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The facility failed to ensure complete two-hour fire rated wall assemblies for three (3) of three (3) occupancy separations.

Observation determined:
1) The 90-minute cross corridor doors that separate the 1996 addition from the original building by the vending machines did not self-close and latch to the frame.

2) There were two (2) unsealed wall penetrations above the cross corridor doors that separate the1996 addition from the original building by the vending machine.

3) The wall above the 90-minute cross corridor doors between the hospital and clinic had unsealed conduit penetrations and unsealed gypsum board seams.

4) The west door to Patient Room #1 did not self close and latch into the frame.

5) There was an open pipe penetration above the west door to Patient Room #1.

The facility failed to ensure Type II (111) building construction was maintained.

Observation determined:
1) The facility failed to maintain a one-hour resistive rated ceiling/roof assembly throughout the building.
a) The Storage Room by the Maintenance Office had an open ceiling tile and unsealed penetrations through the ceiling.
b) The Biohazard Storage Room had a ceiling tile missing.
c) The soiled Utility Room in the Acute Care Wing had a ceiling tile missing.
d) The Operating Room had an open ceiling tile.
e) There were broken ceiling tiles in the Phone Equipment Room.
2) The facility failed to provide a construction type of at least Type II (111) non-combustible construction throughout the facility as required for one-story health care occupancies without an automatic sprinkler system.
a) There was combustible wood above the suspended ceiling in the exit corridor by the Biohazard Storage Room.
b) There was combustible wood above the suspended ceiling in the entire corridor from Dietary to the Laundry Soiled Utility Room.

The facility failed to provide corridors separated from use areas by walls with at least 1/2 hour fire resistance rating.

Observation determined:

The patient wing (B Wing) of the hospital had membrane ceilings in the patient rooms and suspended ceilings in the corridor. The corridor walls in the patient wing do not extend to the roof deck.

The facility failed to ensure the corridor doors resisted the passage of smoke.

Observation determined:
1) The two (2) doors to the Kitchen would not self-close tightly to the door frame.
2) The door to Patient Room #13 was blocked open by a bed stored in the room.
3) The door to the Nutrition Room was held in the open position with a rubber wedge.
4) The door to the Ice machine Room was held in the open position with a rubber wedge.

The facility failed to separate hazardous areas from other spaces with one-hour fire resistive rated partitions and self-closing fire-rated door assemblies.

Observation determined:
1) The door to the Mechanical Room by the Maintenance Office would not self-close to the latched position.
2) The door to the Shipping and Receiving Storage Room would not self-close to the latched position.
3) The door to the Storage Room in the Acute Care Wing would not self-close to the latched position.
4) The door to the Ambulance Bay would not self-close to the latched position.
5) Patient Room #24 was being used for storage and was not equipped with a 45 minute fire rated door and self-closing hardware.
6) The Auxiliary Supply Room was not equipped with self closing hardware.
7) The south wall of the Mechanical Room by the Maintenance Office had a hot water heating pipe penetration that was not sealed with fire rated material.
8) The south wall of the unsprinklered Laundry Room had two (2) pipe penetrations into the connecting link of the 1996 addition that were not sealed with fire rated material.

The facility failed to ensure one-hour fire resistive enclosure in exit stairwells.

Observation determined the Storage Room on the first floor under the stairwell had a hole in the ceiling.

Keyed locks, dead bolt locks and multi-latching devices create an impediment to egress from habitable spaces. Doors shall be operable with not more than one releasing operation. 7.2.1.5.4

The facility failed to ensure exit access was readily accessible at all times.

Observation determined:
1) The corridor door to the Maintenance Office was equipped with a lever latch and a dead-bolt thumb latch.
2) The corridor door to Board Room was equipped with a lever latch and a dead-bolt thumb latch.

A functional test must be conducted on every required emergency lighting system at 30-day intervals for a minimum of 30 seconds. An annual test must be conducted for 1 1/2-hour duration. Written records of testing must be kept by the owner for inspection by the authority having jurisdiction.

The facility failed to conduct functional testing of the emergency lighting.

Review of records could not verify that monthly 30 second tests and a 1 ? hour annual test of the battery-operated emergency lighting packs located throughout the facility were being done.

The facility failed to conduct quarterly fire drills on each shift.

Record review determined there were no fire drills conducted from May of 2012 through February of 2013.

The facility failed to ensure the fire alarm system was in compliance with NFPA 72, National Fire Alarm Code.

1) Observation determined the heat detector in the Mechanical Room by the Maintenance Office was hanging from the wiring and not attached to the junction box on the ceiling.

2) Review of the fire alarm test records indicated the facility failed conduct monthly tests of the fire alarm from May 2012 through September 2012 and from November 2012 through February 2013.

3) Review of the fire alarm test records indicated that the fire alarm system automatic dialer does not supervise the phone lines.

Automatic fire sprinkler systems must be installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

The facility failed to ensure all areas were protected by the automatic fire sprinkler system.
1) The New Maintenance Room had no sprinkler coverage under duct work greater than 48 inches in depth.
2) The X Ray Room had openings from an old electrical box and around pipes though the ceiling tiles that could delay the activation of the sprinkler heads.
3) The Janitor Room by the Nurses station was missing ceiling tiles that could delay the activation of the sprinkler system.

The facility failed to ensure the fire alarm system sounds a local trouble alarm in the event the main sprinkler valve is closed.

Observation determined the facility has not ensured the required automatic sprinkler system has valves supervised so that at least a local alarm will sound when the valves are closed. The system reliability cannot be ensured since the Post Indicator Valve was not electronically monitored.

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.
1) Review of sprinkler system records could not verify that the quarterly tests of the sprinkler system were conducted in the past twelve (12) months.
2) The covers for the sprinkler system flow switches were not installed to protect the switches.

Fire extinguishing systems for commercial cooking operations must meet NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. NFPA 96 requires an inspection and servicing of the fire-extinguishing system be made at least every 6 months by properly trained and qualified persons.
Where a fire alarm signaling system is serving the occupancy where the extinguishing system is located, the activation of the kitchen hood automatic fire-extinguishing system must activate the fire alarm signaling system. NFPA 96, 10-6.2

The facility failed to connect the kitchen hood extinguishing system to the building fire alarm system and failed to install grease filters in the kitchen exhaust hood.
1) Review of the kitchen hood suppression system test reports and the fire alarm system test reports could not verify the kitchen hood extinguishing system activated the fire alarm system.
2) Observation determined there were no grease filters installed in the kitchen exhaust hood.

The facility failed to maintain exit corridors free of all obstructions or impediments.

Observation determined there was a dirty instrument cabinet stored in the corridor outside of the Operating Room.

Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart. NFPA 99 4-3.5.2.1(b)27
The facility failed to secure all medical gas cylinders.
1) One (1) nitrous oxide cylinder and two (2) oxygen cylinders were not secured in the outside oxygen storage area.
2) Four (4) oxygen cylinders were not secured in the Procedure Room Closet.

The facility failed to ensure oxygen supply piping and all shut-off valves were identified with markings/labels. 4-3.1.2.3.

1) Observation determined the main oxygen supply line shut-off valve in the Storage Room by the Maintenance Office was not identified as the "Main Shut-off valve". No labels or other markings identified the valve.
2) Observation determined the oxygen emergency shut off valves in the corridor by Patient Room #12 and Patient Room #13 were not properly labeled.
3) Observation determined the piping for the oxygen supply in the Storage Room by the Maintenance Office had no markings or labels applied to the piping to indicate the content of the gas line.

1) Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code. NFPA 101 9.1.2

The facility failed to ensure electrical wiring and electrical equipment complies with NFPA 70

Observation determined that there was a power strip in use on the crash cart in the Procedure Room.

2) Portable fire extinguishers shall be provided in every business occupancy in accordance with 9.7.4.1, 39.3.5

The facility failed to maintain the portable fire extinguishers.

Observation determined that two (2) of two (2) fire extinguishers were last inspected in April 2011.

3) Doors complying with 7.2.1 shall be permitted. 39.2.2.2.1

The facility failed to ensure exit access was readily accessible at all times.

Observation determined the front exit was equipped with a dead bolt lock keyed on both sides and the rear exit was equipped with a lever latch and dead-bolt thumb Latch.

4) Emergency lighting in accordance with Section 7.9 shall be provided for all underground and windowless structures as defined in 3.3.205 and 3.3.212. 39.2.9.2

The facility failed to ensure the illumination of means of egress.

Observation determined that the north exit battery-operated emergency lighting pack failed.


5) The clearances shall not be such as to interfere with combustion air, draft hood clearance and relief, and accessibility for servicing. Listed water heaters shall be installed in accordance with their listing and the manufacturers ' instructions.
Unlisted water heaters shall be installed with a clearance of 12 in. (300 mm) on all sides and rear. Combustible floors under unlisted water heaters shall be protected in an approved manner. NFPA 54 6.29.3

The facility failed to maintain proper clearances around the gas water heater.

Observation determined that there were combustibles store against the gas water heater in the Mechanical Room.

The facility failed to inspect the emergency generator on a weekly and monthly basis.

Review of generator test records could not verify that weekly and monthly inspections were being done and the monthly 30-minute load tests were done.

Electrical wiring throughout a health care occupancy must comply with NFPA 70, National Electrical Code.

The facility failed to ensure electrical wiring and electrical equipment complies with NFPA 70.

1) There were uncovered electrical junction boxes above the suspended ceiling in the Storage Room by the Maintenance Office, above the ceiling in the corridor by the kitchen, and on the east wall of the Old Boiler Room.
2) The Mechanical Room by the Maintenance Office had exposed wiring from a missing circulating pump, covers were missing from three (3) pressure switches, and the electrical panel for the air handlers was missing a cover.
3) The Storage Room next to the Maintenance Office had exposed wiring from a missing wall clock.
4) The GFCI Outlet in the Storage Room by the Nurses Station did not work.
5) One (1) of three (3) freezers in the Dietary Storage Room was plugged into a power strip.
6) An endoscope reprocessor and solution heater in the Emergency Utility Room were plugged into an extension cord and power strip.
7) A lamp in the DON Office was plugged into a power strip.
8) The crash cart in Patient Room #1 had a 4-way outlet with a cord on it used to power the equipment on the cart.