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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:
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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The facility failed to maintain the hazardous areas per code. Findings include:

During the survey, the following are examples of what was observed:
First Floor
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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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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27382


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.

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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27382


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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