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Observations, and staff interview revealed that there were several fire barriers located throughout the facility that did not meet the rated requirements for two hour fire separation and are not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.1.1.4.3,. These deficient practices could allow the products of combustion to travel from one building to another, which could negatively impact all the patients, staff and visitors of the facility.

Findings include:

On facility tour between 9:00 AM and 3:30 PM on 06/03/2014, observation revealed that the 2-hour fire rated building separation between the Hospital and the Nursing home that is located outside of the Administrators office has penetrations around the conduit that is running through that separation above the 90 minute fire rated doors.


This deficient practices was confirmed by the Maintenance Supervisor (TA).

Observations, and staff interview revealed that there were several fire barriers located throughout the facility that did not meet the rated requirements for two hour fire separation and are not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.1.1.4.3,. These deficient practices could allow the products of combustion to travel from one building to another, which could negatively impact all the patients, staff and visitors of the facility.

Findings include:

On facility tour between 9:00 AM and 3:30 PM on 06/03/2014, observation revealed the following deficient conditions:

1) The 2-hour fire rated building separation wall between the hospital access corridor and the clinic has a opening around the sprinkler piping located in the clinic wall that is across from the ED entry doors.


2) The 90 minute fire rated doors in the 2 hour fire separation located between the ambulance garage - Type V(111) construction, and the hospital - Type II(111) Construction had a gap of 1/4 of an inch between the fire door leaves and the doors did not have any latching device on the doors to ensure that they would positively latch into the rated frame assemble. This deficient condition could cause the facility to be downgraded from the hospital's Type II(111) rated construction down to the ambulance garage's Type V(111) rated construction.

3) There are penetrations around the conduit that is running through the 2 hour fire barrier that is separating the ambulance garage - Type V(111) and the hospital access corridor - Type II(111) Construction. This deficient condition could cause the facility to be downgraded from the hospital's Type II(111) rated construction down to the ambulance garage's Type V(111) rated construction.



This deficient practices was confirmed by the Maintenance Supervisor (TA).

Based on observations and staff interview, it was revealed that the facility has failed to provide proper protection from 1 of several hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.2.1. This deficient conditions could in the event of a fire, allow smoke and flames to spread throughout the effected corridors and areas making them untenable, which could negatively affect the exiting capabilities for 2 of 15 patients, staff and visitors.



Findings include:

On facility tour between 9:00 AM and 3:30 PM on 06/03/2014, observation revealed, that the door leading to the freight elevator equipment room on the lower level was not equipped with a self-closing device and positively latch into the frame; and the the door to the boiler room located on the lower level also did not positively latch into the frame.


This deficient practices was confirmed by the Maintenance Supervisor (TA).

Based on observations and staff interview, the facility has failed to maintain 1 of 4 exit stairway in accordance with NFPA 101 Life Safety Code (2000) section 7.2.2. This deficient practice could negatively affect the use of the exit stairway used by patients, staff, and visitors in the event of an emergency.

Findings include:

On facility tour between 9:00 AM and 3:30 PM on 06/03/2014, observation revealed, that the door leading to the exit stairwell enclosure that is located on the lower level next to the boiler room did not fully close and positively latch into the frame.


This deficient practices was confirmed by the Maintenance Supervisor (TA).

Based on review of reports, records and staff interview, it was determined that the facility failed to conduct fire drills in accordance with NFPA Life Safety Code 101(00), 18.7.1.2, during the last 12-month period. This deficient practice could affect how staff react in the event of a fire. Improper reaction by staff would affect the safety of all patients, visitors, and staff.

Findings include:

On facility tour between 9:00 AM and 3:30 PM on 06/03/2014, during a documentation review of the available fire drill reports for the last 12 months and an interview with the Maintenance Supervisor (TA), it was revealed that the facility had failed to conduct a fire drill for the day shift staff for the fourth quarter of the calendar year.

This deficient practices was confirmed by the Maintenance Supervisor (TA).

Based on review of reports, records and staff interview, it was determined that the facility failed to conduct fire drills in accordance with NFPA Life Safety Code 101(00), 19.7.1.2, during the last 12-month period. This deficient practice could affect how staff react in the event of a fire. Improper reaction by staff would affect the safety of all patients, visitors and staff.

Findings include:

On facility tour between 9:00 AM and 3:30 PM on 06/03/2014, during a documentation review of the available fire drill reports for the last 12 months and an interview with the Maintenance Supervisor (TA), it was revealed that the facility had failed to conduct a fire drill for the day shift staff for the fourth quarter of the calendar year.

This deficient practices was confirmed by the Maintenance Supervisor (TA).

Based on review of reports, records and staff interview, it was determined that the facility failed to conduct fire drills in accordance with NFPA Life Safety Code 101(00), 19.7.1.2, during the last 12-month period. This deficient practice could affect how staff react in the event of a fire. Improper reaction by staff would affect the safety of all patients, visitors, and staff.

Findings include:

On facility tour between 9:00 AM and 3:30 PM on 06/03/2014, during a documentation review of the available fire drill reports for the last 12 months and an interview with the Maintenance Supervisor (TA), it was revealed that the facility had failed to conduct a fire drill for the day shift staff for the fourth quarter of the calendar year.

This deficient practices was confirmed by the Maintenance Supervisor (TA).

Based on observation and staff interview it was revealed that the facility failed to maintain the unobstructed access to 1 of several manually actuated alarm-initiating devices located throughout the facility in accordance with NFPA 101 Life Safety Code (00), Sections 19.3.4.2 and 9.6.2.6 as well as NFPA 72 National Fire Alarm Code (99), Sections 2-8.2.1. This deficient condition could adversely affect the ability to initiate the fire alarm system and delay emergency actions, and emergency forces notification in the event of an emergency, thus negatively affecting patients, staff, and visitors of the facility.

Findings include:

On facility tour between 9:00 AM and 3:30 PM on 06/03/2014, observation revealed, that the manual fire alarm pull station located at the exit by the loading dock was blocked from view and from access by a soft drink vending machine. The requirements of both the NFPA 101 (00) and the NFPA 72 (99) require that manual fire alarm boxes shall be unobstructed and accessible at all times.


This deficient practices was confirmed by the Maintenance Supervisor (TA).

Based on observation and staff interview, it was revealed that the facility had failed to install and maintain the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1999 NFPA 72, Sections 7.1. This deficient condition could adversely affect the functioning of the fire alarm system, and could delay the timely notification and emergency actions for the facility thus negatively affecting all patients, staff, and visitors of the facility.


Findings include:

On facility tour between 9:00 AM and 3:30 PM on 06/03/2014, a review of all available fire alarm documentation for the last 12 months, and by an interview with the Maintenance Supervisor (TA), revealed that at the time of the inspection the facility had failed to conduct 1 of 12 required monthly tests of the DACT for the facility's fire alarm system.


This deficient practices was confirmed by the Maintenance Supervisor (TA).

Based on observations and staff interview, the automatic sprinkler system is not installed and maintained in accordance with NFPA 101 (2000), Chapter 9, Section 9.7.2.1 and NFPA 72 (1999) and NFPA 13 (1999).accordance with NFPA 13 the Standard for the Installation of Sprinkler Systems (99). The failure to maintain the sprinkler system in compliance could allow for the failure of the fire sprinkler system and affect all the patients, visitors and staff of the facility.


FINDINGS INCLUDE:

On facility tour between 9:00 AM and 3:30 PM on 06/03/2014, observations revealed that the facility failed to have the fire sprinkler system's outside Post Indicator Valve electronically monitored and to also have the valve wrench secured (locked in place) to prevent the fire sprinkler system from being shut down. Without the valve being secured and monitored the water supply to the fire sprinkler system could be shut off without any notification to the facility.


This deficient practices was confirmed by the Maintenance Supervisor (TA).

Based on documentation review and staff interview, it was determined that the facility failed to maintain portable fire extinguishers in accordance with NFPA 101-2000 edition, Section 9.7.4.1 and NFPA 10. This deficient practice could affect 4 of 15 patients, staff and visitors.

Findings include:

On facility tour between 9:00 AM and 3:30 PM on 06/03/2014, observation revealed that the fire extinguish that is located in the hospital's pharmacy was not mounted on the wall or stored in a cabinet at the time of the inspection.


This deficient practices was confirmed by the Maintenance Supervisor (TA).

Based on observation and interview with the staff the facility was using extension cords in place of permanent wiring that is not in accordance with NFPA 70 (99), National Electrical Code. This deficient practice could negatively affect the safety of 4 of 15 patients, staff and visitors.


Findings include:

On facility tour between 9:00 AM and 3:30 PM on 06/03/2014, observations revealed that the facility failed to limit the use of extension cords within the facility as seen by the the extension cords found at the main nurses desk and in the hospital's central supply storage room.


This deficient practices was confirmed by the Maintenance Supervisor (TA).

Observations, and staff interview revealed that there were several fire barriers located throughout the facility that did not meet the rated requirements for two hour fire separation and are not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.1.1.4.3,. These deficient practices could allow the products of combustion to travel from one building to another, which could negatively impact all the patients, staff and visitors of the facility.

Findings include:

On facility tour between 9:00 AM and 3:30 PM on 06/03/2014, observation revealed that the 2-hour fire rated building separation between the Hospital and the Nursing home that is located outside of the Administrators office has penetrations around the conduit that is running through that separation above the 90 minute fire rated doors.


This deficient practices was confirmed by the Maintenance Supervisor (TA).

Observations, and staff interview revealed that there were several fire barriers located throughout the facility that did not meet the rated requirements for two hour fire separation and are not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.1.1.4.3,. These deficient practices could allow the products of combustion to travel from one building to another, which could negatively impact all the patients, staff and visitors of the facility.

Findings include:

On facility tour between 9:00 AM and 3:30 PM on 06/03/2014, observation revealed the following deficient conditions:

1) The 2-hour fire rated building separation wall between the hospital access corridor and the clinic has a opening around the sprinkler piping located in the clinic wall that is across from the ED entry doors.


2) The 90 minute fire rated doors in the 2 hour fire separation located between the ambulance garage - Type V(111) construction, and the hospital - Type II(111) Construction had a gap of 1/4 of an inch between the fire door leaves and the doors did not have any latching device on the doors to ensure that they would positively latch into the rated frame assemble. This deficient condition could cause the facility to be downgraded from the hospital's Type II(111) rated construction down to the ambulance garage's Type V(111) rated construction.

3) There are penetrations around the conduit that is running through the 2 hour fire barrier that is separating the ambulance garage - Type V(111) and the hospital access corridor - Type II(111) Construction. This deficient condition could cause the facility to be downgraded from the hospital's Type II(111) rated construction down to the ambulance garage's Type V(111) rated construction.



This deficient practices was confirmed by the Maintenance Supervisor (TA).

Based on observations and staff interview, it was revealed that the facility has failed to provide proper protection from 1 of several hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.2.1. This deficient conditions could in the event of a fire, allow smoke and flames to spread throughout the effected corridors and areas making them untenable, which could negatively affect the exiting capabilities for 2 of 15 patients, staff and visitors.



Findings include:

On facility tour between 9:00 AM and 3:30 PM on 06/03/2014, observation revealed, that the door leading to the freight elevator equipment room on the lower level was not equipped with a self-closing device and positively latch into the frame; and the the door to the boiler room located on the lower level also did not positively latch into the frame.


This deficient practices was confirmed by the Maintenance Supervisor (TA).

Based on observations and staff interview, the facility has failed to maintain 1 of 4 exit stairway in accordance with NFPA 101 Life Safety Code (2000) section 7.2.2. This deficient practice could negatively affect the use of the exit stairway used by patients, staff, and visitors in the event of an emergency.

Findings include:

On facility tour between 9:00 AM and 3:30 PM on 06/03/2014, observation revealed, that the door leading to the exit stairwell enclosure that is located on the lower level next to the boiler room did not fully close and positively latch into the frame.


This deficient practices was confirmed by the Maintenance Supervisor (TA).

Based on review of reports, records and staff interview, it was determined that the facility failed to conduct fire drills in accordance with NFPA Life Safety Code 101(00), 18.7.1.2, during the last 12-month period. This deficient practice could affect how staff react in the event of a fire. Improper reaction by staff would affect the safety of all patients, visitors, and staff.

Findings include:

On facility tour between 9:00 AM and 3:30 PM on 06/03/2014, during a documentation review of the available fire drill reports for the last 12 months and an interview with the Maintenance Supervisor (TA), it was revealed that the facility had failed to conduct a fire drill for the day shift staff for the fourth quarter of the calendar year.

This deficient practices was confirmed by the Maintenance Supervisor (TA).

Based on review of reports, records and staff interview, it was determined that the facility failed to conduct fire drills in accordance with NFPA Life Safety Code 101(00), 19.7.1.2, during the last 12-month period. This deficient practice could affect how staff react in the event of a fire. Improper reaction by staff would affect the safety of all patients, visitors and staff.

Findings include:

On facility tour between 9:00 AM and 3:30 PM on 06/03/2014, during a documentation review of the available fire drill reports for the last 12 months and an interview with the Maintenance Supervisor (TA), it was revealed that the facility had failed to conduct a fire drill for the day shift staff for the fourth quarter of the calendar year.

This deficient practices was confirmed by the Maintenance Supervisor (TA).

Based on review of reports, records and staff interview, it was determined that the facility failed to conduct fire drills in accordance with NFPA Life Safety Code 101(00), 19.7.1.2, during the last 12-month period. This deficient practice could affect how staff react in the event of a fire. Improper reaction by staff would affect the safety of all patients, visitors, and staff.

Findings include:

On facility tour between 9:00 AM and 3:30 PM on 06/03/2014, during a documentation review of the available fire drill reports for the last 12 months and an interview with the Maintenance Supervisor (TA), it was revealed that the facility had failed to conduct a fire drill for the day shift staff for the fourth quarter of the calendar year.

This deficient practices was confirmed by the Maintenance Supervisor (TA).

Based on observation and staff interview it was revealed that the facility failed to maintain the unobstructed access to 1 of several manually actuated alarm-initiating devices located throughout the facility in accordance with NFPA 101 Life Safety Code (00), Sections 19.3.4.2 and 9.6.2.6 as well as NFPA 72 National Fire Alarm Code (99), Sections 2-8.2.1. This deficient condition could adversely affect the ability to initiate the fire alarm system and delay emergency actions, and emergency forces notification in the event of an emergency, thus negatively affecting patients, staff, and visitors of the facility.

Findings include:

On facility tour between 9:00 AM and 3:30 PM on 06/03/2014, observation revealed, that the manual fire alarm pull station located at the exit by the loading dock was blocked from view and from access by a soft drink vending machine. The requirements of both the NFPA 101 (00) and the NFPA 72 (99) require that manual fire alarm boxes shall be unobstructed and accessible at all times.


This deficient practices was confirmed by the Maintenance Supervisor (TA).

Based on observation and staff interview, it was revealed that the facility had failed to install and maintain the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1999 NFPA 72, Sections 7.1. This deficient condition could adversely affect the functioning of the fire alarm system, and could delay the timely notification and emergency actions for the facility thus negatively affecting all patients, staff, and visitors of the facility.


Findings include:

On facility tour between 9:00 AM and 3:30 PM on 06/03/2014, a review of all available fire alarm documentation for the last 12 months, and by an interview with the Maintenance Supervisor (TA), revealed that at the time of the inspection the facility had failed to conduct 1 of 12 required monthly tests of the DACT for the facility's fire alarm system.


This deficient practices was confirmed by the Maintenance Supervisor (TA).

Based on observations and staff interview, the automatic sprinkler system is not installed and maintained in accordance with NFPA 101 (2000), Chapter 9, Section 9.7.2.1 and NFPA 72 (1999) and NFPA 13 (1999).accordance with NFPA 13 the Standard for the Installation of Sprinkler Systems (99). The failure to maintain the sprinkler system in compliance could allow for the failure of the fire sprinkler system and affect all the patients, visitors and staff of the facility.


FINDINGS INCLUDE:

On facility tour between 9:00 AM and 3:30 PM on 06/03/2014, observations revealed that the facility failed to have the fire sprinkler system's outside Post Indicator Valve electronically monitored and to also have the valve wrench secured (locked in place) to prevent the fire sprinkler system from being shut down. Without the valve being secured and monitored the water supply to the fire sprinkler system could be shut off without any notification to the facility.


This deficient practices was confirmed by the Maintenance Supervisor (TA).

Based on documentation review and staff interview, it was determined that the facility failed to maintain portable fire extinguishers in accordance with NFPA 101-2000 edition, Section 9.7.4.1 and NFPA 10. This deficient practice could affect 4 of 15 patients, staff and visitors.

Findings include:

On facility tour between 9:00 AM and 3:30 PM on 06/03/2014, observation revealed that the fire extinguish that is located in the hospital's pharmacy was not mounted on the wall or stored in a cabinet at the time of the inspection.


This deficient practices was confirmed by the Maintenance Supervisor (TA).

Based on documentation review, the fire/smoke damper system has not been maintained in accordance with the requirements of NFPA 90(99) section 3-4.7. This deficient practice does not ensure the proper operation of the fire/smoke dampers and could allow smoke migration to negatively affect the safety of all patients, staff and visitors in the event of a fire.


Findings include:

On facility tour between 9:00 AM and 3:30 PM on 06/03/2014, it was revealed during the review of the facility's fire and smoke damper test/inspection documentation and was confirmed by interview with the Maintenance Supervisor (TA), that the facility failed to provide documentation that the fire and smoke dampers have been tested/inspected within the last 4 years in accordance with NFPA 90(99) section 3-4.7.


This deficient practices was confirmed by the Maintenance Supervisor (TA).

Based on observation and interview with the staff the facility was using extension cords in place of permanent wiring that is not in accordance with NFPA 70 (99), National Electrical Code. This deficient practice could negatively affect the safety of 4 of 15 patients, staff and visitors.


Findings include:

On facility tour between 9:00 AM and 3:30 PM on 06/03/2014, observations revealed that the facility failed to limit the use of extension cords within the facility as seen by the the extension cords found at the main nurses desk and in the hospital's central supply storage room.


This deficient practices was confirmed by the Maintenance Supervisor (TA).