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Based on observation and interview, the facility failed to maintain the fire and smoke barrier walls. The deficient practice affected all smoke compartments, staff, and patients on the dates of the survey.

Findings include:

Observation between 07/23/12 and 07/26/12 revealed that the fire/smoke barrier walls in the following locations had various conduits, wire, and pipe penetrations that were not sealed: C4 communication closet, electric closet next to RT clean equipment room; Pharmacy shell/Ultrasound; basement electric room, Oncology Infusion floor electric closet; 2nd floor Environmental Services next to men ' s locker; kitchen, above ceiling by C9232 cross corridor doors; above ceiling corridor by 9217; EHP electric closet; and above ceiling 1st floor northeast stairwell. Interview with the Engineering Manager on 07/26/12 . revealed that the facility was not aware of the unsealed penetrations in the fire and smoke barrier walls. These findings are only inclusive of the limited samples taken.


Actual NFPA Standards:
NFPA 101, 19.3.7.3. Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

NFPA 101, 8.3.6.1 (1) a and b. Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected by filling the space between the penetrating item and the smoke barrier with a material that is capable of maintaining the smoke resistance of the smoke barrier or it shall be protected by an approved device that is designed for the specific purpose.

Based on observation and interview, the facility failed to maintain smoke barrier doors that would close and resist the passage of smoke. The deficient practice affected two of five smoke compartments, staff and patients.

Findings include:

Observation on 7/26/12 at 11:53 a.m. revealed that the smoke doors that separated the corridor by room 105 would not fully open. One of the doors auto closure devices would only allow the door to open 50% of the way. Interview with the Engineering Manager on 07/26/12 at 11:53 a.m. revealed that the facility was not aware that the smoke door was not opening properly.

Actual NFPA Standard:

NFPA 101, 7.1.10.1
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.

Based on observation and interview, the facility failed to assure that exit accesses are readily accessible to evacuate the facility at all times. This deficient practice affected visitors, facility personnel, and patients
Based on observations and staff interview, the findings are as follows:
During the facility tour on 07/26/12 at 12:25 p.m., observed that the facility failed to provide a continuous egress pathway to a public way from the designated exit, at the northwest exit . This exit discharged on to a small landing blocked by landscaping, there was no walking surface beyond the landing. Interview with the Engineering Manager revealed that the facility was not aware the exit did not terminate at a public way..
Actual NFPA 101 reference:
7.7 DISCHARGE FROM EXITS
7.7.1
Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.
Exception No. 1: This requirement shall not apply to interior exit discharge as otherwise provided in 7.7.2.
Exception No. 2: This requirement shall not apply to rooftop exit discharge as otherwise provided in 7.7.6.
Exception No. 3: Means of egress shall be permitted to terminate in an exterior area of refuge as provided in Chapters 22 and 23.

Based on observation and interview, the facility failed to post the required precautionary signage at an oxygen shutoff valve location. This deficient practice affected all staff and patients in the facility.


The findings include:

Observation on 07/26/12 at 10:15 a.m. revealed that the oxygen shutoff panel located in the decontamination room was not secure or posted with a caution to not close or open the valve except in an emergency sign. Interview with the Engineering Manager on 07/26/12 at 10:15 a.m. revealed that the facility was not aware that oxygen shutoff valve was not secured and not labeled.

Actual NFPA Standard:
NFPA 99, 4-3.1.2.3 Gas Shutoff Valves.
Shutoff valves accessible to other than authorized personnel shall be installed in valve boxes with frangible or removable windows large enough to permit manual operation of valves.

(b) Main Valve. The main supply line shall be provided with a shutoff valve. The valve shall be located to permit access by authorized personnel only (e.g., by locating in a ceiling or behind a locked access door). The main supply line valve shall be located downstream of the source valve and outside of the source room, enclosure, or where the main line first enters the building. This valve shall be identified. A main line valve shall not be required where the source shutoff valve is accessible from within the building.

Based on observation and interview, the facility failed to provide for the generator annunciator panel to be located at a constantly attended location. This deficient practice affected all staff and patients in the facility.
Findings include:

During the facility tour on 07/26/12 at 10:30 a.m., it was observed that the generator annunciator panel was located at an unoccupied location on the vacant 2nd floor nurses ' station. Interview with the Engineering Manager revealed the facility was unaware the generator annunciator panel; was located in an unattended area. .

NFPA 99 ?3-4.1.1.15 Alarm Annunciator.
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].

Based on observation and interview, the facility failed to ensure electrical wiring was in accordance with the National Electrical Code. This deficient practice affected all smoke compartments, staff and patients on the dates of the survey.

Findings include:

1. Observation between 07/23/12 and 7/25/12, revealed electric circuit breakers were not labeled as to what they control in the Central Tower and Kitchen Interview with the Engineering Manager on 07/23/12 revealed that the facility was not aware the circuits were not properly labeled. These findings are only inclusive of the sample taken.

2. Observation between 07/23/12 and 7/25/12 revealed relocatable power taps utilized outside of their UL listing in the following locations: RT Office; 2nd floor NICU; Learning Systems office; office behind Endo Reception, and the doctors lounge Interview with the Engineering Manager on 07/23/12, revealed that the facility was not aware of the requirement that prohibits the use of power strips for appliances. These findings are only inclusive of the sample taken.

3. Observation on 07/25/12 at 11:15 a.m. revealed exposed wires protruding from an electric raceway disconnected from the junction box underneath the kitchen sink. Interview with the Engineering Manager on 07/25/12, revealed that the facility was not aware of the exposed wires.




Actual NFPA Standard(s):

Item #1

NFPA 70, 110-22. Identification of Disconnecting Means
Each disconnecting means required by this Code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.

Item #2
NFPA 70,110-3. Examination, Identification, Installation, and Use of Equipment
(a) Examination. In judging equipment, considerations such as the following shall be evaluated:
1. Suitability for installation and use in conformity with the provisions of this Code
FPN: Suitability of equipment use may be identified by a description marked on or provided with a product to identify the suitability of the product for a specific purpose, environment, or application. Suitability of equipment may be evidenced by listing or labeling.
2. Mechanical strength and durability, including, for parts designed to enclose and protect other equipment, the adequacy of the protection thus provided
3. Wire-bending and connection space
4. Electrical insulation
5. Heating effects under normal conditions of use and also under abnormal conditions likely to arise in service
6. Arcing effects
7. Classification by type, size, voltage, current capacity, and specific use
8. Other factors that contribute to the practical safeguarding of persons using or likely to come in contact with the equipment
(b) Installation and Use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.

Item #3
NFPA 70, 300-12. Mechanical Continuity - Raceways and Cables
Metal or nonmetallic raceways, cable armors, and cable sheaths shall be continuous between cabinets, boxes, fittings, or other enclosures or outlets.

Based on observation and interview, the facility failed to maintain the fire and smoke barrier walls. The deficient practice affected all smoke compartments, staff, and patients on the dates of the survey.

Findings include:

Observation between 07/23/12 and 07/26/12 revealed that the fire/smoke barrier walls in the following locations had various conduits, wire, and pipe penetrations that were not sealed: C4 communication closet, electric closet next to RT clean equipment room; Pharmacy shell/Ultrasound; basement electric room, Oncology Infusion floor electric closet; 2nd floor Environmental Services next to men ' s locker; kitchen, above ceiling by C9232 cross corridor doors; above ceiling corridor by 9217; EHP electric closet; and above ceiling 1st floor northeast stairwell. Interview with the Engineering Manager on 07/26/12 . revealed that the facility was not aware of the unsealed penetrations in the fire and smoke barrier walls. These findings are only inclusive of the limited samples taken.


Actual NFPA Standards:
NFPA 101, 19.3.7.3. Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

NFPA 101, 8.3.6.1 (1) a and b. Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected by filling the space between the penetrating item and the smoke barrier with a material that is capable of maintaining the smoke resistance of the smoke barrier or it shall be protected by an approved device that is designed for the specific purpose.

Based on observation and interview, the facility failed to maintain smoke barrier doors that would close and resist the passage of smoke. The deficient practice affected two of five smoke compartments, staff and patients.

Findings include:

Observation on 7/26/12 at 11:53 a.m. revealed that the smoke doors that separated the corridor by room 105 would not fully open. One of the doors auto closure devices would only allow the door to open 50% of the way. Interview with the Engineering Manager on 07/26/12 at 11:53 a.m. revealed that the facility was not aware that the smoke door was not opening properly.

Actual NFPA Standard:

NFPA 101, 7.1.10.1
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.

Based on observation and interview, the facility failed to assure that exit accesses are readily accessible to evacuate the facility at all times. This deficient practice affected visitors, facility personnel, and patients
Based on observations and staff interview, the findings are as follows:
During the facility tour on 07/26/12 at 12:25 p.m., observed that the facility failed to provide a continuous egress pathway to a public way from the designated exit, at the northwest exit . This exit discharged on to a small landing blocked by landscaping, there was no walking surface beyond the landing. Interview with the Engineering Manager revealed that the facility was not aware the exit did not terminate at a public way..
Actual NFPA 101 reference:
7.7 DISCHARGE FROM EXITS
7.7.1
Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.
Exception No. 1: This requirement shall not apply to interior exit discharge as otherwise provided in 7.7.2.
Exception No. 2: This requirement shall not apply to rooftop exit discharge as otherwise provided in 7.7.6.
Exception No. 3: Means of egress shall be permitted to terminate in an exterior area of refuge as provided in Chapters 22 and 23.

Based on observation and interview, the facility failed to post the required precautionary signage at an oxygen shutoff valve location. This deficient practice affected all staff and patients in the facility.


The findings include:

Observation on 07/26/12 at 10:15 a.m. revealed that the oxygen shutoff panel located in the decontamination room was not secure or posted with a caution to not close or open the valve except in an emergency sign. Interview with the Engineering Manager on 07/26/12 at 10:15 a.m. revealed that the facility was not aware that oxygen shutoff valve was not secured and not labeled.

Actual NFPA Standard:
NFPA 99, 4-3.1.2.3 Gas Shutoff Valves.
Shutoff valves accessible to other than authorized personnel shall be installed in valve boxes with frangible or removable windows large enough to permit manual operation of valves.

(b) Main Valve. The main supply line shall be provided with a shutoff valve. The valve shall be located to permit access by authorized personnel only (e.g., by locating in a ceiling or behind a locked access door). The main supply line valve shall be located downstream of the source valve and outside of the source room, enclosure, or where the main line first enters the building. This valve shall be identified. A main line valve shall not be required where the source shutoff valve is accessible from within the building.

Based on observation and interview, the facility failed to provide for the generator annunciator panel to be located at a constantly attended location. This deficient practice affected all staff and patients in the facility.
Findings include:

During the facility tour on 07/26/12 at 10:30 a.m., it was observed that the generator annunciator panel was located at an unoccupied location on the vacant 2nd floor nurses ' station. Interview with the Engineering Manager revealed the facility was unaware the generator annunciator panel; was located in an unattended area. .

NFPA 99 ?3-4.1.1.15 Alarm Annunciator.
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].

Based on observation and interview, the facility failed to ensure electrical wiring was in accordance with the National Electrical Code. This deficient practice affected all smoke compartments, staff and patients on the dates of the survey.

Findings include:

1. Observation between 07/23/12 and 7/25/12, revealed electric circuit breakers were not labeled as to what they control in the Central Tower and Kitchen Interview with the Engineering Manager on 07/23/12 revealed that the facility was not aware the circuits were not properly labeled. These findings are only inclusive of the sample taken.

2. Observation between 07/23/12 and 7/25/12 revealed relocatable power taps utilized outside of their UL listing in the following locations: RT Office; 2nd floor NICU; Learning Systems office; office behind Endo Reception, and the doctors lounge Interview with the Engineering Manager on 07/23/12, revealed that the facility was not aware of the requirement that prohibits the use of power strips for appliances. These findings are only inclusive of the sample taken.

3. Observation on 07/25/12 at 11:15 a.m. revealed exposed wires protruding from an electric raceway disconnected from the junction box underneath the kitchen sink. Interview with the Engineering Manager on 07/25/12, revealed that the facility was not aware of the exposed wires.




Actual NFPA Standard(s):

Item #1

NFPA 70, 110-22. Identification of Disconnecting Means
Each disconnecting means required by this Code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.

Item #2
NFPA 70,110-3. Examination, Identification, Installation, and Use of Equipment
(a) Examination. In judging equipment, considerations such as the following shall be evaluated:
1. Suitability for installation and use in conformity with the provisions of this Code
FPN: Suitability of equipment use may be identified by a description marked on or provided with a product to identify the suitability of the product for a specific purpose, environment, or application. Suitability of equipment may be evidenced by listing or labeling.
2. Mechanical strength and durability, including, for parts designed to enclose and protect other equipment, the adequacy of the protection thus provided
3. Wire-bending and connection space
4. Electrical insulation
5. Heating effects under normal conditions of use and also under abnormal conditions likely to arise in service
6. Arcing effects
7. Classification by type, size, voltage, current capacity, and specific use
8. Other factors that contribute to the practical safeguarding of persons using or likely to come in contact with the equipment
(b) Installation and Use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.

Item #3
NFPA 70, 300-12. Mechanical Continuity - Raceways and Cables
Metal or nonmetallic raceways, cable armors, and cable sheaths shall be continuous between cabinets, boxes, fittings, or other enclosures or outlets.