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The facility failed to maintain the interior finish for rooms per code. Findings include:

During the survey, the following is an example of what was observed:
The Disaster Food Supply Room had two wall areas covered with plywood, the facility failed to provide documentation of a flame spread rating for this plywood

__________________

2000 NFPA 101, 19.3.3.2 Interior wall and ceiling finish materials complying with 10.2.3 shall be permitted as follows:
(1) Existing materials - Class A or Class B
Exception: In rooms protected by an approved, supervised automatic sprinkler system, existing Class C interior finish shall be permitted to be continued to be used on walls and ceilings within rooms separated from the exit access corridors in accordance with 19.3.6.
(2) Newly installed materials - Class A
Exception No. 1: Newly installed walls and ceilings shall be permitted to have Class A or Class B interior finish in individual rooms having a capacity not exceeding four persons.
Exception No. 2: Newly installed corridor wall finish not exceeding 4 ft (1.2 m) in height that is restricted to the lower half of the wall shall be permitted to be Class A or Class B.
.

The facility failed to maintain the emergency lighting per code. Findings include:

During the survey, the following are examples of what was observed:
1. The outside emergency egress lighting:
a. The facility could not verify the outside emergency egress lighting was on the generator
b. The facility failed to provide documentation of monthly and annual testing of the outside emergency egress lighting
2. The corridor emergency lighting was not automatic, the surveyor was able to switch off

___________________

2000 NFPA 101, 7.9.1.1 Emergency lighting facilities for means of egress shall be provided in accordance with Section 7.9 for the following:
(1) Buildings or structures where required in Chapters 11 through 42
(2) Underground and windowless structures as addressed in Section 11.7
(3) High-rise buildings as required by other sections of this Code
(4) Doors equipped with delayed egress locks
(5) The stair shaft and vestibule of smokeproof enclosures, which shall be permitted to include a standby generator that is installed for the smokeproof enclosure mechanical ventilation equipment and used for the stair shaft and vestibule emergency lighting power supply
For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, ramps, aisles, walkways, and escalators leading to a public way.
2000 NFPA 101, 7.9.3 A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
2000 NFPA 101, 7.9.2.5 The emergency lighting system shall be either continuously in operation or shall be capable of repeated automatic operation without manual intervention.
2000 NFPA 101, 7.9.2.2 The emergency lighting system shall be arranged to provide the required illumination automatically in the event of any of the following:
(1) Interruption of normal lighting such as any failure of a public utility or other outside electrical power supply
(2) Opening of a circuit breaker or fuse
(3) Manual act(s), including accidental opening of a switch controlling normal lighting facilities
.

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

During the survey, the following is an example of what was observed:
Second Shift (7 am - 7 pm)
10/08/2013 - 7:41 pm
08/01/2013 - 7:31 pm
05/02/2013 - 7:18 pm
03/04/2013 - 7:31 pm

_________________

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.
.

The facility failed to maintain the fire alarm system per code. Findings include:

During the survey, the following is an example of what was observed:
The facility failed to provide documentation of a smoke detector sensitivity test being done in the past two years

_________________

1999 NFPA 72, 7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter.

.

The facility failed to maintain the automatic sprinkler system per code. Findings include:

During the survey, the following is an example of what was observed:
Five of five automatic sprinkler system gauges located at the riser had dates of either 2002 or 2003. The facility failed to provide documentation of replacement or calibration of said gauges with in the past five years

_______________

1998 NFPA 25, 2-3.2 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.
.

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

During the survey, the following are examples of what was observed:
1. The following designated smoking areas (per facility) did not have an ashtray or metal container with self-closing cover device:
a. Designated smoking area in rear of building
b. East Front Exit
2. The East Front Exit was observed with excessive cigarette butts on the ground and in the bricks on the building (stuck in the brick holes)
3. The smoking policy provided by the facility did not match the actual areas designated (per facility):
a. Per the facility's smoking policy the front of building was a designated smoking area, but according to the administrator the front of the building was not a designated smoking area
b. Per the facility's smoking policy the rear of building was not a designated smoking area, but according to the administrator the rear of the building was a designated smoking area
____________________

2000 NFPA 101, 19.7.4 Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
Exception: In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(2) Smoking by patients classified as not responsible shall be prohibited.
Exception: The requirement of 19.7.4(2) shall not apply where the patient is under direct supervision.
(3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
.

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 kitchen hood inspections

_________________

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.
.

The facility failed to maintain the 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

___________________


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.
.

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

During the survey, the following is an example of what was observed:
The generator took thirteen seconds to pick up the load when tested

_________________

1999 NFPA 99, 3-4.1.1.8 The generator set(s) shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. [110: 3-4.1]

The facility failed to maintain the interior finish for rooms per code. Findings include:

During the survey, the following is an example of what was observed:
The Disaster Food Supply Room had two wall areas covered with plywood, the facility failed to provide documentation of a flame spread rating for this plywood

__________________

2000 NFPA 101, 19.3.3.2 Interior wall and ceiling finish materials complying with 10.2.3 shall be permitted as follows:
(1) Existing materials - Class A or Class B
Exception: In rooms protected by an approved, supervised automatic sprinkler system, existing Class C interior finish shall be permitted to be continued to be used on walls and ceilings within rooms separated from the exit access corridors in accordance with 19.3.6.
(2) Newly installed materials - Class A
Exception No. 1: Newly installed walls and ceilings shall be permitted to have Class A or Class B interior finish in individual rooms having a capacity not exceeding four persons.
Exception No. 2: Newly installed corridor wall finish not exceeding 4 ft (1.2 m) in height that is restricted to the lower half of the wall shall be permitted to be Class A or Class B.
.

The facility failed to maintain the emergency lighting per code. Findings include:

During the survey, the following are examples of what was observed:
1. The outside emergency egress lighting:
a. The facility could not verify the outside emergency egress lighting was on the generator
b. The facility failed to provide documentation of monthly and annual testing of the outside emergency egress lighting
2. The corridor emergency lighting was not automatic, the surveyor was able to switch off

___________________

2000 NFPA 101, 7.9.1.1 Emergency lighting facilities for means of egress shall be provided in accordance with Section 7.9 for the following:
(1) Buildings or structures where required in Chapters 11 through 42
(2) Underground and windowless structures as addressed in Section 11.7
(3) High-rise buildings as required by other sections of this Code
(4) Doors equipped with delayed egress locks
(5) The stair shaft and vestibule of smokeproof enclosures, which shall be permitted to include a standby generator that is installed for the smokeproof enclosure mechanical ventilation equipment and used for the stair shaft and vestibule emergency lighting power supply
For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, ramps, aisles, walkways, and escalators leading to a public way.
2000 NFPA 101, 7.9.3 A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
2000 NFPA 101, 7.9.2.5 The emergency lighting system shall be either continuously in operation or shall be capable of repeated automatic operation without manual intervention.
2000 NFPA 101, 7.9.2.2 The emergency lighting system shall be arranged to provide the required illumination automatically in the event of any of the following:
(1) Interruption of normal lighting such as any failure of a public utility or other outside electrical power supply
(2) Opening of a circuit breaker or fuse
(3) Manual act(s), including accidental opening of a switch controlling normal lighting facilities
.

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

During the survey, the following is an example of what was observed:
Second Shift (7 am - 7 pm)
10/08/2013 - 7:41 pm
08/01/2013 - 7:31 pm
05/02/2013 - 7:18 pm
03/04/2013 - 7:31 pm

_________________

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.
.

The facility failed to maintain the fire alarm system per code. Findings include:

During the survey, the following is an example of what was observed:
The facility failed to provide documentation of a smoke detector sensitivity test being done in the past two years

_________________

1999 NFPA 72, 7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter.

.

The facility failed to maintain the automatic sprinkler system per code. Findings include:

During the survey, the following is an example of what was observed:
Five of five automatic sprinkler system gauges located at the riser had dates of either 2002 or 2003. The facility failed to provide documentation of replacement or calibration of said gauges with in the past five years

_______________

1998 NFPA 25, 2-3.2 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.
.

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

During the survey, the following are examples of what was observed:
1. The following designated smoking areas (per facility) did not have an ashtray or metal container with self-closing cover device:
a. Designated smoking area in rear of building
b. East Front Exit
2. The East Front Exit was observed with excessive cigarette butts on the ground and in the bricks on the building (stuck in the brick holes)
3. The smoking policy provided by the facility did not match the actual areas designated (per facility):
a. Per the facility's smoking policy the front of building was a designated smoking area, but according to the administrator the front of the building was not a designated smoking area
b. Per the facility's smoking policy the rear of building was not a designated smoking area, but according to the administrator the rear of the building was a designated smoking area
____________________

2000 NFPA 101, 19.7.4 Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
Exception: In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(2) Smoking by patients classified as not responsible shall be prohibited.
Exception: The requirement of 19.7.4(2) shall not apply where the patient is under direct supervision.
(3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
.

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 kitchen hood inspections

_________________

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.
.

The facility failed to maintain the 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

___________________


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.
.

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

During the survey, the following is an example of what was observed:
The generator took thirteen seconds to pick up the load when tested

_________________

1999 NFPA 99, 3-4.1.1.8 The generator set(s) shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. [110: 3-4.1]