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The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include: During the survey, the following are examples of what was observed:


1. The Admin. storage room door failed to positive latch, located across from the Corp. Office.

2. Patient Room 316 door failed to close tight in the frame, this surveyor could see into the room at the top of the door.

3. The copy room door failed to positive latch.

4. Asst. Admin.Office door failed to positive latch.

5. Employees Break Room door failed to positive latch.


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6. Second Floor
Room 214 corridor door was not positive latching
7. Third Floor
The following corridor doors did not have positive latching hardware
a. Maintenance Storage Room
b. Maintenance Room - across from the Lab.



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.
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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 are examples of what was observed:

1. Unsealed penetrations around conduit, and at the end of a sleeve, in the Smoke barrier, by the Corp. Office.

2. Unsealed penetrations around conduit, in the Smoke Barrier, access to this area is inside the Restroom, across from Corp. Office.

3. Unsealed penetrations around a group of wiring, in the Smoke Barrier, by ULTRA Sound Office.

4. Unsealed penetrations around a single white wire, and around a sprinkler line, in the Smoke Barrier, by Patient Room 217.



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 separation of hazardous areas. Findings include: During the survey, the following are examples of what was observed:

1. Basement
Unsealed penetrations around flex condiut, two separate locations, in the wall of the Boiler Room, located in the Basement.


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2. Third Floor
a. Radiology Filing Dept. (storage) was over 140 sq. ft. with combustible materials; the door did not have a self-closing device.
b. Central Supply was over 50 sq. ft. with combustible materials; the door did not have a self-closing device.



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.

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

During the survey, the following are examples of what was observed:
1. Second Floor
All Geripsych patient room corridor doors locked with a key from the outside, cannot unlock the doors without a key from the inside.

2. Third Floor
The following rooms had deadbolt locks on them, which could allow someone to be locked in the room and not be able to get out:
a. Maintenance Room - across from the Lab.
b. Mamogram Room
c. E.R. Hopper Room
d. Triage Room - across from Admissions and next to the Janitor's Room
e. Janitor's Room - across from Admissions and next to the Triage Room



2000 NFPA 101, 7.1.9 Any device or alarm installed to restrict the improper use of a means of egress shall be designed and installed so that it cannot, even in case of failure, impede or prevent emergency use of such means of egress unless otherwise provided in 7.2.1.6 and Chapters 18, 19, 22, and 23.
2000 NFPA 101, 7.1.10.1 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, 7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
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The facility failed to provide illumination of means of egress per code. Findings include:

During the survey, the following is an example of what was observed:
The Gateway Exit had a single fixture with a single bulb.



2000 NFPA 101, 7.8.1.2 Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use. Artificial lighting shall be employed at such locations and for such periods of time as required to maintain the illumination to the minimum criteria values herein specified.
2000 NFPA 101, 7.8.1.4 Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2 lux) in any designated area.
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The facility failed to provide continuously illuminated exit signs. Findings include: During the survey, the following are examples of what was observed:

1. Basement
Three exit signs were not illuminated in the Basement.


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2. Second Floor
The following exit signs were not illuminated:
a. The two exit signs to the "smoking area"
b. The exit sign for the stairs by the elevator
c. The exit sign by room 204



2000 NFPA 101, 7.10.5.2 Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.
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The facility failed to conduct fire drills per code. Findings include:

During the survey, the following are examples of what was observed:
1. Not all employees participated/signed the fire drills reports
2. The facility failed to conduct a fire drill for the third quarter on the second shift



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

During the survey, the following are examples of what was observed:
1. Second Floor
The following egress doors did not release:
a. Under the fire alarm
b. When the primary power was loss to the fire alarm
1. Stairwell door at the T.V. Room
2 Both Nures' Station doors
3. Both Dayroom doors
4. The double doors for Gateway
2. Third Floor
The double doors for Bradford did not release when the primary power was loss to the fire alarm



1999 NFPA 72, 3-9.7.1 Any device or system intended to actuate the locking or unlocking of exits shall be connected to the fire alarm system serving the protected premises.
1999 NFPA 72, 3-9.7.2 All exits connected in accordance with 3-9.7.1 shall unlock upon receipt of any fire alarm signal by means of the fire alarm system serving the protected premises.
Exception: Where otherwise required or permitted by the authority having jurisdiction or other codes.
1999 NFPA 72, 3-9.7.3 All exits connected in accordance with 3-9.7.1 shall unlock upon loss of the primary power to the fire alarm system serving the protected premises. The secondary power supply shall not be utilized to maintain these doors in the locked condition.
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Documentation provided by the facility during the survey did not indicate sensitivity testing of the smoke detectors. Detector sensitivity shall be checked with one year after installation and every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).

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The facility failed to provide complete sprinkler coverage to all parts of the facility.
Findings include: During the survey, the following are examples of what was observed:


1. Ceiling tile missing in the Stairwell basement level by the elevator.

2. Ceiling tile missing in the Elevator Equipment Room, located in the Basement.

3. Ceiling tile missing in Housekeeping located in the Basement.


NFPA 13 5-6., Sprinklers shall be arranged to be in compliance.

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

1. The Quarterly sprinkler inspection report for 5/24/2011, noted that the water motor gong assembly needed to be repaired, fastener sheared off. Also the 5 year obstruction inspection is due.



Every required sprinkler system shall be continuously maintained in proper operating condition. NFPA 101, 4.6.12.1.

NFPA 101, 4.6.12, and NFPA 25, 2-2 and Table 2-1 Requires an inspection every quarter (three months).


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2. The Outside Automatic Sprinkler Riser Room stock of spare sprinklers for the two story addition - had four spare sprinkler heads that only had one of each.

3. Third Floor
In the following rooms the sprinkler head was missing the escutcheon plate
a. E.R. Nurses' Station Storage Room
b. Triage Room - across from Admissions/next to Janitor's Room
c. Radiology Bathroom



1998 NFPA 25, 2-4.1.4 A supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. The cabinet shall be so located that it will not be exposed to moisture, dust, corrosion, or a temperature exceeding 100?F (38?C).
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.
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The facility failed to maintain the fire extinguishers per code. Findings include:

1. During the survey, the Fire Extingusher across the corridor from the Director of Nursing Office, was mounted approximatley (2) ft from the floor to the top of the extinguisher.



1998 NFPA 10, 1-6.10 Fire extinguishers weighting not more than 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.


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2. During the survey, the following are examples of what was observed:
Through out the facility the last documented monthly inspection on the fire extinguishers was 01/07/2011.

3. Second Floor
The fire extinguisher in the Laundry Room had an annual inspection date of 02/2011 with no documented monthly inspections

4. Third Floor
The fire extinguisher in the Maintenance Room across from the Lab. had an annual inspection date of 2008.



1998 NFPA 10, 4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.

1998 NFPA 10, 4-3.4.3 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.

1998 NFPA 10, 4-3.1* Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.

1998 NFPA 10, 4-4.1 Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.

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The facility failed to provide a smoking policy per code. Findings include:

During the survey, the following are examples of what was observed:
1. The facility failed to provide a smoking policy.

Second Floor
2. The smoking area for Gateway did not have an ashtray



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.
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The facility failed to adequately perform testing and inspection of the dietary hood
extinguishment system. Findings include: During the survey, the following are examples of what was observed:

1. The provided documentation for the monthly inspection of the hood system was the inspection card attached to the pull station of the hood extinguishing system. This card was observed with space on the reverse side to date and initial each month an inspection was conducted by facility staff. This side of the inspection card was blank.



NFPA 17, 9-2.1- On a monthly basis, inspection shall be conducted in accordance with the manufacturer 's listed installation and maintenance manual or 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) The system shows no physical damage or condition that might prevent operation. (f) The pressure gauge(s), if provided, is in operable range. (g) The nozzle blow-off caps, where provided, are intact and undamaged. (h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.



2. The K-Extinguisher was not provided with a placard identifying the use.




NFPA 96 7-2.1.1 A placard identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system shall be conspicuously placed near each portable fire extinguisher in the cooking area.

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The facility failed to prohibit portable space heating devices per code. Findings include:

During the survey, the following are examples of what was observed:
Third Floor
The following rooms had portable space heating devices, the devices were not plugged in:
1. E.R. Nurses' Station Storage Room
2. Medical Records Room



2000 NFPA 101, 19.7.8 Portable space-heating devices shall be prohibited in all health care occupancies. Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212?F (100?C).
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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 are examples of what was observed:

1. Tables, Carts, in the corridor in the Basement from approximatley 10:45am- 11:30am.

2. Two cleaning carts wre stored in the corridor by Patient Room 315, from approximatley 1:15pm- 2:00pm.


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3. Exit at the Police Dept. was blocked by a vehicle

Second Floor
4. The rear exit for Gateway's Dayroom did not have an all weather sound path of travel
5. The Psych Unit at Gateway had three chairs that stayed in the corridor during the survey

Third Floor
6. The stairwell exit by room 321 had a sign on the door that said "this is not an exit". According to the staff this sign was put there to deter patients from using this door. This is a required exit.
7. The corridor at the the Police Dept. exit had three chairs, one huge cart, two sheets of sheet rock being stored and a sign that read " Please break down your boxes before placing them here".



2000 NFPA 101, 7.1.10.1 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, 7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.
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The facility failed to maintain the curtains/draperies per code. Findings include:

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

The facility failed to provide flame resistant documentation for all of the curtains/draperies on the second floor, Assistant Administrator's Office, and The Central Supply Office.



2000 NFPA 101, 10.3.1 Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.
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The facility failed to provide proper storage of oxygen cylinders. Findings include: During the survey, the following are examples of what was observed:

Two unsecured oxygen cylinders in the Soil Utility Room, by Patient Room 306.



1999 NFPA 99, 4-3.1.1.1 and 4-5.1.1.1 Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.


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The facility failed to maintain proper emergency lighting at the generator set and controls. Findings include: During the survey, the following are examples of what was observed:

The battery-powered light in the generator set/control room was inoperable.


1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1. Emergency generator equipment locations are to be equiuped with battery- powered lights.


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

During the survey, the following are examples of what was observed:
1. "Overcrank" was illuminated when the surveyors arrived on site, but there was no audible
2. When the generator was taken off "auto" the light illuminated, but there was no audible



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 provide receptacles for appliances. Findings include: During the survey, the following are examples of what was observed:


1. Cover missing on an Electrical Panel in the Electrical Room, by Patient Room 306.

2. Telephone equipment room by Patient Room 310, had an overcurrent protection cord, plugged into an overcurrent cord.



1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.

NFPA 101 Life Safety Code (Sec. 19-5.1) utilities shall comply with NFPA 101 (Sec. 9-1.) . Electrical shall comply with the NFPA 70 National Electrical Code. NEC 400-7(b) Requires each flexible cord to "be energized from a receptacle outlet."


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3. Second Floor
The Counselor's Office had a fridge and a microwave plugged into a GFCI extension cord.


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.

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The facility failed to provide an automatic sprinkler system fire watch policy per code. Findings include:

During the survey, the following is an example of what was observed:
The facility failed to provide an automatic sprinkler system fire watch policy



2000 NFPA 101, 9.7.6.1 Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.
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The facility failed to provide a fire alarm fire watch policy per code. Findings include:

During the survey, the following is an example of what was observed:
The facility failed to provide a fire alarm fire watch policy.



2000 NFPA 101, 9.6.1.8 Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.
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The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include: During the survey, the following are examples of what was observed:


1. The Admin. storage room door failed to positive latch, located across from the Corp. Office.

2. Patient Room 316 door failed to close tight in the frame, this surveyor could see into the room at the top of the door.

3. The copy room door failed to positive latch.

4. Asst. Admin.Office door failed to positive latch.

5. Employees Break Room door failed to positive latch.


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6. Second Floor
Room 214 corridor door was not positive latching
7. Third Floor
The following corridor doors did not have positive latching hardware
a. Maintenance Storage Room
b. Maintenance Room - across from the Lab.



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.
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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 are examples of what was observed:

1. Unsealed penetrations around conduit, and at the end of a sleeve, in the Smoke barrier, by the Corp. Office.

2. Unsealed penetrations around conduit, in the Smoke Barrier, access to this area is inside the Restroom, across from Corp. Office.

3. Unsealed penetrations around a group of wiring, in the Smoke Barrier, by ULTRA Sound Office.

4. Unsealed penetrations around a single white wire, and around a sprinkler line, in the Smoke Barrier, by Patient Room 217.



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 separation of hazardous areas. Findings include: During the survey, the following are examples of what was observed:

1. Basement
Unsealed penetrations around flex condiut, two separate locations, in the wall of the Boiler Room, located in the Basement.


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2. Third Floor
a. Radiology Filing Dept. (storage) was over 140 sq. ft. with combustible materials; the door did not have a self-closing device.
b. Central Supply was over 50 sq. ft. with combustible materials; the door did not have a self-closing device.



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.

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

During the survey, the following are examples of what was observed:
1. Second Floor
All Geripsych patient room corridor doors locked with a key from the outside, cannot unlock the doors without a key from the inside.

2. Third Floor
The following rooms had deadbolt locks on them, which could allow someone to be locked in the room and not be able to get out:
a. Maintenance Room - across from the Lab.
b. Mamogram Room
c. E.R. Hopper Room
d. Triage Room - across from Admissions and next to the Janitor's Room
e. Janitor's Room - across from Admissions and next to the Triage Room



2000 NFPA 101, 7.1.9 Any device or alarm installed to restrict the improper use of a means of egress shall be designed and installed so that it cannot, even in case of failure, impede or prevent emergency use of such means of egress unless otherwise provided in 7.2.1.6 and Chapters 18, 19, 22, and 23.
2000 NFPA 101, 7.1.10.1 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, 7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
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The facility failed to provide illumination of means of egress per code. Findings include:

During the survey, the following is an example of what was observed:
The Gateway Exit had a single fixture with a single bulb.



2000 NFPA 101, 7.8.1.2 Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use. Artificial lighting shall be employed at such locations and for such periods of time as required to maintain the illumination to the minimum criteria values herein specified.
2000 NFPA 101, 7.8.1.4 Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2 lux) in any designated area.
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The facility failed to provide continuously illuminated exit signs. Findings include: During the survey, the following are examples of what was observed:

1. Basement
Three exit signs were not illuminated in the Basement.


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2. Second Floor
The following exit signs were not illuminated:
a. The two exit signs to the "smoking area"
b. The exit sign for the stairs by the elevator
c. The exit sign by room 204



2000 NFPA 101, 7.10.5.2 Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.
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The facility failed to conduct fire drills per code. Findings include:

During the survey, the following are examples of what was observed:
1. Not all employees participated/signed the fire drills reports
2. The facility failed to conduct a fire drill for the third quarter on the second shift



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

During the survey, the following are examples of what was observed:
1. Second Floor
The following egress doors did not release:
a. Under the fire alarm
b. When the primary power was loss to the fire alarm
1. Stairwell door at the T.V. Room
2 Both Nures' Station doors
3. Both Dayroom doors
4. The double doors for Gateway
2. Third Floor
The double doors for Bradford did not release when the primary power was loss to the fire alarm



1999 NFPA 72, 3-9.7.1 Any device or system intended to actuate the locking or unlocking of exits shall be connected to the fire alarm system serving the protected premises.
1999 NFPA 72, 3-9.7.2 All exits connected in accordance with 3-9.7.1 shall unlock upon receipt of any fire alarm signal by means of the fire alarm system serving the protected premises.
Exception: Where otherwise required or permitted by the authority having jurisdiction or other codes.
1999 NFPA 72, 3-9.7.3 All exits connected in accordance with 3-9.7.1 shall unlock upon loss of the primary power to the fire alarm system serving the protected premises. The secondary power supply shall not be utilized to maintain these doors in the locked condition.
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Documentation provided by the facility during the survey did not indicate sensitivity testing of the smoke detectors. Detector sensitivity shall be checked with one year after installation and every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).

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The facility failed to provide complete sprinkler coverage to all parts of the facility.
Findings include: During the survey, the following are examples of what was observed:


1. Ceiling tile missing in the Stairwell basement level by the elevator.

2. Ceiling tile missing in the Elevator Equipment Room, located in the Basement.

3. Ceiling tile missing in Housekeeping located in the Basement.


NFPA 13 5-6., Sprinklers shall be arranged to be in compliance.

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

1. The Quarterly sprinkler inspection report for 5/24/2011, noted that the water motor gong assembly needed to be repaired, fastener sheared off. Also the 5 year obstruction inspection is due.



Every required sprinkler system shall be continuously maintained in proper operating condition. NFPA 101, 4.6.12.1.

NFPA 101, 4.6.12, and NFPA 25, 2-2 and Table 2-1 Requires an inspection every quarter (three months).


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2. The Outside Automatic Sprinkler Riser Room stock of spare sprinklers for the two story addition - had four spare sprinkler heads that only had one of each.

3. Third Floor
In the following rooms the sprinkler head was missing the escutcheon plate
a. E.R. Nurses' Station Storage Room
b. Triage Room - across from Admissions/next to Janitor's Room
c. Radiology Bathroom



1998 NFPA 25, 2-4.1.4 A supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. The cabinet shall be so located that it will not be exposed to moisture, dust, corrosion, or a temperature exceeding 100?F (38?C).
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.
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The facility failed to maintain the fire extinguishers per code. Findings include:

1. During the survey, the Fire Extingusher across the corridor from the Director of Nursing Office, was mounted approximatley (2) ft from the floor to the top of the extinguisher.



1998 NFPA 10, 1-6.10 Fire extinguishers weighting not more than 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.


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2. During the survey, the following are examples of what was observed:
Through out the facility the last documented monthly inspection on the fire extinguishers was 01/07/2011.

3. Second Floor
The fire extinguisher in the Laundry Room had an annual inspection date of 02/2011 with no documented monthly inspections

4. Third Floor
The fire extinguisher in the Maintenance Room across from the Lab. had an annual inspection date of 2008.



1998 NFPA 10, 4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.

1998 NFPA 10, 4-3.4.3 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.

1998 NFPA 10, 4-3.1* Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.

1998 NFPA 10, 4-4.1 Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.

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The facility failed to provide a smoking policy per code. Findings include:

During the survey, the following are examples of what was observed:
1. The facility failed to provide a smoking policy.

Second Floor
2. The smoking area for Gateway did not have an ashtray



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.
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The facility failed to adequately perform testing and inspection of the dietary hood
extinguishment system. Findings include: During the survey, the following are examples of what was observed:

1. The provided documentation for the monthly inspection of the hood system was the inspection card attached to the pull station of the hood extinguishing system. This card was observed with space on the reverse side to date and initial each month an inspection was conducted by facility staff. This side of the inspection card was blank.



NFPA 17, 9-2.1- On a monthly basis, inspection shall be conducted in accordance with the manufacturer 's listed installation and maintenance manual or 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) The system shows no physical damage or condition that might prevent operation. (f) The pressure gauge(s), if provided, is in operable range. (g) The nozzle blow-off caps, where provided, are intact and undamaged. (h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.



2. The K-Extinguisher was not provided with a placard identifying the use.




NFPA 96 7-2.1.1 A placard identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system shall be conspicuously placed near each portable fire extinguisher in the cooking area.

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The facility failed to prohibit portable space heating devices per code. Findings include:

During the survey, the following are examples of what was observed:
Third Floor
The following rooms had portable space heating devices, the devices were not plugged in:
1. E.R. Nurses' Station Storage Room
2. Medical Records Room



2000 NFPA 101, 19.7.8 Portable space-heating devices shall be prohibited in all health care occupancies. Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212?F (100?C).
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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 are examples of what was observed:

1. Tables, Carts, in the corridor in the Basement from approximatley 10:45am- 11:30am.

2. Two cleaning carts wre stored in the corridor by Patient Room 315, from approximatley 1:15pm- 2:00pm.


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3. Exit at the Police Dept. was blocked by a vehicle

Second Floor
4. The rear exit for Gateway's Dayroom did not have an all weather sound path of travel
5. The Psych Unit at Gateway had three chairs that stayed in the corridor during the survey

Third Floor
6. The stairwell exit by room 321 had a sign on the door that said "this is not an exit". According to the staff this sign was put there to deter patients from using this door. This is a required exit.
7. The corridor at the the Police Dept. exit had three chairs, one huge cart, two sheets of sheet rock being stored and a sign that read " Please break down your boxes before placing them here".



2000 NFPA 101, 7.1.10.1 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, 7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.
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The facility failed to maintain the curtains/draperies per code. Findings include:

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

The facility failed to provide flame resistant documentation for all of the curtains/draperies on the second floor, Assistant Administrator's Office, and The Central Supply Office.



2000 NFPA 101, 10.3.1 Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.
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The facility failed to provide proper storage of oxygen cylinders. Findings include: During the survey, the following are examples of what was observed:

Two unsecured oxygen cylinders in the Soil Utility Room, by Patient Room 306.



1999 NFPA 99, 4-3.1.1.1 and 4-5.1.1.1 Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.


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The facility failed to maintain proper emergency lighting at the generator set and controls. Findings include: During the survey, the following are examples of what was observed:

The battery-powered light in the generator set/control room was inoperable.


1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1. Emergency generator equipment locations are to be equiuped with battery- powered lights.


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

During the survey, the following are examples of what was observed:
1. "Overcrank" was illuminated when the surveyors arrived on site, but there was no audible
2. When the generator was taken off "auto" the light illuminated, but there was no audible



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 provide receptacles for appliances. Findings include: During the survey, the following are examples of what was observed:


1. Cover missing on an Electrical Panel in the Electrical Room, by Patient Room 306.

2. Telephone equipment room by Patient Room 310, had an overcurrent protection cord, plugged into an overcurrent cord.



1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.

NFPA 101 Life Safety Code (Sec. 19-5.1) utilities shall comply with NFPA 101 (Sec. 9-1.) . Electrical shall comply with the NFPA 70 National Electrical Code. NEC 400-7(b) Requires each flexible cord to "be energized from a receptacle outlet."


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3. Second Floor
The Counselor's Office had a fridge and a microwave plugged into a GFCI extension cord.


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.

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The facility failed to provide an automatic sprinkler system fire watch policy per code. Findings include:

During the survey, the following is an example of what was observed:
The facility failed to provide an automatic sprinkler system fire watch policy



2000 NFPA 101, 9.7.6.1 Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.
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The facility failed to provide a fire alarm fire watch policy per code. Findings include:

During the survey, the following is an example of what was observed:
The facility failed to provide a fire alarm fire watch policy.



2000 NFPA 101, 9.6.1.8 Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.
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