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Building A1-West Building

Through observation during the survey, August 2 through 9, 2011, it was determined that the facility failed to maintain the two hour fire resistance rating of the common wall between this Hospital and an adjoining Hospital.

During the walk through of the facility, with the Maintenance Director, the 1-1/2-hour, fire-rated door, located in the basement corridor, did not latch when closed as required by 19.1.2.2 and 1999 edition of NFPA 80, (Chapter 2, Paragraph 2-1.4). This set of double doors were the two hour separation doors between this Hospital and an adjoining Hospital.
Note: This deficiency was corrected during the survey by Maintenance staff.

Building A1-West Building

Through observation during the survey, August 2 through 9, 2011, it was determined that the facility failed to maintain the fire resistance rating of the corridor walls.

During the walk through of the facility, with the Maintenance Director, the corridor wall, outside of the air compressor room located in the basement, contained an air hose through the wall. The staff stated that they utilize the air hose to fill wheelchair wheels after the maintenance department has left for the evening or on weekends.

Building A1-West Building

Through observation during the survey, August 2 through 9, 2011, it was determined the facility failed to maintain the doors to the corridor.

During the walk through of the facility with the Maintenance Director;
1) Corridor door contained a gap larger than 1/2" between the door and the doorstop, which would not maintain a positive smoke seal.
a) Resident room #302
b) Resident room #303
c) Resident room #305
d) Resident room #317
e) Resident room #201

2) The gymnasium door was propped open using a large metal trash can. The gymnasium was being utilized as a patient treatment/therapy room at the time of the survey.

3) The mechanical room door, located off of the corridor in the basement, contained one set of double doors that were not considered to be positive latching, on one side of the doors, when in the closed position. The door contained a slide lock type lock on one door.

Building A1-West Building

Through observation during the survey, August 2 through 9, 2011, it was determined that the facility failed to maintain the smoke barrier walls.

During the walk through of the facility with the Maintenance Supervisor, one (1) smoke wall, located adjacent to room #202, contained one (1) unsealed electrical conduit penetration without fire caulking or other approved method of maintaining the smoke rating of the wall per 19.3.7.3 and 8.3.2.
Note: The deficiency was corrected by Maintenance staff during the survey.

Building A1-West Building

Through observation during the survey, August 2 through 9, 2011, it was determined that the facility failed to maintain the smoke barrier doors.

During the walk through of the facility with the Maintenance Director, the smoke barrier doors, located adjacent to the third (3rd) floor nurse station, would not operate correctly with the door sequencer. The door sequencer would not hold open the door with the astragal so that the door without the astragal could shut first. When this occurred the door would not maintain a positive smoke seal.
Note: Corrected by Maintenance staff during the survey.

Building A1-West Building

Through observation during the survey, August 2 through 9, 2011, it was determined that the facility failed to maintain the doors to the hazardous areas.

During the walk through of the facility with the Maintenance Director:
1) The storage room, adjacent to room #305, contained no self closing device.
2) The third (3rd) floor patient shower room is also used as a storage room for wheelchairs, towels etc. This room contains a self-closing device-however the self-closing device would not shut and latch the door into the frame.
3) The maintenance shop door was on a hold open device, however the hold open device was not connected to the fire alarm system to self release during a fire alarm.
4) The soiled linen door, located in the basement, would not latch into the frame from the corridor side. Note: this door was located by the clean linen storage room.
5) The door to the wheelchair charging room was dragging on the floor when in the closing position. Therefore the door would not close into the frame.

Building A2-East Building

Through observation during the survey, August 2 through 9, 2011, it was determined that the facility failed to maintain the doors at a two hour stairwell door.

During the walk through of the facility, with the Maintenance Director, the 1-1/2-hour, fire-rated doors, located at the first (1st) floor exit access corridor, did not latch when closed. These doors were located adjacent to the Pharmacy.
Per NFPA 101, section 19.2.2.2.6
Note: Corrected by Maintenance staff during the survey.

Through observation during the survey, August 2 through 9, 2011, it was determined that the facility failed to maintain the exit stairs free of combustible materials.

During the walk through of the facility, with the Maintenance Director, the third (3rd) floor Northeast stairwell contained combustible artwork on the wall.
Per 7.1.3.2(d) "An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge."

Building A1-West Building

Through observation testing during the survey, August 2 through 9, 2011, it was determined that the facility failed to maintain the exits as readily accessible at all times.

During the walk through of the facility, with the Maintenance Director, the facility contained a "Code Alert" system at four (4) doors on the second (2nd) floor, see list below of areas which were involved. This system allows for the doors to lock when a resident/patient, who are wearing a special bracelet, are within the vicinity of the door. When the doors lock, they then contain a delayed egress function in which the door unlocks within fifteen 915) seconds of pushing on the door.

The four (4) doors did not have the complete signage posted to indicate how the delayed function worked from the egress side of the door. The door contained the wording "15 seconds" only on the door. Per NFPA 101, section 7.2.1.6.1(d) states "On the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high and not less than 1/8 in. (0.3 cm) in stroke width on a contrasting background that reads as follows:
PUSH UNTIL ALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS

Doors affected:
1) Stairwell exit door outside of the Nurse station.
2) Stairwell exit door outside of speech therapy room.
3) Stairwell exit door outside room #210.
4) Stairwell exit door outside of therapy gym.

Building A1-West Building

Through record review and interviews with staff during the survey, August 2 through 9, 2011, it was determined that the facility failed to conduct fire drills on each shift quarterly.

During the review of the facility records, with the Maintenance Director, the facility failed to conduct a fire drill on the second (2nd) shift of the third (3rd) quarter in fiscal year 2010.
During an interview with the Safety Manager, a scheduled fire drill was missed in the month of September 2010 and was "made up" in the fourth (4th) quarter of 2010.

Building A1-West Building

Through observation during the survey, August 2 through 9, 2011, it was determined that the facility failed to install a fire alarm system in accordance with NFPA 101.

During record review, interviews and testing of the fire alarm system, with the Maintenance Director, it was determined that the fire alarm system does not automatically notify the local fire department when activated by pull stations, supervisory switches or smoke detection. The fire alarm system notifies a central station monitoring company first, the alarm company reconfirms the alarm with the facility, then notifies the fire department if a fire is confirmed.
Per NFPA 101, section 9.6.4 and NFPA 72, section 5-4.6.1
"If the remote supervising station is at a location other than the public fire service communications center, alarm signals shall be immediately retransmitted to the public fire service communications center."

Building A1-West Building

Through observation during the survey, August 2 through 9, 2011, it was determined that the facility failed to maintain the smoke detectors in all areas.

During the walk through of the facility, with the Maintenance Director, one (1) smoke detector, located in a janitor closet on the third (3rd) floor, contained a rubber glove covering the smoke detector.
Note: The glove was removed by Maintenance staff during the survey.

Building A1-West Building

Through observation during the survey, August 2 through 9, 2011, it was determined that the facility failed to install an automatic sprinkler system per NFPA 13.

During the walk through of the facility, with the Maintenance Director, two (2) areas were missing sprinkler coverage;
1) No sprinkler coverage covering the space located under the garage door, when it is in the open position, in the Materials Management area.
Note: Facility was in the process of getting this repaired during the survey.
2) No sprinkler coverage in the soiled utility/mechanical room under the four foot (4') ductwork. This is in the pre-holding room off of the corridor between the linen chute room and the mechanical room.

Building A1-West Building

Through observation during the survey, August 2 through 9, 2011, it was determined that the facility failed to maintain the automatic fire sprinkler system per NFPA 13 and NFPA 25.

During the walk through of the facility, with the Maintenance Director;
1) Escutcheon plates were missing in the following areas;
a) In room #30
b) Clinic procedure room on 1st floor
c) Medical office space
d) Outside room #217 in corridor
e) Outside electrical room #3 in corridor (west building)
f) Carpenter/wood shop
Note: all missing escutcheon plate deficiencies were corrected during survey by Maintenance staff.

2) The kitchen dry storage contained two (2) Quick Response (QR) sprinkler heads and two (2) Standard Response (SR) sprinkler heads within the same compartment.
Per NFPA 13 1999 Edition, section 5-4.5.3 "Where residential sprinklers are installed in a compartment as defined in 1-4.2, all sprinklers within the compartment shall be of the fast-response type that meets the criteria of 1-4.5.1(a)1."
Note: The sprinkler heads that were different in the compartments were corrected during the survey.

3) Sprinkler heads contained corrosion or paint around the working parts of the sprinkler head in two (2) areas;
a) Two (2) sprinkler heads in the Outpatient Clinic Nurse Office.
b) Three (3) sprinkler heads in the Nurse Training Classroom.
Per 1999 Edition of NFPA 25, Section 2-2.1.1 "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation."
Note: All corroded sprinkler heads were corrected during the survey.

4) Documentation was not available to verify that sprinkler gauges were calibrated or replaced every five (5) years;
a) One (1) gauge located in the North Central stairwell at floor #1.
b) Three (3) gauges located at the fire pump.
c) Three (3) gauges located at the dry sprinkler system- in which two (2) were dated 2000 and one (1) was dated 2002.
Per 1999 Edition NFPA 25, Chapter 5, section 5.3.2 "Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced."

5) Sprinklers in three (3) resident rooms, were obstructed by the lift mechanism rails. These rails were located in a way that the spray pattern was obstructed from reaching the hazard.
a) Resident room #307 contained a bed rail that was located within six and a quarter inches (6-1/4") from the pendant sprinkler head. With no sprinkler coverage on the other side of the lift rail.
b) Resident room #207 contained a bed rail that was located within six and a quarter inches (6-1/4") from the pendant sprinkler head. With no sprinkler coverage on the other side of the lift rail.
c) Resident room #216 contained a sidewall, two lift rails that obstructed the sidewall sprinkler head. This room did not contain any other sprinkler protection except for the sidewall sprinkler head.
Per NFPA 13, section 5-6.5.2.3 "The distance from sprinklers to privacy curtains, free standing partitions, room dividers, and similar obstructions in light hazard occupancies shall be in accordance with Table 5-6.5.2.3 and Figure 5-6.5.2.3."

Through record review, during the survey August 2 through 9, 2011, it was determined that the facility failed to test the fire sprinkler pump per NFPA 25.

During the review of the facility records, with the Maintenance Director, documentation available indicated that the diesel fire pump was tested weekly for twenty (20) minutes and not thirty (30) minutes as required by NFPA 25 for diesel fire pumps.
Per NFPA 25, section 5-3.2.2 "A weekly test of diesel engine-driven pump assemblies shall be conducted without flowing water. This test shall be conducted by starting the pump automatically, and the pump shall run a minimum of 30 minutes."

Building A1-West Building

Through observation during the survey, August 2 through 9, 2011, it was determined the facility failed to install all portable fire extinguishers as required by NFPA 10.

During the walk through of the facility, with the Maintenance Director, one (1) fire extinguisher, located in first (1st) floor therapy room, was mounted at a height of the six and a half feet (6-1/2') above the floor.
Per NFPA 10, section 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)."

Building A1-West Building

Through observation during the survey, August 2 through 9, 2011, it was determined that the facility failed to maintain the rubbish chute doors.

During the walk through of the facility, with the Maintenance Director, the third (3rd) floor laundry chute would not latch into the frame when closing. The door contained a hasp type latch on the door for the positive latch hardware.

Building A1-West Building

Through observation during the survey, August 2 through 9, 2011, it was determined that the facility failed to continuously maintain the means of egress free of all obstructions or impediments to full instant use in case of fire or other emergency.

During the walk through of the facility, with the Maintenance Director;
1) A portable x-ray machine was being stored and charged in the corridor outside of the x-ray technicians office. The portable machine was observed at 2:30 p.m. and again at 3:45 p.m., in the same position.
2) Two (2) liquid oxygen tanks stored in corridor outside of the second (2nd) floor nurse station. Note: The oxygen tanks were moved immediately by staff. 3) Two (2) wheelchairs were stored outside of the cafeteria in the corridor at 9:15 a.m. and again at 10:00 a.m.
4) The third (3rd) floor nurse station contained a table outside of the nurse station at 10:00 a.m. and again at 10:30 a.m.

Building A1-West Building

Through observation during the survey, August 2 through 9, 2011, it was determined that the facility failed to maintain decorations and loose hanging fabrics per NFPA 101.

During the walk through of the facility, with the Maintenance Director, the large therapy room, located on the third (3rd) floor, contains approximately one-hundred (100) hanging sports pennants from the drop ceiling. Documentation for the pennants could not be located to determine that the fabric met NFPA 701 standards.
Per NFPA 101, section 10.3.1 "Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films."

Building A1-West Building

Through observation during the survey, August 2 through 9, 2011, it was determined the facility failed to maintain the oxygen storage rooms in accordance with NFPA 99.

During the walk through of the facility with the Maintenance Director, two (2) oxygen transfer rooms did not meet the requirements of NFPA 99.
1) The third (3rd) floor oxygen transfer/storage room;
a) The flooring in the room was Carpet and Vinyl Composition Tile (CVT).
b) The room did not contain mechanical ventilation to the exterior of the building.
c) The room did not contain a no smoking sign.
d) The room contained one (1) duplex receptacle located eighteen inches (18") off of the floor.
e) The room contained one (1) light switch/duplex receptacle outlet located fifty three inches (53") off of the floor.

2) The second (2nd) floor oxygen transfer/storage room;
a) The flooring in the room was Vinyl Composite Tile (VCT).
b) The room contained one (1) duplex receptacle located thirty six inches (36") off of the floor.
c) The room contained one (1) light switch located at fifty three inches (53") off of the floor.
d) The mechanical ventilation fan was inoperable and was not running during the survey.
Note: The mechanical fan for the second floor (2nd) was corrected by Maintenance staff during the survey.

Per NFPA 99
Section 8-6.2.5.2
"Transferring of liquid oxygen from one container to another shall be accomplished at a location specifically designated for the transferring that is as follows:
(a) Separated from any portion of a facility wherein patients are housed, examined, or treated by a separation of a fire barrier of 1-hour fire-resistive construction; and
(b) The area is mechanically ventilated, is sprinklered, and has ceramic or concrete flooring; and
(c) The area is posted with signs indicating that transferring is occurring, and that smoking in the immediate area is not permitted."
and
Section 4-3.1.1.2(4)
"The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage."

Building A1-West Building

Through record review and testing during the survey, August 2 through 9, 2011, it was determined that the facility failed to install generator components per NFPA 99 requirements.

During the review of the facility records, observation and testing, with the Maintenance Director;
1) The diesel fueled emergency generator failed to have a remote alarm annunciator in a location readily observed by operating personnel. The emergency panel was located in the maintenance office only, which is located in the basement and is not readily observable twenty four (24) hours a day.
Per 19.2.9.1, 7.9.2.3 and 2000 Edition of NFPA 110 section 3-5.6.1 "A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2(d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel."
2) The generator did not contain a remote shut off switch outside of the generator housing. The only emergency shut off switch was located inside the generator on the control panel.
Per NFPA 110, section 3-5.5.6 "All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building."
3) During the transfer switch test, the transfer time from power shut off to power supplied back to the building by the generator was observed to be between twelve (12) seconds and eighteen (18) seconds for all transfer switches.
Per NFPA 99, Section 3-6.3.1.2 "The emergency system shall be so arranged that, in the event of failure of normal power source, the alternate source of power shall be automatically connected to the load within 10 seconds."

Building A1-West Building

Through observation and testing during the survey, August 2 through 9, 2011, it was determined the facility failed to divide the essential electrical system onto the correct branches per NFPA 99.

During the document review and observation, with the Maintenance Director, the essential electrical system is setup as a Type II electrical system with a Critical Branch and an Equipment Branch only, and did not contain a Life Safety Branch. The facility contains and utilizes life support equipment and must maintain a Type I essential electrical system.

Building A1-West Building

Through observation during the survey, August 2 through 9, 2011, it was determined that the facility failed to install and maintain the electrical system in accordance with NFPA 70.

During the walk through of the facility, with the Maintenance Director, the media room work room contained one (1) power strip daisy chained/piggy backed together to reach an electrical source.
Note: This deficiency was corrected by the Maintenance Director during the survey.

Building A1-West Building

Through observation during the survey, August 2 through 9, 2011, it was determined that the facility failed to install the Alcohol Based Hand Rub (ABHR) dispensers correctly.

During the walk through of the facility, with the Maintenance Director, alcohol based hand rub dispensers (ABHR) were located above an electrical source;
1) One (1) located in the therapy room above a duplex electrical receptacle.
2) One (1) in the west shower room on the second (2nd) floor above a light switch
3) One (1) in room #204 located above a combo light switch/duplex receptacle.
4) One (1) in the kitchen area contained above a duplex receptacle.
Note: All ABHR dispensers were corrected by the Maintenance Director during the survey.