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Based on observation and staff interview the facility fails to maintain barriers to at least one half hour fire resistance and ensure that all penetrations are properly sealed. This deficient practice would prevent containment of fire and smoke, affecting two of twenty five smoke zones on six floors. This facility has a capacity of 199 and census of 119 at the time of this survey.

Findings Include:

During the survey on 08/07/12 between 9:00 AM and 5:00 PM, 08/08/12 between 8:00 AM and 6:00 PM and 08/09/12 between 8:00 AM and 11:00 AM the following is observed:

1. There is an approximately 1 inch by 5 inch hole in the smoke barrier wall above the smoke doors to the 4100 hall.

Maintenance Staff B was present and acknowledged the finding.

NFPA Standard: Requires smoke walls to have a fire resistance rating of at least a half hour and to be continuous from floor to roof deck and from outside wall to outside wall. 2000 NFPA 101, 19.3.7.3.

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1.

Based on observation and staff interview the facility failed to provide adequate emergency lighting as required. The deficient practice could leave the area without illumination during a disruption of normal power or in the event of an emergency. This deficiency affects one of twenty five smoke zones on six floors. This facility has a capacity of 199 and a census of 119 at the time of the survey.

Findings Include:

During the survey on 08/07/12 between 9:00 AM and 5:00 PM, 08/08/12 between 8:00 AM and 6:00 PM and 08/09/12 between 8:00 AM and 11:00 AM the following is observed:

1. The emergency light in the cafeteria kitchen has one bulb inoperative.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Emergency lighting for means of egress shall be provided in accordance with Section 7.9 for the following: buildings or structures where required by the occupancy chapters, underground and windowless structures as required by Section 11.7, high rise buildings as required by other sections of this Code, doors equipped with delayed egress locks, and stair shaft and vestibules of smoke proof enclosures. For the purposes of this requirement, exit access shall include designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit and exit discharge shall include designated stairs, ramps, aisles, walkways, and escalators leading to a public way. 2000 NFPA 101, 7.9.1.1.

NFPA Standard: Emergency illumination shall be provided for not less than 1 1/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 foot candle. 2000 NFPA 101, 7.9.2.1.

Based on observation, record review and staff interview the facility failed to provide illuminated exit signs marking the exit paths. The deficient practice may prevent the occupants of the building to be directed to the exit path and delay egress, affecting one of twenty five smoke zones on six floors. This facility has a capacity of 199 and a census of 119 at the time of this survey.

Findings Include:

During the survey on 08/07/12 between 9:00 AM and 5:00 PM, 08/08/12 between 8:00 AM and 6:00 PM and 08/09/12 between 8:00 AM and 11:00 AM the following is observed:

1. The exit sign from the old Sleep Lab area in the Same Day Surgery portion of the facility into the waiting area near the exterior exit was not illuminated.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Means of egress shall have signs in accordance with Section 7.10.
Exception: Where the path of egress travel is obvious, signs shall not be required in one-story buildings with an occupant load of fewer than 30 persons. 2000 NFPA 101, 19.2.10.1.

NFPA Standard: Power Source. Where emergency lighting facilities are required by the applicable provisions of Chapters 11 through 42 for individual occupancies, the signs, other than approved self-luminous signs, shall be illuminated by the emergency lighting facilities. The level of illumination of the signs shall be in accordance with 7.10.6.3 or 7.10.7 for the required emergency lighting duration as specified in 7.9.2.1. However, the level of illumination shall be permitted to decline to 60 percent at the end of the emergency lighting duration. 2000 NFPA 101, 7.10.4.

NFPA Standard: Battery-operated electric lights and other types of portable lamps or lanterns shall not be used for primary illumination of means of egress. Battery-operated electric lights shall be permitted to be used as an emergency source to the extent
permitted under Section 7.9. 2000 NFPA 101, 7.8.2.2.

Based on record review and staff interview, the facility is not conducting fire drills as required quarterly on each shift and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency and affects all twenty five smoke zones on six floors. This facility has a capacity of 199 and a census of 119 at the time of the survey.

Findings Include:

During the survey on 08/07/12 between 9:00 AM and 5:00 PM, 08/08/12 between 8:00 AM and 6:00 PM and 08/09/12 between 8:00 AM and 11:00 AM the following is observed:

1. Fire drills conducted on the second shift were conducted each quarter starting between 3:05 PM and 4:00 PM.

2. Fire drills conducted on the third shift were conducted each quarter starting between 4:10 AM and 4:53 AM.

Maintenance Staff B was present and acknowledged the finding.

NFPA Standard: 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.

Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 2000 NFPA 101, 19.7.1.2.

Based on observation, interview and record review, the facility fails to maintain all components of the fire alarm system as required by NFPA 72. The deficient practice could result in the fire alarm system not activating and notifying occupant of a potential emergency affecting all twenty five smoke zones on six floors. The facility has a capacity of 199 with a census of 119 at the time of the survey.

Findings Include:

During the survey on 08/07/12 between 9:00 AM and 5:00 PM, 08/08/12 between 8:00 AM and 6:00 PM and 08/09/12 between 8:00 AM and 11:00 AM the following is observed:

1. The fire alarm panel was showing trouble for 2 heat detectors which have been disabled due to sustaining heat and or water damage during a dryer vent fire in the facility at approximately 1:30 AM on 08/07/12.

Maintenance Staff A and B were present and acknowledged the finding.

NFPA Standard: Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7 2.2. 1999 NFPA 72, 7 2.2.

NFPA Standard: A permanent record of all inspections, testing, and maintenance shall be maintained that includes periodic tests and applicable information, per 1999 NFPA 72, 7 5.2.2 and figure 7 5.2.2; A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70. 2000 NFPA 101, 9.6.1.4.

Based on observation and staff interview the facility fails to ensure that all means of egress are free of all obstructions or impediments to a full instant use. This deficient practice could impede all occupants from exiting in the event of a fire or other emergency situation, affecting seven of twenty five smoke zones on six floors. This facility has a capacity of 199 and a census of 119 at the time of the survey.

Findings Include:

During the survey on 08/07/12 between 9:00 AM and 5:00 PM, 08/08/12 between 8:00 AM and 6:00 PM and 08/09/12 between 8:00 AM and 11:00 AM the following is observed:

1. Vitals carts obstructing the corridors throughout the 5th floor.

2. Vitals carts obstructing the skilled nursing unit on the 3rd floor.

3. Tables, chairs and carts obstructing the corridors in the old Sleep Lab portion of the Same Day Surgery area.

4. Equipment stored in the corridors throughout the Radiology Department.

5. Beds, wheelchairs and carts obstructing the corridors throughout the Emergency Department.

Maintenance Staff A and B were present and acknowledged the findings. Some obstructions were corrected at time of discovery.

NFPA Standard: No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress from, or visibility thereof. 2000 NFPA 101, 7.1.10.2.1.

NFPA Standard: Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1.

Based on observation and staff interview, the facility did not ensure that electrical wiring and equipment is installed and maintained in accordance with NFPA 70, National Electrical Code. This deficient practice does not ensure prevention of an electrical fire or electric shock hazard, affecting two of twenty-five smoke zones on six floors. This facility has a capacity of 199 and a census of 119 at the time of this survey..

Findings Include:

During the survey on 08/07/12 between 9:00 AM and 5:00 PM, 08/08/12 between 8:00 AM and 6:00 PM and 08/09/12 between 8:00 AM and 11:00 AM the following is observed:

1. A power strip was hanging from a shelf bracket by the cord which has been wrapped around the bracket in the staff lounge in the skilled nursing unit.

2. A junction box was missing a cover on the ceiling by elevator equipment number 4 in the penthouse.

Maintenance Staff B was present and acknowledged the finding.

NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8
NFPA Standard: Temporary electrical power and lighting installations shall be permitted (600 volts or less): (a) During Construction - temporary electric power and lighting installations shall be permitted during the period of construction, remodeling, maintenance, repair, or demolition of buildings, structures, equipment, or similar activities; (b) 90 Days - temporary electrical power and lighting installations shall be permitted for a period not to exceed 90 days for Christmas decorative lighting and similar purposes; (c) Emergencies and Tests - temporary electrical power and lighting installations shall be permitted during emergencies and for tests, experiments, and developmental work.; (d) Removal - temporary wiring shall be removed immediately upon completion of construction or purpose for which the wiring was installed. 1999 NFPA 70, 3-1.2.1.

Based on observation and staff interview the facility fails to maintain barriers to at least one half hour fire resistance and ensure that all penetrations are properly sealed. This deficient practice would prevent containment of fire and smoke, affecting two of twenty five smoke zones on six floors. This facility has a capacity of 199 and census of 119 at the time of this survey.

Findings Include:

During the survey on 08/07/12 between 9:00 AM and 5:00 PM, 08/08/12 between 8:00 AM and 6:00 PM and 08/09/12 between 8:00 AM and 11:00 AM the following is observed:

1. There is an approximately 1 inch by 5 inch hole in the smoke barrier wall above the smoke doors to the 4100 hall.

Maintenance Staff B was present and acknowledged the finding.

NFPA Standard: Requires smoke walls to have a fire resistance rating of at least a half hour and to be continuous from floor to roof deck and from outside wall to outside wall. 2000 NFPA 101, 19.3.7.3.

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1.

Based on observation and staff interview the facility failed to provide adequate emergency lighting as required. The deficient practice could leave the area without illumination during a disruption of normal power or in the event of an emergency. This deficiency affects one of twenty five smoke zones on six floors. This facility has a capacity of 199 and a census of 119 at the time of the survey.

Findings Include:

During the survey on 08/07/12 between 9:00 AM and 5:00 PM, 08/08/12 between 8:00 AM and 6:00 PM and 08/09/12 between 8:00 AM and 11:00 AM the following is observed:

1. The emergency light in the cafeteria kitchen has one bulb inoperative.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Emergency lighting for means of egress shall be provided in accordance with Section 7.9 for the following: buildings or structures where required by the occupancy chapters, underground and windowless structures as required by Section 11.7, high rise buildings as required by other sections of this Code, doors equipped with delayed egress locks, and stair shaft and vestibules of smoke proof enclosures. For the purposes of this requirement, exit access shall include designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit and exit discharge shall include designated stairs, ramps, aisles, walkways, and escalators leading to a public way. 2000 NFPA 101, 7.9.1.1.

NFPA Standard: Emergency illumination shall be provided for not less than 1 1/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 foot candle. 2000 NFPA 101, 7.9.2.1.

Based on observation, record review and staff interview the facility failed to provide illuminated exit signs marking the exit paths. The deficient practice may prevent the occupants of the building to be directed to the exit path and delay egress, affecting one of twenty five smoke zones on six floors. This facility has a capacity of 199 and a census of 119 at the time of this survey.

Findings Include:

During the survey on 08/07/12 between 9:00 AM and 5:00 PM, 08/08/12 between 8:00 AM and 6:00 PM and 08/09/12 between 8:00 AM and 11:00 AM the following is observed:

1. The exit sign from the old Sleep Lab area in the Same Day Surgery portion of the facility into the waiting area near the exterior exit was not illuminated.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Means of egress shall have signs in accordance with Section 7.10.
Exception: Where the path of egress travel is obvious, signs shall not be required in one-story buildings with an occupant load of fewer than 30 persons. 2000 NFPA 101, 19.2.10.1.

NFPA Standard: Power Source. Where emergency lighting facilities are required by the applicable provisions of Chapters 11 through 42 for individual occupancies, the signs, other than approved self-luminous signs, shall be illuminated by the emergency lighting facilities. The level of illumination of the signs shall be in accordance with 7.10.6.3 or 7.10.7 for the required emergency lighting duration as specified in 7.9.2.1. However, the level of illumination shall be permitted to decline to 60 percent at the end of the emergency lighting duration. 2000 NFPA 101, 7.10.4.

NFPA Standard: Battery-operated electric lights and other types of portable lamps or lanterns shall not be used for primary illumination of means of egress. Battery-operated electric lights shall be permitted to be used as an emergency source to the extent
permitted under Section 7.9. 2000 NFPA 101, 7.8.2.2.

Based on record review and staff interview, the facility is not conducting fire drills as required quarterly on each shift and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency and affects all twenty five smoke zones on six floors. This facility has a capacity of 199 and a census of 119 at the time of the survey.

Findings Include:

During the survey on 08/07/12 between 9:00 AM and 5:00 PM, 08/08/12 between 8:00 AM and 6:00 PM and 08/09/12 between 8:00 AM and 11:00 AM the following is observed:

1. Fire drills conducted on the second shift were conducted each quarter starting between 3:05 PM and 4:00 PM.

2. Fire drills conducted on the third shift were conducted each quarter starting between 4:10 AM and 4:53 AM.

Maintenance Staff B was present and acknowledged the finding.

NFPA Standard: 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.

Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 2000 NFPA 101, 19.7.1.2.

Based on observation, interview and record review, the facility fails to maintain all components of the fire alarm system as required by NFPA 72. The deficient practice could result in the fire alarm system not activating and notifying occupant of a potential emergency affecting all twenty five smoke zones on six floors. The facility has a capacity of 199 with a census of 119 at the time of the survey.

Findings Include:

During the survey on 08/07/12 between 9:00 AM and 5:00 PM, 08/08/12 between 8:00 AM and 6:00 PM and 08/09/12 between 8:00 AM and 11:00 AM the following is observed:

1. The fire alarm panel was showing trouble for 2 heat detectors which have been disabled due to sustaining heat and or water damage during a dryer vent fire in the facility at approximately 1:30 AM on 08/07/12.

Maintenance Staff A and B were present and acknowledged the finding.

NFPA Standard: Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7 2.2. 1999 NFPA 72, 7 2.2.

NFPA Standard: A permanent record of all inspections, testing, and maintenance shall be maintained that includes periodic tests and applicable information, per 1999 NFPA 72, 7 5.2.2 and figure 7 5.2.2; A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70. 2000 NFPA 101, 9.6.1.4.

Based on observation and staff interview the facility fails to ensure that all means of egress are free of all obstructions or impediments to a full instant use. This deficient practice could impede all occupants from exiting in the event of a fire or other emergency situation, affecting seven of twenty five smoke zones on six floors. This facility has a capacity of 199 and a census of 119 at the time of the survey.

Findings Include:

During the survey on 08/07/12 between 9:00 AM and 5:00 PM, 08/08/12 between 8:00 AM and 6:00 PM and 08/09/12 between 8:00 AM and 11:00 AM the following is observed:

1. Vitals carts obstructing the corridors throughout the 5th floor.

2. Vitals carts obstructing the skilled nursing unit on the 3rd floor.

3. Tables, chairs and carts obstructing the corridors in the old Sleep Lab portion of the Same Day Surgery area.

4. Equipment stored in the corridors throughout the Radiology Department.

5. Beds, wheelchairs and carts obstructing the corridors throughout the Emergency Department.

Maintenance Staff A and B were present and acknowledged the findings. Some obstructions were corrected at time of discovery.

NFPA Standard: No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress from, or visibility thereof. 2000 NFPA 101, 7.1.10.2.1.

NFPA Standard: Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1.

Based on observation and staff interview, the facility did not ensure that electrical wiring and equipment is installed and maintained in accordance with NFPA 70, National Electrical Code. This deficient practice does not ensure prevention of an electrical fire or electric shock hazard, affecting two of twenty-five smoke zones on six floors. This facility has a capacity of 199 and a census of 119 at the time of this survey..

Findings Include:

During the survey on 08/07/12 between 9:00 AM and 5:00 PM, 08/08/12 between 8:00 AM and 6:00 PM and 08/09/12 between 8:00 AM and 11:00 AM the following is observed:

1. A power strip was hanging from a shelf bracket by the cord which has been wrapped around the bracket in the staff lounge in the skilled nursing unit.

2. A junction box was missing a cover on the ceiling by elevator equipment number 4 in the penthouse.

Maintenance Staff B was present and acknowledged the finding.

NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8
NFPA Standard: Temporary electrical power and lighting installations shall be permitted (600 volts or less): (a) During Construction - temporary electric power and lighting installations shall be permitted during the period of construction, remodeling, maintenance, repair, or demolition of buildings, structures, equipment, or similar activities; (b) 90 Days - temporary electrical power and lighting installations shall be permitted for a period not to exceed 90 days for Christmas decorative lighting and similar purposes; (c) Emergencies and Tests - temporary electrical power and lighting installations shall be permitted during emergencies and for tests, experiments, and developmental work.; (d) Removal - temporary wiring shall be removed immediately upon completion of construction or purpose for which the wiring was installed. 1999 NFPA 70, 3-1.2.1.