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Based on observations which were made on March 24, 2009, the facility failed to maintain the fire resistive construction of all corridor walls in order that they would be resistant to the passage of smoke. In sprinklered buildings, wall partitions are only required to resist the passage of smoke. 19.3.6.1

Findings include:

The electrical room for the hospital was observed at 10:56 a.m. on March 24, 2010. A cable runway extended through the corridor wall into the open space above the ceiling tile. A service technician had installed a few cable wires without using a proper grommet to plug the hole around the wiring leaving a penetration between the mechanical room and the open space above the ceiling in the corridor. The cable runway must be resistant to the passage of smoke.

Based on observations made on March 24, 2010, the facility failed to assure that vertical openings between floors were sealed and/or enclosed by fire resistive construction.

Findings include:

In accordance with Section 19.3.1.1 of NFPA 101, 2000 edition, any vertical opening shall be enclosed or protected in accordance with Section 8.2.5 of NFPA 101. Where enclosure is provided, the construction shall have not less than a 1-hour resistance rating.

In accordance with Section 8.3.6.1 of NFPA 101; 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/filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

The electrical room in the hospital was observed at 10:55 a.m. on March 24, 2010. There were two, two inch conduits with communication cables in them linked to the first floor,upper level which were not sealed to resist the passage of smoke/fire.

Based on observations made on March 24, 2010, the facility failed to provide for a self-closing device on a corridor door protecting a hazardous area.

The findings include:

1. The upper level of the hospital was observed at 10:00 a.m. on March 24, 2010.
a) The medical records storeroom on the upper level did not have a self-closing device on the corridor door. This room was over 50 square feet and was used to store a large amount of combustibles.
b) The medical records office on the upper level did not have a self-closing device on the corridor door. This room was over 50 square feet and was used to store a large amount of combustibles.

2. The laundry room in the hospital was observed at 11:15 a.m. on March 24, 2010. The west wall had a two inch by five inch hole, near a floor level pipe, which was not sealed.

Based on observation and staff interview on March 24, 2010, the facility failed to ensure that the location of the dedicated power circuit branch servicing the fire alarm panel was permanently addressed on the alarm panel. Also, the circuit disconnecting means was not identified with a red marking.

Findings include:

In accordance with Section 1-5.2.5.2 of NFPA 72, 1999 edition; the connections to the light and power service for the Fire Alarm Control Panel (FACP) shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

1.) The FACP was reviewed at 11:05 a.m. on March 24, 2010.
a) The FACP was not identified as to what electrical panel controlled it, and
b) breaker #18 on electrical panel (LS2) was not identified in red.

Based on observations made on March 24, 2010, the facility failed to assure that all portable fire extinguishers were checked and inspected on a monthly basis.

The findings include:

In accordance with Section 1-6.10 1 of NFPA 10, 1998 edition: Fire extinguishers having a gross weight not exceeding 40 pounds shall be installed so that the top of the fire extinguisher is not more than 5 feet above the floor. Fire extinguishers having a gross weight greater than 40 pounds (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 feet above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 inches.

In accordance with Section 4-3.4.1 - 3 of NFPA 10, 1998 edition, (Portable Fire Extinguishers): Personnel making inspections shall keep records of all fire extinguishers inspected, including those found to require corrective action. At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded. Records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or in an electronic system (e.g., bar coding) that provides a permanent record.


1. All portable fire extinguishers in the hospital were checked for proper initials and signature on the maintenance card. The maintenance cards were not being signed on a monthly bases to indicate the extinguishers had been checked. A punch card was being maintained to indicated that they had been checked, but there was no physical evidence on the monthly service tag to indicate that they had been checked.

2. The portable dry chemical extinguisher located in the elevator mechanical room was observed at 2:00 p.m. on March 24, 2010. The extinguisher was sitting on the concrete floor of this room. All portable extinguishers must be mounted on the wall and up off the floor to be accessible.

Based on observations made on March 24, 2010, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, NFPA 99 or the Centers for Medicare and Medicaid Services (CMS) interpretations.

The findings include:

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4 of NFPA 70, 1999 edition; 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99, 1999 edition; and previous interpretations from CMS. The limited use of circuit breaker protected power strips is acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to a power strip. These items must be directly connected to an appropriate receptacle.

The limited use of circuit breaker protected power strips is acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to the power strip per Article 240-4 of NFPA 70; 7-5.1.2.6 & 7-6.2.1.5 of NFPA 99; and CMS interpretations.

1. The Minimum Data Set (MDS) office was observed for electrical code compliance at 12:20 p.m. on March 24, 2010. There was an orange extension cord in use to the Information Technology (IT) server in the small closet which housed the IT network server. The cord was plugged in an outlet in the MDS office on the west wall, run under a door to the IT server and connected to the server.

2. The employee break room was observed for electrical code compliance at 12:45 p.m. on March 24, 2010. The large white refrigerator was plugged into a power strip. Large appliances can no longer be served by a circuit breaker protected power strip, but must be plugged directly into a wall outlet.

Based on observations made on March 24, 2010, the facility failed to assure that Alcohol Based Hand Rub (ABHR) dispensers were not installed over an ignition source.

The findings include:

1. An ABHR dispenser was installed directly above two light switches in the Laboratory suite as observed at 10:45 a.m. on March 24, 2010.

2. An ABHR dispenser was installed directly above two light switches in room 107 of the hospital as observed at 2:00 p.m. on March 24, 2010.

Based on observations which were made on March 24, 2009, the facility failed to maintain the fire resistive construction of all corridor walls in order that they would be resistant to the passage of smoke. In sprinklered buildings, wall partitions are only required to resist the passage of smoke. 19.3.6.1

Findings include:

The electrical room for the hospital was observed at 10:56 a.m. on March 24, 2010. A cable runway extended through the corridor wall into the open space above the ceiling tile. A service technician had installed a few cable wires without using a proper grommet to plug the hole around the wiring leaving a penetration between the mechanical room and the open space above the ceiling in the corridor. The cable runway must be resistant to the passage of smoke.

Based on observations made on March 24, 2010, the facility failed to assure that vertical openings between floors were sealed and/or enclosed by fire resistive construction.

Findings include:

In accordance with Section 19.3.1.1 of NFPA 101, 2000 edition, any vertical opening shall be enclosed or protected in accordance with Section 8.2.5 of NFPA 101. Where enclosure is provided, the construction shall have not less than a 1-hour resistance rating.

In accordance with Section 8.3.6.1 of NFPA 101; 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/filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

The electrical room in the hospital was observed at 10:55 a.m. on March 24, 2010. There were two, two inch conduits with communication cables in them linked to the first floor,upper level which were not sealed to resist the passage of smoke/fire.

Based on observations made on March 24, 2010, the facility failed to provide for a self-closing device on a corridor door protecting a hazardous area.

The findings include:

1. The upper level of the hospital was observed at 10:00 a.m. on March 24, 2010.
a) The medical records storeroom on the upper level did not have a self-closing device on the corridor door. This room was over 50 square feet and was used to store a large amount of combustibles.
b) The medical records office on the upper level did not have a self-closing device on the corridor door. This room was over 50 square feet and was used to store a large amount of combustibles.

2. The laundry room in the hospital was observed at 11:15 a.m. on March 24, 2010. The west wall had a two inch by five inch hole, near a floor level pipe, which was not sealed.

Based on observation and staff interview on March 24, 2010, the facility failed to ensure that the location of the dedicated power circuit branch servicing the fire alarm panel was permanently addressed on the alarm panel. Also, the circuit disconnecting means was not identified with a red marking.

Findings include:

In accordance with Section 1-5.2.5.2 of NFPA 72, 1999 edition; the connections to the light and power service for the Fire Alarm Control Panel (FACP) shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

1.) The FACP was reviewed at 11:05 a.m. on March 24, 2010.
a) The FACP was not identified as to what electrical panel controlled it, and
b) breaker #18 on electrical panel (LS2) was not identified in red.

Based on observations made on March 24, 2010, the facility failed to assure that all portable fire extinguishers were checked and inspected on a monthly basis.

The findings include:

In accordance with Section 1-6.10 1 of NFPA 10, 1998 edition: Fire extinguishers having a gross weight not exceeding 40 pounds shall be installed so that the top of the fire extinguisher is not more than 5 feet above the floor. Fire extinguishers having a gross weight greater than 40 pounds (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 feet above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 inches.

In accordance with Section 4-3.4.1 - 3 of NFPA 10, 1998 edition, (Portable Fire Extinguishers): Personnel making inspections shall keep records of all fire extinguishers inspected, including those found to require corrective action. At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded. Records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or in an electronic system (e.g., bar coding) that provides a permanent record.


1. All portable fire extinguishers in the hospital were checked for proper initials and signature on the maintenance card. The maintenance cards were not being signed on a monthly bases to indicate the extinguishers had been checked. A punch card was being maintained to indicated that they had been checked, but there was no physical evidence on the monthly service tag to indicate that they had been checked.

2. The portable dry chemical extinguisher located in the elevator mechanical room was observed at 2:00 p.m. on March 24, 2010. The extinguisher was sitting on the concrete floor of this room. All portable extinguishers must be mounted on the wall and up off the floor to be accessible.

Based on observations made on March 24, 2010, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, NFPA 99 or the Centers for Medicare and Medicaid Services (CMS) interpretations.

The findings include:

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4 of NFPA 70, 1999 edition; 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99, 1999 edition; and previous interpretations from CMS. The limited use of circuit breaker protected power strips is acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to a power strip. These items must be directly connected to an appropriate receptacle.

The limited use of circuit breaker protected power strips is acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to the power strip per Article 240-4 of NFPA 70; 7-5.1.2.6 & 7-6.2.1.5 of NFPA 99; and CMS interpretations.

1. The Minimum Data Set (MDS) office was observed for electrical code compliance at 12:20 p.m. on March 24, 2010. There was an orange extension cord in use to the Information Technology (IT) server in the small closet which housed the IT network server. The cord was plugged in an outlet in the MDS office on the west wall, run under a door to the IT server and connected to the server.

2. The employee break room was observed for electrical code compliance at 12:45 p.m. on March 24, 2010. The large white refrigerator was plugged into a power strip. Large appliances can no longer be served by a circuit breaker protected power strip, but must be plugged directly into a wall outlet.