HospitalInspections.org

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Based on the observation of the fire barriers on 05/24/2016 the facility failed to maintain a fire barrier. Findings include:

The fire barrier in the "Glass Corridor" (between fire door A 138 North Wing and the exit) was observed with an unsealed penetration of three black antenna cables above the ceiling.

The deficiency impacted 1 of 1 smoke compartments.
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Review of 2000 NFPA 101, 18.1.1.1 Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition. (See 4.6.11 and 4.6.6.)

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* This tag was written the last three surveys.

Based on the observation of the corridor doors on 05/24/2016 the facility failed to maintain a means suitable for keeping the corridor doors closed that is acceptable to the authority having jurisdiction and resist the passage of smoke. Findings include:

1. Infection Control's corridor door was observed without positive latching hardware.
2. The OR Suite's corridor double doors were observed:
a. without positive latching hardware
b. a gap of approximately 1/4" where the two doors meet (not smoke resistive)

The deficiency impacted 8 of 8 smoke compartments.
___________

Review of 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. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.

Review of 2000 NFPA 101, 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.

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Based on the observation of the smoke barriers on 05/24/2016 the facility failed to maintain the smoke barriers smoke resistive and half hour fire resistant. Findings include:

1. The smoke barrier at the Administration Office, above the smoke doors was observed with two penetrations sealed with a flammable orange foam substance.
2. The smoke barrier in the South Wing (Psych. Unit) above the smoke doors was observed with two penetrations sealed with a flammable orange foam substance.
3. The smoke barrier in the "Old Ice Machine Room" was observed not continuing to the roof deck, the smoke barrier was observed stopping at the bottom of a beam.

The deficiency impacted 4 of 8 smoke compartments.
___________

Review of 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.

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Based on the observation of the hazardous areas on 05/24/2016 the facility failed to maintain the separation of a hazardous area. Findings include:

The North Wing Nurses' Station Soiled Linen corridor door self-closing device was observed not bringing the door to close and positive latching.

The deficiency impacted 1 of 8 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 observation on 5/24/2016 the facility failed to maintain the exit signs. Findings include:

Two exit signs located in front of the exit doors in the breeze way were not illuminated.

The deficiency impacted 1 of 8 smoke compartments.

_________________

Review of 2000 NFPA 101, 18.2.10.1
Means of egress shall have signs in accordance with Section 7.10.

Review of 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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Based on observation on 5/24/2016, the facility failed to maintain components of the fire alarm system. Findings include:

The manual pull station for the fire alarm system, located in the surgery Lounge was damaged, observed hanging loose from the wall.


The deficiency impacted 8 of 8 smoke compartments.
__________________

Review of 2000 NFPA 101, 9.6.1.7 Components of the fire alarm system were not maintained.

Review of 2000 NFPA 101, 9.6.1.4 The fire alarm system to be installed, tested, and maintained in accordance with the requirements of NFPA 70 and NFPA 72.

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Based on observation on 5/24/2016, the facility failed to provide complete sprinkler coverage for all parts of the facility. Findings include:

1. A eight foot combustible overhang at the exit discharge from surgery, was not provided with sprinkler coverage. Maintenance confirmed the measurement of eight feet.

2. A five foot combustible overhang at the exit discharge by Patient Room 161, was not provided with sprinkler coverage. Maintenance confirmed the measurement of five feet.


The deficiency impacted 2 of 8 smoke compartments.
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1999 NFPA 13, 5-13.8 Sprinklers shall be installed under exterior combustible roofs or canopies exceeding four feet in width, or over areas where combustibles are stored.

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Based on observation the facility failed to maintain the automatic sprinkler system. Findings include:

1. Documentation was not provided for the 5 year obstruction inspection of the sprinkler system.

The deficiency impacted 8 of 8 smoke compartments.
_____________

2000 NFPA 101, 19.7.6 Maintenance and Testing. (See 4.6.12.)

2000 NFPA 101, 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 25,1998 Edition, 10-2.2* Obstruction Prevention.


27382

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Based on the observation of the automatic sprinkler pipes above the ceiling on 05/24/2016 the facility failed to maintain the automatic sprinkler pipes free of external loads. Findings include:

2. Two wires were observed resting on the automatic sprinkler pipes above the ceiling at the smoke barrier in the South Wing (Psych. Unit).

The deficiency impacted 1 of 8 smoke compartments.
_____________

Review of 1998 NFPA 25, 2-2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.

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Based on observation the facility failed to maintain the automatic sprinkler system. Findings include:

Documentation was not provided for the 5 year obstruction inspection of the sprinkler system.

The deficiency impacted 8 of 8 smoke compartments.
_______________

2000 NFPA 101, 19.7.6 Maintenance and Testing. (See 4.6.12.)

2000 NFPA 101, 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 25,1998 Edition, 10-2.2* Obstruction Prevention.



27382

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Based on the observation of the automatic sprinkler pipes above the ceiling on 05/24/2016 the facility failed to maintain the automatic sprinkler pipes free of external loads. Findings include:

2. Two HVAC flex ducts were observed resting on the automatic sprinkler pipes above the ceiling at the fire barrier in the "Glass Corridor" (between fire door A 138 North Wing and the exit).

The deficiency impacted 1 of 1 smoke compartments.
_____________

Review of 1998 NFPA 25, 2-2.2* Pipe and Fittings.
Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.

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Based on observation on 5/24/2016, the facility failed to adequately perform testing and inspection of the dietary hood extinguishment system. Findings include:

During survey, 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. Last six month inspection was conducted 11/2015.
__________________

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.

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Based on observation during the survey on 5/24/2016 the facility failed to maintain the following systems. Findings include:

1. The exit signs at the following locations were not illuminated:
a. Exit sign was not illuminated for the exit door by storage room # 10
b. Exit sign was not illuminated for the exit door by room # 1
c. Exit sign was not illuminated for the exit door main entrance

2. Three fire extinguishers, per the card attached had the annual service conducted on 11/2015. The card for each extinguisher was blank for the monthly inspections.

3. Three battery-powered emergency lights were inoperable, lights are located at differ locations in the corridor for means of egress lighting. This portion of the structure (corridor) was observed lacking access openings (without windows) .
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2000 NFPA 101, 39.2.10, Existing Business Occupancies. Means of egress shall have signs in accordance with Section 7.10.

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.

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, 39.3.5, Existing Business Occupancies. Portable fire extinguishers shall be provided in every business occupancy in accordance with 9.7.4.1.

2000 NFPA 101, 9.7.4.1*
Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

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

2000 NFPA 101, 39.2.10, Existing Business Occupancies. 39.2.9.2 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.

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Based on the observation of the med. gas storage area on 05/24/2016 the facility failed to maintain the med. gas storage area. Findings include:

The OR "Issue Room" was observed with oxygen, carbon dioxide, air compressed and nitrous oxide cylinders in one storage rack within 5'-0" of combustibles.

The deficiency impacted 1 of 8 smoke compartments.
_____________

Review of 1999 NFPA 99, 8-3.1.11.2
Storage for nonflammable gases less than 3000 ft3 (85 m3).
(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.
(d) Liquefied gas container storage shall comply with 4-3.1.1.2(b)4.
(e) Cylinder and container storage locations shall meet 4-3.1.1.2(a)11e with respect to temperature limitations.
(f) Electrical fixtures in storage locations shall meet 4-3.1.1.2(a)11d.

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*This tag was written the last two surveys.

Based on observation on 5/24/2016 the facility failed to maintain the electrical accordance with the National Electrical Code (NFPA 70.) Findings include:

1. Two junction boxes were missing the cover in the ceiling of the boiler room.
2. A file cabinet, and a locker was stored in front of three electrical panels, in the boiler room.
3. Three power strips were observed plugged into each other, in the electrical room across the corridor from the prayer room.


27382

4. Based on observation on 05/24/2016 the facility failed to maintain an adequate number and/or location of electrical receptacles in staff areas. As examples see:
a. The Business Office was observed with a power strip plugged into a power strip
b. The North Wing Nurses' Station was observed with the medical refrigerator plugged into a power strip
5. Based on observation on 05/24/2016 the facility failed to maintain the electrical outlets. As an example see:
The North Wing Break Room - the electrical outlet for the PTAC Unit was observed missing it's cover plate

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Review of the printed statement on the 2567 for K- 147, Electrical wiring and equipment shall be in accordance with National Electrical Code (NFPA 70).

Review of 2000 NFPA 101, 9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

Review of 1999 NFPA 70, 400-7 (b) Attachment Plugs. Where used as permitted in subsections (a)(3), (a)(6), and (a)(8), each flexible cord shall be equipped with an attachment plug and shall be energized from a receptacle outlet.

Review of 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.

Review of 1999 NFPA 70, 370-25. Covers and Canopies
In completed installations, each box shall have a cover, faceplate, or fixture canopy.

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Based on observation during the survey on 05/24/2016, the facility failed to maintain the electrical wiring and equipment in accordance with the National Electrical Code (NFPA 70). Findings include:

Based on observation on 05/24/2016 the facility failed to maintain an adequate number and/or location of electrical receptacles in staff areas. As an example see:
The North Wing Office 1 (A 144) was observed with the microwave plugged into a power strip

The deficiency impacted 1 of 1 smoke compartments.
_____________

Review of the printed statement on the 2567 for K- 147, Electrical wiring and equipment shall be in accordance with National Electrical Code (NFPA 70).

Review of 2000 NFPA 101, 9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

Review of 1999 NFPA 70, 400-7 (b) Attachment Plugs. Where used as permitted in subsections (a)(3), (a)(6), and (a)(8), each flexible cord shall be equipped with an attachment plug and shall be energized from a receptacle outlet.

Review of 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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Based on the observation of the fire barriers on 05/24/2016 the facility failed to maintain a fire barrier. Findings include:

The fire barrier in the "Glass Corridor" (between fire door A 138 North Wing and the exit) was observed with an unsealed penetration of three black antenna cables above the ceiling.

The deficiency impacted 1 of 1 smoke compartments.
_____________

Review of 2000 NFPA 101, 18.1.1.1 Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition. (See 4.6.11 and 4.6.6.)

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* This tag was written the last three surveys.

Based on the observation of the corridor doors on 05/24/2016 the facility failed to maintain a means suitable for keeping the corridor doors closed that is acceptable to the authority having jurisdiction and resist the passage of smoke. Findings include:

1. Infection Control's corridor door was observed without positive latching hardware.
2. The OR Suite's corridor double doors were observed:
a. without positive latching hardware
b. a gap of approximately 1/4" where the two doors meet (not smoke resistive)

The deficiency impacted 8 of 8 smoke compartments.
___________

Review of 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. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.

Review of 2000 NFPA 101, 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.

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Based on the observation of the smoke barriers on 05/24/2016 the facility failed to maintain the smoke barriers smoke resistive and half hour fire resistant. Findings include:

1. The smoke barrier at the Administration Office, above the smoke doors was observed with two penetrations sealed with a flammable orange foam substance.
2. The smoke barrier in the South Wing (Psych. Unit) above the smoke doors was observed with two penetrations sealed with a flammable orange foam substance.
3. The smoke barrier in the "Old Ice Machine Room" was observed not continuing to the roof deck, the smoke barrier was observed stopping at the bottom of a beam.

The deficiency impacted 4 of 8 smoke compartments.
___________

Review of 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.

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Based on the observation of the hazardous areas on 05/24/2016 the facility failed to maintain the separation of a hazardous area. Findings include:

The North Wing Nurses' Station Soiled Linen corridor door self-closing device was observed not bringing the door to close and positive latching.

The deficiency impacted 1 of 8 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 observation on 5/24/2016 the facility failed to maintain the exit signs. Findings include:

Two exit signs located in front of the exit doors in the breeze way were not illuminated.

The deficiency impacted 1 of 8 smoke compartments.

_________________

Review of 2000 NFPA 101, 18.2.10.1
Means of egress shall have signs in accordance with Section 7.10.

Review of 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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Based on observation on 5/24/2016, the facility failed to maintain components of the fire alarm system. Findings include:

The manual pull station for the fire alarm system, located in the surgery Lounge was damaged, observed hanging loose from the wall.


The deficiency impacted 8 of 8 smoke compartments.
__________________

Review of 2000 NFPA 101, 9.6.1.7 Components of the fire alarm system were not maintained.

Review of 2000 NFPA 101, 9.6.1.4 The fire alarm system to be installed, tested, and maintained in accordance with the requirements of NFPA 70 and NFPA 72.

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Based on observation on 5/24/2016, the facility failed to provide complete sprinkler coverage for all parts of the facility. Findings include:

1. A eight foot combustible overhang at the exit discharge from surgery, was not provided with sprinkler coverage. Maintenance confirmed the measurement of eight feet.

2. A five foot combustible overhang at the exit discharge by Patient Room 161, was not provided with sprinkler coverage. Maintenance confirmed the measurement of five feet.


The deficiency impacted 2 of 8 smoke compartments.
____________

1999 NFPA 13, 5-13.8 Sprinklers shall be installed under exterior combustible roofs or canopies exceeding four feet in width, or over areas where combustibles are stored.

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Based on observation the facility failed to maintain the automatic sprinkler system. Findings include:

1. Documentation was not provided for the 5 year obstruction inspection of the sprinkler system.

The deficiency impacted 8 of 8 smoke compartments.
_____________

2000 NFPA 101, 19.7.6 Maintenance and Testing. (See 4.6.12.)

2000 NFPA 101, 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 25,1998 Edition, 10-2.2* Obstruction Prevention.


27382

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Based on the observation of the automatic sprinkler pipes above the ceiling on 05/24/2016 the facility failed to maintain the automatic sprinkler pipes free of external loads. Findings include:

2. Two wires were observed resting on the automatic sprinkler pipes above the ceiling at the smoke barrier in the South Wing (Psych. Unit).

The deficiency impacted 1 of 8 smoke compartments.
_____________

Review of 1998 NFPA 25, 2-2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.

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Based on observation the facility failed to maintain the automatic sprinkler system. Findings include:

Documentation was not provided for the 5 year obstruction inspection of the sprinkler system.

The deficiency impacted 8 of 8 smoke compartments.
_______________

2000 NFPA 101, 19.7.6 Maintenance and Testing. (See 4.6.12.)

2000 NFPA 101, 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 25,1998 Edition, 10-2.2* Obstruction Prevention.



27382

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Based on the observation of the automatic sprinkler pipes above the ceiling on 05/24/2016 the facility failed to maintain the automatic sprinkler pipes free of external loads. Findings include:

2. Two HVAC flex ducts were observed resting on the automatic sprinkler pipes above the ceiling at the fire barrier in the "Glass Corridor" (between fire door A 138 North Wing and the exit).

The deficiency impacted 1 of 1 smoke compartments.
_____________

Review of 1998 NFPA 25, 2-2.2* Pipe and Fittings.
Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.

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Based on observation on 5/24/2016, the facility failed to adequately perform testing and inspection of the dietary hood extinguishment system. Findings include:

During survey, 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. Last six month inspection was conducted 11/2015.
__________________

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.

.

.
Based on observation during the survey on 5/24/2016 the facility failed to maintain the following systems. Findings include:

1. The exit signs at the following locations were not illuminated:
a. Exit sign was not illuminated for the exit door by storage room # 10
b. Exit sign was not illuminated for the exit door by room # 1
c. Exit sign was not illuminated for the exit door main entrance

2. Three fire extinguishers, per the card attached had the annual service conducted on 11/2015. The card for each extinguisher was blank for the monthly inspections.

3. Three battery-powered emergency lights were inoperable, lights are located at differ locations in the corridor for means of egress lighting. This portion of the structure (corridor) was observed lacking access openings (without windows) .
______________

2000 NFPA 101, 39.2.10, Existing Business Occupancies. Means of egress shall have signs in accordance with Section 7.10.

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.

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, 39.3.5, Existing Business Occupancies. Portable fire extinguishers shall be provided in every business occupancy in accordance with 9.7.4.1.

2000 NFPA 101, 9.7.4.1*
Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

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

2000 NFPA 101, 39.2.10, Existing Business Occupancies. 39.2.9.2 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.

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Based on the observation of the med. gas storage area on 05/24/2016 the facility failed to maintain the med. gas storage area. Findings include:

The OR "Issue Room" was observed with oxygen, carbon dioxide, air compressed and nitrous oxide cylinders in one storage rack within 5'-0" of combustibles.

The deficiency impacted 1 of 8 smoke compartments.
_____________

Review of 1999 NFPA 99, 8-3.1.11.2
Storage for nonflammable gases less than 3000 ft3 (85 m3).
(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.
(d) Liquefied gas container storage shall comply with 4-3.1.1.2(b)4.
(e) Cylinder and container storage locations shall meet 4-3.1.1.2(a)11e with respect to temperature limitations.
(f) Electrical fixtures in storage locations shall meet 4-3.1.1.2(a)11d.

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*This tag was written the last two surveys.

Based on observation on 5/24/2016 the facility failed to maintain the electrical accordance with the National Electrical Code (NFPA 70.) Findings include:

1. Two junction boxes were missing the cover in the ceiling of the boiler room.
2. A file cabinet, and a locker was stored in front of three electrical panels, in the boiler room.
3. Three power strips were observed plugged into each other, in the electrical room across the corridor from the prayer room.


27382

4. Based on observation on 05/24/2016 the facility failed to maintain an adequate number and/or location of electrical receptacles in staff areas. As examples see:
a. The Business Office was observed with a power strip plugged into a power strip
b. The North Wing Nurses' Station was observed with the medical refrigerator plugged into a power strip
5. Based on observation on 05/24/2016 the facility failed to maintain the electrical outlets. As an example see:
The North Wing Break Room - the electrical outlet for the PTAC Unit was observed missing it's cover plate

_____________

Review of the printed statement on the 2567 for K- 147, Electrical wiring and equipment shall be in accordance with National Electrical Code (NFPA 70).

Review of 2000 NFPA 101, 9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

Review of 1999 NFPA 70, 400-7 (b) Attachment Plugs. Where used as permitted in subsections (a)(3), (a)(6), and (a)(8), each flexible cord shall be equipped with an attachment plug and shall be energized from a receptacle outlet.

Review of 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.

Review of 1999 NFPA 70, 370-25. Covers and Canopies
In completed installations, each box shall have a cover, faceplate, or fixture canopy.

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Based on observation during the survey on 05/24/2016, the facility failed to maintain the electrical wiring and equipment in accordance with the National Electrical Code (NFPA 70). Findings include:

Based on observation on 05/24/2016 the facility failed to maintain an adequate number and/or location of electrical receptacles in staff areas. As an example see:
The North Wing Office 1 (A 144) was observed with the microwave plugged into a power strip

The deficiency impacted 1 of 1 smoke compartments.
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Review of the printed statement on the 2567 for K- 147, Electrical wiring and equipment shall be in accordance with National Electrical Code (NFPA 70).

Review of 2000 NFPA 101, 9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

Review of 1999 NFPA 70, 400-7 (b) Attachment Plugs. Where used as permitted in subsections (a)(3), (a)(6), and (a)(8), each flexible cord shall be equipped with an attachment plug and shall be energized from a receptacle outlet.

Review of 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.