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Based on the observation during the survey on 08/18/2015, the facility failed to maintain the smoke barriers. Findings include:

First Floor
The smoke barrier in Sterile Supply at Fire Compartment "D" Door was observed with an approximately 1" x 2" unsealed penetration with a blue IT wire.

This deficiency impacted 2 of 4 smoke compartments.
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Review of 2000 NFPA 101, 8.2.4.4.1

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Based on the observation during the survey on 08/18/2015, the facility failed to maintain the smoke barriers. Findings include:

Second Floor
The smoke barrier in Behavioral Health Unit's Med. Room #2622 was observed with one unsealed penetration of a flex conduit at the door above the ceiling.

This deficiency impacted 2 of 6 smoke compartments.
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Review of 2000 NFPA 101, 8.2.4.4.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through smoke partitions shall be protected as follows:
(1) The space between the penetrating item and the smoke partition shall meet one of the following conditions:
a. It shall be filled with a material that is capable of limiting the transfer of smoke.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke partition, the sleeve shall be solidly set in the smoke partition, and the space between the item and the sleeve shall meet one of the following conditions:a. It shall be filled with a material that is capable of limiting the transfer of smoke.b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibrations into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke partitions.
b. It shall be made by an approved device that is designed for the specific purpose.

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Based on the observation during the survey on 08/19/2015, the facility failed to maintain the hazardous areas. Findings include:

First Floor
The Medical Records File Room was over 50 sq. ft. with combustibles; an unsealed hole was observed in the corridor wall near the fire extinguisher.

This deficiency impacted 1 of 6 smoke compartments.
_______________

Review of 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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Based on the observation during the survey on 08/18/2015, the facility failed to maintain the fire alarm system. Findings include:

1. The visual fire alarm devices throughout the Second Floor were observed to be within 20' of each other and were not in sync.
2. The visual fire alarm devices at the First Floor PACU Prep/Recovery 1305 were observed to be within 20' of each other and were not in sync.

This deficiency impacted 3 of 4 smoke compartments.
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Review of 1999 NFPA 72, 4-4.4.2.3
In corridors where there are more than two visible notification appliances in any field of view, they shall be spaced a minimum of 55 ft (16.76 m) from each other or they shall flash in synchronization.

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Based on the observation during the survey on 08/18/2015, the facility failed to maintain the fire alarm system. Findings include:

First Floor
The Admin. Hallway at the Breeze Way (New Addition Doors) was observed with two visual fire alarm devices within 20' of each other that were not in sync.

This deficiency impacted 1 of 6 smoke compartments.
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Review of 1999 NFPA 72, 4-4.4.2.3
In corridors where there are more than two visible notification appliances in any field of view, they shall be spaced a minimum of 55 ft (16.76 m) from each other or they shall flash in synchronization.

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Based on the observation on 8/18/2015, the facility failed to adequately provide sprinkler coverage. Findings include:

Sprinkler coverage was not provided in the tower part of the third floor. All other parts of the third floor is provided with sprinkler coverage, the other area is of a different design, and protected with upright sprinklers.
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NFPA 19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
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Based on the observation during the survey on 08/18/2015, the facility failed to maintain the following systems. Findings include:

1. The generator remote annunciator did not indicate "genset supplying load" when the generator was tested under load.
2. Oxygen was observed being stored in the Storage/Electrical Room E177 in the ER Dept.

This deficiency impacted 6 of 6 smoke compartments.
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Review of 1999 NFPA 110, 3-5.5.2 An automatic control and safety panel shall be a part of the EPS and shall contain the following equipment or possess the following characteristics, or both:
(a) Cranking control equipment to provide the complete cranking cycle described in 3-5.4.2 and Table 3-5.4.2.
(b) A panel-mounted control switch(es) marked " run-off-automatic " to perform the following functions:
1. Run: Manually initiate, start, and run prime mover
2. Off: Stop prime mover or reset safeties, or both
3. Automatic: Allow prime mover to start by closing a remote contact and stop by opening the remote contact
(c) Controls to shut down and lock out the prime mover under the following conditions: failing to start after specified cranking time, overspeed, low lubricating-oil pressure, high engine temperature, or operation of remote manual stop station. An automatic engine shutdown device for high lubricating-oil temperature shall not be required. (See 3-5.5.6.)
(d) Battery-powered individual alarm indication to annunciate visually at the control panel the occurrence of any of the conditions in Table 3-5.5.2(d); additional contacts or circuits for a common audible alarm that signals locally and remotely when any of the itemized conditions occurs. A lamp test switch(es) shall be provided to test the operation of all alarm lamps listed in Table 3-5.5.2(d).
(e) Controls to shut down the prime mover upon removal of the initiating signal or manual emergency shutdown.
(f) The ac instruments listed in 3-5.9.7. Where the control panel is mounted on the energy converter, it shall be mounted by means of antivibration shock mounts, if required, to maximize reliability.

Table 3-5.5.2(d) Safety Indications and Shutdowns

Review of 1999 NFPA 99, 8-3.1.11.2
Storage for nonflammable gases less than 3000 ft3 (85 m3).
(a) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
(b) Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor.
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
1. A minimum distance of 20 ft (6.1 m), or
2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.

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Based on the observation during the survey on 08/18/2015, the facility failed to maintain the generator remote annunciator. Findings include:

The generator remote annunciator did not indicate "genset supplying load" when the generator was tested under load.

This deficiency impacted 4 of 4 smoke compartments.
_______________

Review of 1999 NFPA 110, 3-5.5.2 An automatic control and safety panel shall be a part of the EPS and shall contain the following equipment or possess the following characteristics, or both:
(a) Cranking control equipment to provide the complete cranking cycle described in 3-5.4.2 and Table 3-5.4.2.
(b) A panel-mounted control switch(es) marked " run-off-automatic " to perform the following functions:
1. Run: Manually initiate, start, and run prime mover
2. Off: Stop prime mover or reset safeties, or both
3. Automatic: Allow prime mover to start by closing a remote contact and stop by opening the remote contact
(c) Controls to shut down and lock out the prime mover under the following conditions: failing to start after specified cranking time, overspeed, low lubricating-oil pressure, high engine temperature, or operation of remote manual stop station. An automatic engine shutdown device for high lubricating-oil temperature shall not be required. (See 3-5.5.6.)
(d) Battery-powered individual alarm indication to annunciate visually at the control panel the occurrence of any of the conditions in Table 3-5.5.2(d); additional contacts or circuits for a common audible alarm that signals locally and remotely when any of the itemized conditions occurs. A lamp test switch(es) shall be provided to test the operation of all alarm lamps listed in Table 3-5.5.2(d).
(e) Controls to shut down the prime mover upon removal of the initiating signal or manual emergency shutdown.
(f) The ac instruments listed in 3-5.9.7. Where the control panel is mounted on the energy converter, it shall be mounted by means of antivibration shock mounts, if required, to maximize reliability.

Table 3-5.5.2(d) Safety Indications and Shutdowns

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Based on the observation during the survey on 08/18/2015, the facility failed to maintain the smoke barriers. Findings include:

First Floor
The smoke barrier in Sterile Supply at Fire Compartment "D" Door was observed with an approximately 1" x 2" unsealed penetration with a blue IT wire.

This deficiency impacted 2 of 4 smoke compartments.
_______________

Review of 2000 NFPA 101, 8.2.4.4.1

.

.
Based on the observation during the survey on 08/18/2015, the facility failed to maintain the smoke barriers. Findings include:

Second Floor
The smoke barrier in Behavioral Health Unit's Med. Room #2622 was observed with one unsealed penetration of a flex conduit at the door above the ceiling.

This deficiency impacted 2 of 6 smoke compartments.
_______________

Review of 2000 NFPA 101, 8.2.4.4.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through smoke partitions shall be protected as follows:
(1) The space between the penetrating item and the smoke partition shall meet one of the following conditions:
a. It shall be filled with a material that is capable of limiting the transfer of smoke.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke partition, the sleeve shall be solidly set in the smoke partition, and the space between the item and the sleeve shall meet one of the following conditions:a. It shall be filled with a material that is capable of limiting the transfer of smoke.b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibrations into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke partitions.
b. It shall be made by an approved device that is designed for the specific purpose.

.

.
Based on the observation during the survey on 08/19/2015, the facility failed to maintain the hazardous areas. Findings include:

First Floor
The Medical Records File Room was over 50 sq. ft. with combustibles; an unsealed hole was observed in the corridor wall near the fire extinguisher.

This deficiency impacted 1 of 6 smoke compartments.
_______________

Review of 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.

.

.
Based on the observation during the survey on 08/18/2015, the facility failed to maintain the fire alarm system. Findings include:

1. The visual fire alarm devices throughout the Second Floor were observed to be within 20' of each other and were not in sync.
2. The visual fire alarm devices at the First Floor PACU Prep/Recovery 1305 were observed to be within 20' of each other and were not in sync.

This deficiency impacted 3 of 4 smoke compartments.
_______________

Review of 1999 NFPA 72, 4-4.4.2.3
In corridors where there are more than two visible notification appliances in any field of view, they shall be spaced a minimum of 55 ft (16.76 m) from each other or they shall flash in synchronization.

.

.
Based on the observation during the survey on 08/18/2015, the facility failed to maintain the fire alarm system. Findings include:

First Floor
The Admin. Hallway at the Breeze Way (New Addition Doors) was observed with two visual fire alarm devices within 20' of each other that were not in sync.

This deficiency impacted 1 of 6 smoke compartments.
_______________

Review of 1999 NFPA 72, 4-4.4.2.3
In corridors where there are more than two visible notification appliances in any field of view, they shall be spaced a minimum of 55 ft (16.76 m) from each other or they shall flash in synchronization.

.

.
Based on the observation on 8/18/2015, the facility failed to adequately provide sprinkler coverage. Findings include:

Sprinkler coverage was not provided in the tower part of the third floor. All other parts of the third floor is provided with sprinkler coverage, the other area is of a different design, and protected with upright sprinklers.
___________

NFPA 19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
.

.
Based on the observation during the survey on 08/18/2015, the facility failed to maintain the following systems. Findings include:

1. The generator remote annunciator did not indicate "genset supplying load" when the generator was tested under load.
2. Oxygen was observed being stored in the Storage/Electrical Room E177 in the ER Dept.

This deficiency impacted 6 of 6 smoke compartments.
_______________

Review of 1999 NFPA 110, 3-5.5.2 An automatic control and safety panel shall be a part of the EPS and shall contain the following equipment or possess the following characteristics, or both:
(a) Cranking control equipment to provide the complete cranking cycle described in 3-5.4.2 and Table 3-5.4.2.
(b) A panel-mounted control switch(es) marked " run-off-automatic " to perform the following functions:
1. Run: Manually initiate, start, and run prime mover
2. Off: Stop prime mover or reset safeties, or both
3. Automatic: Allow prime mover to start by closing a remote contact and stop by opening the remote contact
(c) Controls to shut down and lock out the prime mover under the following conditions: failing to start after specified cranking time, overspeed, low lubricating-oil pressure, high engine temperature, or operation of remote manual stop station. An automatic engine shutdown device for high lubricating-oil temperature shall not be required. (See 3-5.5.6.)
(d) Battery-powered individual alarm indication to annunciate visually at the control panel the occurrence of any of the conditions in Table 3-5.5.2(d); additional contacts or circuits for a common audible alarm that signals locally and remotely when any of the itemized conditions occurs. A lamp test switch(es) shall be provided to test the operation of all alarm lamps listed in Table 3-5.5.2(d).
(e) Controls to shut down the prime mover upon removal of the initiating signal or manual emergency shutdown.
(f) The ac instruments listed in 3-5.9.7. Where the control panel is mounted on the energy converter, it shall be mounted by means of antivibration shock mounts, if required, to maximize reliability.

Table 3-5.5.2(d) Safety Indications and Shutdowns

Review of 1999 NFPA 99, 8-3.1.11.2
Storage for nonflammable gases less than 3000 ft3 (85 m3).
(a) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
(b) Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor.
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
1. A minimum distance of 20 ft (6.1 m), or
2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.

.

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Based on the observation during the survey on 08/18/2015, the facility failed to maintain the generator remote annunciator. Findings include:

The generator remote annunciator did not indicate "genset supplying load" when the generator was tested under load.

This deficiency impacted 4 of 4 smoke compartments.
_______________

Review of 1999 NFPA 110, 3-5.5.2 An automatic control and safety panel shall be a part of the EPS and shall contain the following equipment or possess the following characteristics, or both:
(a) Cranking control equipment to provide the complete cranking cycle described in 3-5.4.2 and Table 3-5.4.2.
(b) A panel-mounted control switch(es) marked " run-off-automatic " to perform the following functions:
1. Run: Manually initiate, start, and run prime mover
2. Off: Stop prime mover or reset safeties, or both
3. Automatic: Allow prime mover to start by closing a remote contact and stop by opening the remote contact
(c) Controls to shut down and lock out the prime mover under the following conditions: failing to start after specified cranking time, overspeed, low lubricating-oil pressure, high engine temperature, or operation of remote manual stop station. An automatic engine shutdown device for high lubricating-oil temperature shall not be required. (See 3-5.5.6.)
(d) Battery-powered individual alarm indication to annunciate visually at the control panel the occurrence of any of the conditions in Table 3-5.5.2(d); additional contacts or circuits for a common audible alarm that signals locally and remotely when any of the itemized conditions occurs. A lamp test switch(es) shall be provided to test the operation of all alarm lamps listed in Table 3-5.5.2(d).
(e) Controls to shut down the prime mover upon removal of the initiating signal or manual emergency shutdown.
(f) The ac instruments listed in 3-5.9.7. Where the control panel is mounted on the energy converter, it shall be mounted by means of antivibration shock mounts, if required, to maximize reliability.

Table 3-5.5.2(d) Safety Indications and Shutdowns