Edition and NFPA 99, 1999 Edition; or interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings include:

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against over current conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4 of NFPA 70; and Sections 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99; and previous interpretations from CMS.

At approximately 8:30 a.m. the "Old Medical Clinic" was inspected by the surveyor. In the staff break/ utility room an extension cord was connected to another electrical cord. This is not an acceptable use of the electrical equipment.

Based on observations of 9/14/10 in the basement, the surveyor determined the facility failed to maintain a fire separation between the basement and the floor above.

Findings include:

In accordance with Section 8.4.1.1 of NFPA 101, protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42.

Between 9:00 a.m. and 9:30 a.m., it was determined by the surveyor the basement is not separated from the upstairs with fire rated construction. Due to the furnaces in the basement and the the combustible storage in the basement, the basement is considered a severe hazardous storage area. The clinic is not separated from the basement with at least one hour fire rated construction.

Based on observations which were made on 9/14/10, it was determined that the facility did not ensure that all exit signs were properly illuminated.

Findings include:

Between 9:00 a.m. and 9:30 a.m., the exit lights in the clinic were examined. At least four of the exit lights located at two exit doors and two hallway locations were not illuminated.

Based on surveyor observations made on 9/14/10, the facility failed to maintain the sprinkler system and all its components in accordance with the standards of NFPA 25, 1998 Edition and NFPA 13, 1999 Edition.

The findings include:

In accordance with Chapter 2-2.1.2 of NFPA 25 (1998 Edition), storage of materials shall not block the discharge spray pattern of the sprinklers in the event the system is activated. Surveyor made observations between 9:00 a.m. and 9:30 a.m. in the basement. This code requirement is not being followed for the sprinkler heads located at basement ceiling. Boxes, medical record materials and other combustible items had been placed in storage at some locations in a manner to cause the discharge pattern of the sprinklers to be blocked.

Based on observations of 9/13/010, it was determined that the facility did not ensure that portable fire extinguishers are always maintained in accordance with all the standards of NFPA 10.

Findings include:

In accordance with 1-6.7 and 1-6.10 of NFPA 10, 1998 edition, portable extinguishers other than wheeled types shall be securely installed on the hanger or bracket supplied with them or placed in cabinets or wall recesses. In no case shall the clearance between the bottom of the supported extinguisher and the floor be less than 4 inches. Extinguishers weighing less than or equal to 40 lb shall be installed so that the top of the extinguisher is not more than 5 feet above the floor. Those extinguishers with a weight more than 40 lb shall be installed so that the top of the extinguisher is not more than 3 1/2 feet above the floor.

During an afternoon tour of the "Old Medical Clinic", the surveyor observed a "free standing" fire extinguisher on one of the counters of an office space. The extinguisher was not equipped with a bracket or other means to secure it in a fixed position per the code requirements of NFPA 10.

Based on surveyor observations on 9/14/10, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 Edition and NFPA 99, 1999 Edition; or interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings include:

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against over current conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4 of NFPA 70; and Sections 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99; and previous interpretations from CMS.

At approximately 8:30 a.m. the "Old Medical Clinic" was inspected by the surveyor. In the staff break/ utility room an extension cord was connected to another electrical cord. This is not an acceptable use of the electrical equipment.