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The facility failed to maintain the corridor walls per code. Findings include:

During the survey, the following are examples of what was observed:
First Floor
The following corridor walls were in an unsprinklered smoke compartment of the facility and had unsealed penetrations:
1. At the Lab. - unsealed conduit above the door
2. At the O.R. Women's Locker Room
3. At Information Systems - unsealed penetration of conduit with yellow and blue wires
4. Across from Information Systems - wall at corner not sealed at "I" beam
5. ER/Lab Waiting corridor at the Office and the New Admitting - the corridor wall does not extend to the roof deck

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2000 NFPA 101, 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.
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A) The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include: During the survey, the following is an example of what was observed:

The door from the ER which opens into the corridor failed to positive latch.


NFPA 101, 19.3.6.3.1 Exception No.2. In the smoke compartments protected throughout by an approved, supervised automatic sprinkler system, doors in corridor walls shall be constructed to resist the passage of smoke and be provided with suitable means of keeping the doors closed.


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B) The facility failed to maintain the corridor openings per code. Findings include:

During the survey, the following are examples of what was observed:
First Floor
1. Medical Staff Assistant's Office corridor door had a toe stop
2. Surgery Waiting Room corridor door had a self-closing device on it, but was being held open by a chair
3. Central Sterile corridor door did not have positive latching hardware
4. Business Office Suite corridor door did not have positive latching hardware
5. Dinig Room corridor door at Auxiliary Room did not have positive latching hardware
Second Floor
6. Med. Storage Room corridor door had an unsealed penetration at the door knob
7. Gero-Psych Dining/Activity Room corridor door had an unsealed penetration at the door knob
8. Respitatory Employee Exercise Room - corridor door was not positive latching

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2007 CMS - 2786R There is no impediment to the closing of the corridor doors.


2000 NFPA 101, 19.3.6.3.2 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. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.

2000 NFPA 101, 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
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The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include: During the survey, the following is an example of what was observed:

Unsealed penetrations around a gray wire, and at the deck, of the Smoke Barrier, in front of the Director Of Nursing Office third floor.
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2000 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.
2000 NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
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The facility failed to maintain the smoke barrier to restrict the passage of smoke. Findings include: During the survey, the following is an example of what was observed:

Upon activation of the fire alarm the smoke doors failed to close tight, in the Smoke Barrier by I.C.U. Third Floor.
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NFPA 101, 8.3.4. Doors in the smoke barrier shall close leaving only a minimum opening for the proper operation of the doors.
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The facility failed to maintain the hazardous areas per code. Findings include:

During the survey, the following are examples of what was observed:
First Flor
1. The Dietary Dry Storage Room in the Kitchen had a self-closing device, but was being held open by a wedge
Second Floor
2. The following patient rooms were over 50 sq. ft., not sprinklered, do not have one hour fire rated walls that go the roof deck, doors are not fire rated and do not have self-closing devices on them and were being used to store combustible materials:
a. 217
b. 219
3. The Med. Storage Room is over 50 sq. ft. is used to store combustible materials, did not have a 45 minute fire rated door with a self-closing device
4. The Old Bathroom off of the Med. Storage Room the facility had removed the door to this room making it apart of the larger Med. Storage Room, but this room did not have one hour fire rated walls that continue to the roof deck

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2000 NFPA 101, 19.3.2.1 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.

2000 NFPA 101, 8.4.1.3 Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.
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The facility failed to maintain stairways with at least 1 hour fire resistance rating. Findings include: During the survey, the following are examples of what was observed:

1. Unsealed penetrations at the deck, and around two sections of conduit, in the East Wing Stairwell Third Floor.

2. Unsealed penetrations around a sprinkler line, in the wall of the stairwell, in the Administration Wing Third Floor.

3. Unsealed penetrations at the deck , and in the corner of the wall of the South Wing Stairwell Third Floor.
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NFPA 101, 19.3.1.1, 8.2.3.2.4, and 7.1.3.2.1 requires a fire resistance rating of one hour.
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The facility failed to provide protection of openings in fire barriers to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. Findings include: During the survey, the following is an example of what was observed:


1. The doors in the fire barrier by ER. failed to latch.
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NFPA 101, 19.2.2.5 and 7.2.4, 8.2.3.2; 2-8.2.3 NFPA 80 All single doors and active leaves of pairs of doors shall be provided with an active latch which cannot be held in the retracted position.


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First Floor
2. The fire barrier by the Classroom in the Classroom Addition at the fire doors had 2 unsealed penetrations , one with a black wire
3. The fire barrier by the Ladies Restroom in the Classroom Addition at the fire doors had a group of unsealed conduits at the bottom right corner above the ceiling
4. The fire barrier in the ER Suite, the "Doctors Only" Room had a unsealed penetration of a waste water pipe
5. The fire barrier in the ER Suite, "Restroom" had an unsealed penetration of a white wire
6. The fire barrier at Post/Pre OP (the corridor side) had an unsealed penetration
7. The fire barrier by Purchasing above the fire doors had an unsealed penetration
Second Floor
8. The fire barrier in Respitatory Employee Exercise Room had two unsealed penetrations one with a black cable at the t.v.
9. The fire barrier in the Pharmacy at the Gero-Psych connecting door had an unsealed penetration of grey and tan wires.

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2000 NFPA 101, 8.2.3.2.4.2 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows: (1) The space between the penetrating item and the fire barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met: a. The material shall be capable of maintaining the fire resistance of the fire barrier. b. The material shall be protected by an approved device that is designed for the specific purpose. (4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the fire barrier. b. It shall be made by an approved device that is designed for the specific purpose.
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The facility failed to provide continuous lighting for means of egress. Findings include: During the survey, the following is an example of what was observed:

A single bulb light fixture was observed at the Exit Discharge for the Exit by the Class Room.
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NFPA 101, 19.2.8 and 7.8.1.2 Illumination of means of egress shall be continuous.
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The facility failed to provide continuously illuminated exit signs. Findings include: During the survey, the following is an example of what was observed:

A exit sign was not provided for the Exit from I.C.U. on the Third Floor.
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NFPA 101, 7.10.1.2 Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.
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This is a rewrite from 2009 survey

The facility failed to conduct fire drills per code. Findings include:

During the survey, the following are examples of what was observed:
Per documentation from the facility:
1. Second Shift for the second quarter of 2012 - did not have any signatures
2. Third Shift for the second quarter of 2012 - did not have a report
3. No documentation of a drill for the third shift for the first quarter of 2012
4. No documentation of any drills for any shifts for the third and fourth quarters of 2011

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2000 NFPA 101, 19.7.1.2 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.
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Facility failed to maintain the Digital Alarm Communicator Transmitter in the fire alarm system. Findings include: During the survey, the following are examples of what was observed:


1. When the Auto Dialer was tested for phone line 1, failure was not indicated at the protected premise within the allotted four (4) minute time frame.


2. When the Auto Dialer was tested for phone line 2, failure was not indicated at the protected premise within the allotted four (4) minute time frame.


3. When the Auto Dialer was tested for Communication Failure, failure was not indicated at the protected premise within the allotted fifteen (15) minute time frame (5 minimum to 10 maximum attempts for signal transmission).
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1999 NFPA 72, Section 1-5.4.6, 5-5.3.2.1.5, and 5-5.3.2.1.6.2. Phone line and communication failure shall be indicated at the facility.
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The facility failed to maintain the fire alarm system in proper working order. Findings include: During the survey, the following is an example of what was observed:

1. The South Stairwell Exit was not provided with a manual pull station.


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2. While testing the fire alarm - no audible or visual device was observed in the O.R. Suite and you could not hear it, the facility had decided to do a fire drill with this activation of the fire alarm - someone was suppose to notify the people in the O.R., but they did not.
3. No smoke detectors were observed on either side of the following fire doors:
a. Purchasing/Surgery
b. Lab/Central Sterile
4. No corridor smoke detection was observed in the non sprinklered smoke compartments of this facility:
a. Original Part of the Fisrt Floor
b. Part of Second Floor
c. Most of Third Floor

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NFPA 101, 9.6.1.4 The fire alarm system to be installed, tested, and maintained in accordance with the requirements of NFPA 70 and NFPA 72.

2000 NFPA 101, 9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.

2000 NFPA 101, 9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.

2000 NFPA 101, 19.3.4.5.1 An approved automatic smoke detection system shall be installed in all corridors of limited care facilities. Such system shall be in accordance with Section 9.6

1999 NFPA 72, 2-10.6.6.1 If ceiling-mounted smoke detectors are to be installed on a smooth ceiling for a single or double doorway, they shall be located as follows (Figure 2-10.6.5.3.1 shall apply.): (1) On the centerline of the doorway (2) No more than 5 ft (1.5 m) measured along the ceiling and perpendicular to the doorway (Figure 2-10.6.5.1.1 shall apply.) (3) No closer than shown in Figure 2-10.6.5.1.1, parts B, D, and F

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The facility failed to perform the required maintenance of the facility sprinkler system. Findings include: During the survey, the following is an example of what was observed:

1. Documentation was not provided by the facility for the 5 year replacement or calibration of gauges.
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NFPA 25, 9-2.8.2: 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.

NFPA 25, 9-2.8.1: Gauges shall be inspected monthly to verify that they are in good condition and that normal pressure is being maintained.


27382



First Floor
2. O.R. Women's Locker Room was missing an escutcheon plate
Second Floor
3. The Electrical Room across from the Breakroom:
a. Missing seven ceiling tiles
b. Back sprinkler head was missing an escutcheon plate
4. Pharmacy - a sprinkler head was obstructed by shelving that was closer than 18" at the wall separating the Pharmacy from the corridor

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1999 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.
1999 NFPA 13, 5-5.6 The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.
1999 NFPA 13, 5-8.4.2 Deflectors of sprinklers shall be aligned parallel to ceilings or roofs.
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The facility failed to maintain the fire extinguishers per code. Findings include:

During the survey, the following are examples of what was observed:
The following braket mounted fire extinguishers were mounted at 70" above the finished floor:
1. In Central Sterile Room
2. In Ultra Sound/Mamo Room

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1998 NFPA 10, 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 31/2 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).
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The facility failed to maintain the cooking facilities per code. Findings include:

During the survey, the following is an example of what was observed:
The facility failed to provide documentation of monthly inspection of the Kitchen Hood suppression system for May.

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1998 NFPA 17A, 5-2.1 Inspection shall be conducted on a monthly basis in accordance with the manufacturer ' s listed installation and maintenance manual or the owner ' s manual. As a minimum, this " quick check " or inspection shall include verification of the following: (a) The extinguishing system is in its proper location. (b) The manual actuators are unobstructed. (c) The tamper indicators and seals are intact. (d) The maintenance tag or certificate is in place. (e) No obvious physical damage or condition exists that might prevent operation. (f) The pressure gauge(s), if provided, is in operable range. (g) The nozzle blowoff caps are intact and undamaged. (h) The hood, duct, and protected cooking appliances have not been replaced, modified, or relocated.
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The facility failed to provide a readily accessible means of egress pathway at all times. Findings include: During the survey, the following is an example of what was observed:

A large piece of equipment was stored in the corridor by the Lab, this equipment was observed by this surveyor when the survey began. Maintenance advised that this item had been in the corridor for two days.
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NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments for full instant use in case of fire or other emergencies.

Corridors must be maintained free of all furniture and other items. Items are considered stored in the corridor if they are not both used and moved at least once every half hour. Transmittal #99-94.

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The facility failed to provide proper storage of oxygen cylinders. Findings include: During the survey, the following is an example of what was observed:

Appropriate signs were not provided for the storage of the oxygen cylinders, these signs shall indicate empty/full cylinders.
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CGA G-4, 4.1.10, and 1999 NFPA 99, 4-3.5.2.2(b)2 and 4-5.5.2.2(b)2 Full and empty cylinders shall be stored separately, with appropriate signage.
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A) The facility failed to maintain emergeny lighting. Findings include: During the survey, the following is an example of what was observed:

The battery-powered light in OR # 2 was inoperable.
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1999 NFPA 70, 517-63 Grounded Power Systems in Anesthetizing Locations.
Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with Section 700-12(e).


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B) The facility failed to provide a smoke venting system for the anesthetizing locations (the two O.R.s) per code. Findings include:

During the survey, the following is an example of what was observed:
The two windowless O.R.s did not have smoke venting systems.

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1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.
1999 NFPA 99, 5-4.1.3 Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.
1999 NFPA 99, 5-4.1.4 The electric supply to the ventilating system shall be served by the equipment system of the essential electrical system specified in Chapter 3, " Electrical Systems. "
1999 NFPA 99, 5-6.1.1 Ventilating and humidifying equipment for anesthetizing locations shall be kept in operable condition and be continually operating during surgical procedures (see A-5-4.1).
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A) The facility failed to provide proper signage for the above ground diesel tank. Findings include: During the survey, the following are examples of what was observed:

1. The above ground diesel tank did not have signage to identify hazard.

2. The above ground diesel tank was not provide with a "No Smoking" sign.

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NFPA 30 2-9.3, Unsupervised aboveground storage tanks shall be secured and marked in such a manner as to identify the fire hazards of the tank and its contents to the general public. The area in which the tank is located shall be protected from tampering or trespassing, where necessary.


B) The facility failed to provide proper emergency lighting at the generator set and controls. Findings include:

During the survey, the generator set and controls room was not provided with battery-powered emergency lighting.
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1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting.



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C) The facility failed to maintain the emergency generator remote annunciator per code. Findings include:

During the survey, the following is an example of what was observed:
The emergency generator remote annunciator did not indicate when the generator was running/under load, when it was tested under load

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1999 NFPA 99, 3-4.1.1.15 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]
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The facility failed to maintain the emergency generator per code. Findings include:

During the survey, the following is an example of what was observed:
The facility failed to provide documentation of weekly visual inspections

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1999 NFPA 110, 6-4.1 Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
1999 NFPA 110, 6-3.4 A written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises. The written record shall include the following:
(a) The date of the maintenance report
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer
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The facility failed to maintain the electrical wiring and equipment per code. Findings include:

During the survey, the following are examples of what was observed:
First Floor
1. Linen Room across from the Kitchen had a microwave and a refrigerator plugged into a surge protector
Second Floor
2. Outpatient Coordinator's Office had an extension cord in use

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1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

1999 NFPA 70, 400-7 (b) Attachment Plugs. Where used as permitted in subsections (a)(3), (a)(6), and (a)(8), each flexible cord shall be equipped with an attachment plug and shall be energized from a receptacle outlet.
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The facility failed to maintain the corridor walls per code. Findings include:

During the survey, the following are examples of what was observed:
First Floor
The following corridor walls were in an unsprinklered smoke compartment of the facility and had unsealed penetrations:
1. At the Lab. - unsealed conduit above the door
2. At the O.R. Women's Locker Room
3. At Information Systems - unsealed penetration of conduit with yellow and blue wires
4. Across from Information Systems - wall at corner not sealed at "I" beam
5. ER/Lab Waiting corridor at the Office and the New Admitting - the corridor wall does not extend to the roof deck

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2000 NFPA 101, 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.
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A) The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include: During the survey, the following is an example of what was observed:

The door from the ER which opens into the corridor failed to positive latch.


NFPA 101, 19.3.6.3.1 Exception No.2. In the smoke compartments protected throughout by an approved, supervised automatic sprinkler system, doors in corridor walls shall be constructed to resist the passage of smoke and be provided with suitable means of keeping the doors closed.


27382


B) The facility failed to maintain the corridor openings per code. Findings include:

During the survey, the following are examples of what was observed:
First Floor
1. Medical Staff Assistant's Office corridor door had a toe stop
2. Surgery Waiting Room corridor door had a self-closing device on it, but was being held open by a chair
3. Central Sterile corridor door did not have positive latching hardware
4. Business Office Suite corridor door did not have positive latching hardware
5. Dinig Room corridor door at Auxiliary Room did not have positive latching hardware
Second Floor
6. Med. Storage Room corridor door had an unsealed penetration at the door knob
7. Gero-Psych Dining/Activity Room corridor door had an unsealed penetration at the door knob
8. Respitatory Employee Exercise Room - corridor door was not positive latching

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2007 CMS - 2786R There is no impediment to the closing of the corridor doors.


2000 NFPA 101, 19.3.6.3.2 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. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.

2000 NFPA 101, 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
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The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include: During the survey, the following is an example of what was observed:

Unsealed penetrations around a gray wire, and at the deck, of the Smoke Barrier, in front of the Director Of Nursing Office third floor.
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2000 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.
2000 NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
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The facility failed to maintain the smoke barrier to restrict the passage of smoke. Findings include: During the survey, the following is an example of what was observed:

Upon activation of the fire alarm the smoke doors failed to close tight, in the Smoke Barrier by I.C.U. Third Floor.
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NFPA 101, 8.3.4. Doors in the smoke barrier shall close leaving only a minimum opening for the proper operation of the doors.
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The facility failed to maintain the hazardous areas per code. Findings include:

During the survey, the following are examples of what was observed:
First Flor
1. The Dietary Dry Storage Room in the Kitchen had a self-closing device, but was being held open by a wedge
Second Floor
2. The following patient rooms were over 50 sq. ft., not sprinklered, do not have one hour fire rated walls that go the roof deck, doors are not fire rated and do not have self-closing devices on them and were being used to store combustible materials:
a. 217
b. 219
3. The Med. Storage Room is over 50 sq. ft. is used to store combustible materials, did not have a 45 minute fire rated door with a self-closing device
4. The Old Bathroom off of the Med. Storage Room the facility had removed the door to this room making it apart of the larger Med. Storage Room, but this room did not have one hour fire rated walls that continue to the roof deck

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2000 NFPA 101, 19.3.2.1 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.

2000 NFPA 101, 8.4.1.3 Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.
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The facility failed to maintain stairways with at least 1 hour fire resistance rating. Findings include: During the survey, the following are examples of what was observed:

1. Unsealed penetrations at the deck, and around two sections of conduit, in the East Wing Stairwell Third Floor.

2. Unsealed penetrations around a sprinkler line, in the wall of the stairwell, in the Administration Wing Third Floor.

3. Unsealed penetrations at the deck , and in the corner of the wall of the South Wing Stairwell Third Floor.
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NFPA 101, 19.3.1.1, 8.2.3.2.4, and 7.1.3.2.1 requires a fire resistance rating of one hour.
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The facility failed to provide protection of openings in fire barriers to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. Findings include: During the survey, the following is an example of what was observed:


1. The doors in the fire barrier by ER. failed to latch.
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NFPA 101, 19.2.2.5 and 7.2.4, 8.2.3.2; 2-8.2.3 NFPA 80 All single doors and active leaves of pairs of doors shall be provided with an active latch which cannot be held in the retracted position.


27382


First Floor
2. The fire barrier by the Classroom in the Classroom Addition at the fire doors had 2 unsealed penetrations , one with a black wire
3. The fire barrier by the Ladies Restroom in the Classroom Addition at the fire doors had a group of unsealed conduits at the bottom right corner above the ceiling
4. The fire barrier in the ER Suite, the "Doctors Only" Room had a unsealed penetration of a waste water pipe
5. The fire barrier in the ER Suite, "Restroom" had an unsealed penetration of a white wire
6. The fire barrier at Post/Pre OP (the corridor side) had an unsealed penetration
7. The fire barrier by Purchasing above the fire doors had an unsealed penetration
Second Floor
8. The fire barrier in Respitatory Employee Exercise Room had two unsealed penetrations one with a black cable at the t.v.
9. The fire barrier in the Pharmacy at the Gero-Psych connecting door had an unsealed penetration of grey and tan wires.

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2000 NFPA 101, 8.2.3.2.4.2 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows: (1) The space between the penetrating item and the fire barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met: a. The material shall be capable of maintaining the fire resistance of the fire barrier. b. The material shall be protected by an approved device that is designed for the specific purpose. (4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the fire barrier. b. It shall be made by an approved device that is designed for the specific purpose.
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The facility failed to provide continuous lighting for means of egress. Findings include: During the survey, the following is an example of what was observed:

A single bulb light fixture was observed at the Exit Discharge for the Exit by the Class Room.
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NFPA 101, 19.2.8 and 7.8.1.2 Illumination of means of egress shall be continuous.
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The facility failed to provide continuously illuminated exit signs. Findings include: During the survey, the following is an example of what was observed:

A exit sign was not provided for the Exit from I.C.U. on the Third Floor.
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NFPA 101, 7.10.1.2 Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.
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This is a rewrite from 2009 survey

The facility failed to conduct fire drills per code. Findings include:

During the survey, the following are examples of what was observed:
Per documentation from the facility:
1. Second Shift for the second quarter of 2012 - did not have any signatures
2. Third Shift for the second quarter of 2012 - did not have a report
3. No documentation of a drill for the third shift for the first quarter of 2012
4. No documentation of any drills for any shifts for the third and fourth quarters of 2011

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2000 NFPA 101, 19.7.1.2 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.
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Facility failed to maintain the Digital Alarm Communicator Transmitter in the fire alarm system. Findings include: During the survey, the following are examples of what was observed:


1. When the Auto Dialer was tested for phone line 1, failure was not indicated at the protected premise within the allotted four (4) minute time frame.


2. When the Auto Dialer was tested for phone line 2, failure was not indicated at the protected premise within the allotted four (4) minute time frame.


3. When the Auto Dialer was tested for Communication Failure, failure was not indicated at the protected premise within the allotted fifteen (15) minute time frame (5 minimum to 10 maximum attempts for signal transmission).
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1999 NFPA 72, Section 1-5.4.6, 5-5.3.2.1.5, and 5-5.3.2.1.6.2. Phone line and communication failure shall be indicated at the facility.
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The facility failed to maintain the fire alarm system in proper working order. Findings include: During the survey, the following is an example of what was observed:

1. The South Stairwell Exit was not provided with a manual pull station.


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2. While testing the fire alarm - no audible or visual device was observed in the O.R. Suite and you could not hear it, the facility had decided to do a fire drill with this activation of the fire alarm - someone was suppose to notify the people in the O.R., but they did not.
3. No smoke detectors were observed on either side of the following fire doors:
a. Purchasing/Surgery
b. Lab/Central Sterile
4. No corridor smoke detection was observed in the non sprinklered smoke compartments of this facility:
a. Original Part of the Fisrt Floor
b. Part of Second Floor
c. Most of Third Floor

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NFPA 101, 9.6.1.4 The fire alarm system to be installed, tested, and maintained in accordance with the requirements of NFPA 70 and NFPA 72.

2000 NFPA 101, 9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.

2000 NFPA 101, 9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.

2000 NFPA 101, 19.3.4.5.1 An approved automatic smoke detection system shall be installed in all corridors of limited care facilities. Such system shall be in accordance with Section 9.6

1999 NFPA 72, 2-10.6.6.1 If ceiling-mounted smoke detectors are to be installed on a smooth ceiling for a single or double doorway, they shall be located as follows (Figure 2-10.6.5.3.1 shall apply.): (1) On the centerline of the doorway (2) No more than 5 ft (1.5 m) measured along the ceiling and perpendicular to the doorway (Figure 2-10.6.5.1.1 shall apply.) (3) No closer than shown in Figure 2-10.6.5.1.1, parts B, D, and F

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The facility failed to perform the required maintenance of the facility sprinkler system. Findings include: During the survey, the following is an example of what was observed:

1. Documentation was not provided by the facility for the 5 year replacement or calibration of gauges.
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NFPA 25, 9-2.8.2: 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.

NFPA 25, 9-2.8.1: Gauges shall be inspected monthly to verify that they are in good condition and that normal pressure is being maintained.


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First Floor
2. O.R. Women's Locker Room was missing an escutcheon plate
Second Floor
3. The Electrical Room across from the Breakroom:
a. Missing seven ceiling tiles
b. Back sprinkler head was missing an escutcheon plate
4. Pharmacy - a sprinkler head was obstructed by shelving that was closer than 18" at the wall separating the Pharmacy from the corridor

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1999 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.
1999 NFPA 13, 5-5.6 The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.
1999 NFPA 13, 5-8.4.2 Deflectors of sprinklers shall be aligned parallel to ceilings or roofs.
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The facility failed to maintain the fire extinguishers per code. Findings include:

During the survey, the following are examples of what was observed:
The following braket mounted fire extinguishers were mounted at 70" above the finished floor:
1. In Central Sterile Room
2. In Ultra Sound/Mamo Room

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1998 NFPA 10, 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 31/2 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).
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The facility failed to maintain the cooking facilities per code. Findings include:

During the survey, the following is an example of what was observed:
The facility failed to provide documentation of monthly inspection of the Kitchen Hood suppression system for May.

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1998 NFPA 17A, 5-2.1 Inspection shall be conducted on a monthly basis in accordance with the manufacturer ' s listed installation and maintenance manual or the owner ' s manual. As a minimum, this " quick check " or inspection shall include verification of the following: (a) The extinguishing system is in its proper location. (b) The manual actuators are unobstructed. (c) The tamper indicators and seals are intact. (d) The maintenance tag or certificate is in place. (e) No obvious physical damage or condition exists that might prevent operation. (f) The pressure gauge(s), if provided, is in operable range. (g) The nozzle blowoff caps are intact and undamaged. (h) The hood, duct, and protected cooking appliances have not been replaced, modified, or relocated.
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The facility failed to provide a readily accessible means of egress pathway at all times. Findings include: During the survey, the following is an example of what was observed:

A large piece of equipment was stored in the corridor by the Lab, this equipment was observed by this surveyor when the survey began. Maintenance advised that this item had been in the corridor for two days.
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NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments for full instant use in case of fire or other emergencies.

Corridors must be maintained free of all furniture and other items. Items are considered stored in the corridor if they are not both used and moved at least once every half hour. Transmittal #99-94.

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The facility failed to provide proper storage of oxygen cylinders. Findings include: During the survey, the following is an example of what was observed:

Appropriate signs were not provided for the storage of the oxygen cylinders, these signs shall indicate empty/full cylinders.
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CGA G-4, 4.1.10, and 1999 NFPA 99, 4-3.5.2.2(b)2 and 4-5.5.2.2(b)2 Full and empty cylinders shall be stored separately, with appropriate signage.
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A) The facility failed to maintain emergeny lighting. Findings include: During the survey, the following is an example of what was observed:

The battery-powered light in OR # 2 was inoperable.
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1999 NFPA 70, 517-63 Grounded Power Systems in Anesthetizing Locations.
Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with Section 700-12(e).


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B) The facility failed to provide a smoke venting system for the anesthetizing locations (the two O.R.s) per code. Findings include:

During the survey, the following is an example of what was observed:
The two windowless O.R.s did not have smoke venting systems.

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1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.
1999 NFPA 99, 5-4.1.3 Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.
1999 NFPA 99, 5-4.1.4 The electric supply to the ventilating system shall be served by the equipment system of the essential electrical system specified in Chapter 3, " Electrical Systems. "
1999 NFPA 99, 5-6.1.1 Ventilating and humidifying equipment for anesthetizing locations shall be kept in operable condition and be continually operating during surgical procedures (see A-5-4.1).
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A) The facility failed to provide proper signage for the above ground diesel tank. Findings include: During the survey, the following are examples of what was observed:

1. The above ground diesel tank did not have signage to identify hazard.

2. The above ground diesel tank was not provide with a "No Smoking" sign.

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NFPA 30 2-9.3, Unsupervised aboveground storage tanks shall be secured and marked in such a manner as to identify the fire hazards of the tank and its contents to the general public. The area in which the tank is located shall be protected from tampering or trespassing, where necessary.


B) The facility failed to provide proper emergency lighting at the generator set and controls. Findings include:

During the survey, the generator set and controls room was not provided with battery-powered emergency lighting.
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1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting.



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C) The facility failed to maintain the emergency generator remote annunciator per code. Findings include:

During the survey, the following is an example of what was observed:
The emergency generator remote annunciator did not indicate when the generator was running/under load, when it was tested under load

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1999 NFPA 99, 3-4.1.1.15 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]
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The facility failed to maintain the emergency generator per code. Findings include:

During the survey, the following is an example of what was observed:
The facility failed to provide documentation of weekly visual inspections

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1999 NFPA 110, 6-4.1 Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
1999 NFPA 110, 6-3.4 A written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises. The written record shall include the following:
(a) The date of the maintenance report
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer
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The facility failed to maintain the electrical wiring and equipment per code. Findings include:

During the survey, the following are examples of what was observed:
First Floor
1. Linen Room across from the Kitchen had a microwave and a refrigerator plugged into a surge protector
Second Floor
2. Outpatient Coordinator's Office had an extension cord in use

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1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

1999 NFPA 70, 400-7 (b) Attachment Plugs. Where used as permitted in subsections (a)(3), (a)(6), and (a)(8), each flexible cord shall be equipped with an attachment plug and shall be energized from a receptacle outlet.
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