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Fire barriers between a nonconforming occupancy (Grafton Family Clinic) and the hospital must be fire barriers having at least a two-hour fire resistance rating with openings protected by self-closing and positive latching 90-minute fire rated doors.

The facility failed to ensure doors in occupancy separation walls were positive latching.

Observation determined:
1) The west door leaf of the pair of 90-minute fire rated doors in the two-hour fire rated occupancy separation wall failed to self-close and latch into its frame. 2) Unsealed spaces around two (2) cables passing through the occupancy separation wall above the east 90-minute fire rated door negated the fire resistance rating of the wall. 3) Unsealed spaces around two (2) cables passing through the occupancy separation wall above the west 90-minute fire rated door negated the fire resistance rating of the wall.
The Maintenance Director acknowledged the findings when the deficiencies were identified.

Failure to ensure the fire resistance rating of occupancy separation walls and positive latching of fire rated doors as required increases the risk of death or injury due to fire.

The deficiencies affected the fire resistance of the occupancy separation between the hospital and the clinic.

Ref: 2000 NFPA 101 Section 19.1.1.4.1, 8.2.3.2.1(a), 1999 NFPA 80 Section 2-4.4.1

The facility failed to ensure the appropriate building construction type.

Observation determined:

1) There was an unsealed opening (approximately 8" x 8") in the mesh and plaster ceiling in the first floor Medication Room. The mesh and plaster ceiling is a component of the two-hour fire-rated floor/ceiling assembly. 2) The facility failed to maintain the two-hour fire resistive rating of elevator shaft enclosures.

a) There was a through-wall open conduit penetration of the freight elevator enclosure at the first floor corridor location above the ceiling. b) There were unsealed spaces around a through-wall conduit penetration of the freight elevator enclosure at the first floor corridor location above the ceiling. 4) There were unsealed spaces around a three (3) inch PVC pipe in the roof/ceiling assembly in the Ambulance Garage/Storage Room. These unsealed spaces do not prevent the passage of fire and smoke from this hazardous area to the Emergency Room. 5) There was an unsealed opening approximately 4" x 8" in the roof/ceiling assembly in the Ambulance Garage/Storage Room. These unsealed spaces do not prevent the passage of fire and smoke from this hazardous area to the Emergency Room. 6) Five (5) through-floor penetrations ranging in size from 1/2" to 3" in diameter were open from the first to the second floor in the Information Technology (I.T.) Office.
Failure to maintain the construction type as required increases the risk of death or injury due to fire.

The deficiency affected the entire facility.

Buildings of Type II (222) construction must have vertical shafts constructed with a two-hour fire resistance rating.The facility failed to ensure elevator shafts were enclosed with construction having a fire resistance rating of at least two hours. Observation determined the second floor west stairway door to the Elevator Equipment Room had no label that indicated the fire protection rating of the door and frame.

The deficiency affected one (1) of two (2) elevator shafts in the facility.

The facility failed to ensure doors to hazardous areas in fully sprinklered existing health care occupancies were equipped with self-closing/automatic latching hardware and the hazardous areas were constructed to resist the passage of smoke to adjacent areas.

Observation determined:
1) The corridor door to the second floor Medical Records Storage Room lacked a self-closing device.2) The corridor door to the second floor EMS Office/Storage Room lacked a self-closing device.
3) The corridor door to the second floor Human Resources Records Storage Room lacked a self-closing device.4) The corridor door to the first floor Ambulance Garage/Storage Room had a mechanical hold-open device installed on the self-closing device that prevented the door from self-closing.5) Three (3) unsealed conduits that penetrated the corridor wall separation from the Ambulance Garage/Storage Room were not sealed to prevent the passage of fire/smoke into the space above the west exit corridor ceiling
6) A bundle of low voltage cables that penetrated the corridor wall separation from the Ambulance Garage/Storage Room was not sealed to prevent the passage of fire/smoke into the space above the west exit corridor ceiling.

Failure to ensure hazardous areas are provided with self-closing/positive latching doors and and are separated from other spaces by smoke resisting partitions and doors increases the risk or death or injury due to fire.

This deficiency affected four (4) of eleven (8) hazardous areas in the facility.

The facility failed to ensure emergency lighting of at least 1½ hour duration.

The Minor Surgical Procedure Room lacked battery-pack lighting.

The Maintenance Director acknowledged the finding when the deficiency was identified.

Failure to provide emergency lighting as required increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) Minor Surgical Procedure Room.

The facility failed to establish a comprehensive written plan for the evacuation of patients in the event of a fire emergency.

The administration of health care facilities is to develop and distribute to all supervisory personnel written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees are to be periodically instructed and kept informed with respect to their duties under the plan.

Records review determined the written plan for the evacuation of patients did not include calling the fire department.

The facility failed to test the fire alarm system as required.

Review of fire alarm system test records indicated the semiannual load voltage tests of the sealed lead acid batteries were not performed as required.

Failure to test and maintain the fire alarm system in accordance with NFPA 72, National Fire Alarm Code, increases the risk of death or injury due to fire.

This deficiency affected two (2) of two (2) required load voltage tests of the batteries in the last year.

Ref: 2000 NFPA 101 Section 19.3.4.1, 9.6.1.4; 1999 NFPA 72 table 7-3.2 item 6.d.3.

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. Heat from a fire stratifies to the ceiling and travels along the ceiling to activate the sprinkler. When ceiling tiles are removed, it may delay the activation of the automatic fire sprinkler system. Observation determined:1) Missing ceiling tiles in the second floor Housekeeping Room located across from the Social Services Office, Respiratory Therapy Storage Room, and the Physical Therapy Room.2) The shower curtain suspended from a ceiling mounted track obstructed coverage of the sprinkler in Patient Room #101. 3) The shower curtain suspended from a ceiling mounted track obstructed coverage of the sprinkler in the Tub Room across from Patient Room #101. 4) The sprinkler in the west exit corridor by the entrance to the Ambulance Garage was not ordinary rated, but was high temperature rated. The sprinkler was blue color coded which is an indication of a high temperature rating. These sprinklers are to be used only when the maximum ceiling temperature exceeds 225 deg Fahrenheit. The contents of the corridor did not warrant treatment as a high or extra hazard occupancy. Ordinary temperature rated sprinklers must be used throughout buildings unless located in a location which warrants a higher temperature rated sprinkler. 5) One (1) sprinkler in the first floor Medication Room had paint on the sprinkler deflector.6) One (1) of two (2) covers for the fire department connection was missing.7) A cover was missing from a sprinkler outside the Minor Surgery Room.

Failure to ensure there is no delay in time for the activation of the sprinkler system for all portions of the building increases the risk of injury and death due to fire.

Failure to inspect, test and maintain the automatic sprinkler system in accordance with NFPA 25 increases the risk of death or injury due to fire.The automatic sprinkler system serves the entire building.

Oxygen cylinders must be properly chained or supported in a proper cylinder stand or cart. NFPA 99 Standard for Health Care Facilities, 1999 Edition, Chapter 4.The facility failed to ensure oxygen cylinders were secured in accordance with the requirements of NFPA 99. Observation determined three (3) free standing oxygen cylinders in the EMS Office/Storage Room. Failure to secure oxygen cylinders increases the risk of death or injury due to fire.The deficiency affected the entire facility.

The facility failed to ensure the oxygen supply system and all components were in accordance with the requirements for a Type I Gas System. NFPA 99, Chapter 4. Observation determined: 1) The medical gas system alarm was not connected to the oxygen supply system with an audible and visual alarm installed at an attended location. 2) The oxygen supply piping had no markings or labels applied every 20 feet to the piping to indicate the content of the gas line.3) There was no emergency oxygen supply connection located on the main building.4) There were ten (10) oxygen cylinders for the oxygen supply system that were not secured and located to prevent them from falling or being knocked over. Provisions were not made to protect cylinders from accidental damage or dislocationFailure to ensure oxygen supply systems comply with NFPA 99 increases the risk of death or injury due to fire.The deficiency affected the entire facility.

1) Exit and directional signs must be displayed in accordance with Section 7.10 with continuous illumination also served by the emergency lighting system. The facility failed to ensure exit signs were continuously illuminated.Observation determined the east exit sign was not illuminated at the time of the survey.2) Automatic fire sprinkler systems must be installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems 1999 Edition.

The facility failed to install the automatic sprinkler system in accordance with NFPA 13 to provide adequate coverage for all portions of the building.

Observation determined:

a) The coverage for the sprinkler located in the Employee Locker Room was obstructed by a light fixture.

b) The coverage for the sprinkler located in the Restroom across from Treatment Room B-9 was obstructed by a light fixture.

c) Privacy curtains in Treatment Rooms A-2, A-3, A-4, A-9, B-4, and B-5 had mesh panels at the top 18" less than ½" diagonal measurement.Failure to install the automatic sprinkler system in accordance with NFPA 13 for all portions of the building increases the risk of injury and death due to fire.

The deficiency affected the entire facility.

Maintenance of emergency generator batteries must include checking and recording the value of the specific gravity. NFPA 110, Section A-6-3.6

Record review and interview of maintenance staff determined the batteries in the emergency generator were not tested for specific gravity.

Failure to ensure the emergency generator is in compliance with NFPA 110, Standard for Emergency and Standby Power Systems, increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) emergency generator which provides all emergency power for the building.

Flexible cords must not run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors. NFPA 70, National Electrical Code, Section 400-8.

Observation determined the facility failed to ensure electrical wiring complied with NFPA 70.1) A cover was missing from an electrical box housing four (4) light switches in the H.I.S. Storage Room.
2) Powerstrips were "daisy-chained" from one to the next powerstrip in the second floor Conference Room.3) The heated door seal for the Dietary Department freezer was not installed in accordance with NFPA 70. The wiring to the damaged door seal had electrical wiring plugged into a wall receptcle. The wiring had the insulation removed and exposed wiring was attached to the door seal created a fire hazard as well as an employee electrical shock hazard since the metal door could become energized. 4) Electrical wiring extended from an open conduit near the ceiling into the Housekeeping Room located by the Kitchen corridor. Each conductor extended from the wire insulation out of the conduit and had wire nuts attached. 5) An electrical junction box located above the ceiling tile in the Kitchen corridor had no cover.6) A cover was missing from an electrical receptacle adjacent to the refrigerator in the Nutrition Room.7) Powerstrip cords for televisions in multiple patient rooms on the first floor originated adjacent to the televisions and extended upward through the suspended ceilings and back down through the ceilings to an electrical wall receptacle.These deficiencies were acknowledged by the Maintenance Director.
Failure to ensure the electrical wiring complies with NFPA 70 for all portions of the building increases the risk of injury and death due to fire.

The deficiency affected numerous rooms in the facility.

Fire barriers between a nonconforming occupancy (Grafton Family Clinic) and the hospital must be fire barriers having at least a two-hour fire resistance rating with openings protected by self-closing and positive latching 90-minute fire rated doors.

The facility failed to ensure doors in occupancy separation walls were positive latching.

Observation determined:
1) The west door leaf of the pair of 90-minute fire rated doors in the two-hour fire rated occupancy separation wall failed to self-close and latch into its frame. 2) Unsealed spaces around two (2) cables passing through the occupancy separation wall above the east 90-minute fire rated door negated the fire resistance rating of the wall. 3) Unsealed spaces around two (2) cables passing through the occupancy separation wall above the west 90-minute fire rated door negated the fire resistance rating of the wall.
The Maintenance Director acknowledged the findings when the deficiencies were identified.

Failure to ensure the fire resistance rating of occupancy separation walls and positive latching of fire rated doors as required increases the risk of death or injury due to fire.

The deficiencies affected the fire resistance of the occupancy separation between the hospital and the clinic.

Ref: 2000 NFPA 101 Section 19.1.1.4.1, 8.2.3.2.1(a), 1999 NFPA 80 Section 2-4.4.1

The facility failed to ensure the appropriate building construction type.

Observation determined:

1) There was an unsealed opening (approximately 8" x 8") in the mesh and plaster ceiling in the first floor Medication Room. The mesh and plaster ceiling is a component of the two-hour fire-rated floor/ceiling assembly. 2) The facility failed to maintain the two-hour fire resistive rating of elevator shaft enclosures.

a) There was a through-wall open conduit penetration of the freight elevator enclosure at the first floor corridor location above the ceiling. b) There were unsealed spaces around a through-wall conduit penetration of the freight elevator enclosure at the first floor corridor location above the ceiling. 4) There were unsealed spaces around a three (3) inch PVC pipe in the roof/ceiling assembly in the Ambulance Garage/Storage Room. These unsealed spaces do not prevent the passage of fire and smoke from this hazardous area to the Emergency Room. 5) There was an unsealed opening approximately 4" x 8" in the roof/ceiling assembly in the Ambulance Garage/Storage Room. These unsealed spaces do not prevent the passage of fire and smoke from this hazardous area to the Emergency Room. 6) Five (5) through-floor penetrations ranging in size from 1/2" to 3" in diameter were open from the first to the second floor in the Information Technology (I.T.) Office.
Failure to maintain the construction type as required increases the risk of death or injury due to fire.

The deficiency affected the entire facility.

Buildings of Type II (222) construction must have vertical shafts constructed with a two-hour fire resistance rating.The facility failed to ensure elevator shafts were enclosed with construction having a fire resistance rating of at least two hours. Observation determined the second floor west stairway door to the Elevator Equipment Room had no label that indicated the fire protection rating of the door and frame.

The deficiency affected one (1) of two (2) elevator shafts in the facility.

The facility failed to ensure doors to hazardous areas in fully sprinklered existing health care occupancies were equipped with self-closing/automatic latching hardware and the hazardous areas were constructed to resist the passage of smoke to adjacent areas.

Observation determined:
1) The corridor door to the second floor Medical Records Storage Room lacked a self-closing device.2) The corridor door to the second floor EMS Office/Storage Room lacked a self-closing device.
3) The corridor door to the second floor Human Resources Records Storage Room lacked a self-closing device.4) The corridor door to the first floor Ambulance Garage/Storage Room had a mechanical hold-open device installed on the self-closing device that prevented the door from self-closing.5) Three (3) unsealed conduits that penetrated the corridor wall separation from the Ambulance Garage/Storage Room were not sealed to prevent the passage of fire/smoke into the space above the west exit corridor ceiling
6) A bundle of low voltage cables that penetrated the corridor wall separation from the Ambulance Garage/Storage Room was not sealed to prevent the passage of fire/smoke into the space above the west exit corridor ceiling.

Failure to ensure hazardous areas are provided with self-closing/positive latching doors and and are separated from other spaces by smoke resisting partitions and doors increases the risk or death or injury due to fire.

This deficiency affected four (4) of eleven (8) hazardous areas in the facility.

The facility failed to ensure emergency lighting of at least 1½ hour duration.

The Minor Surgical Procedure Room lacked battery-pack lighting.

The Maintenance Director acknowledged the finding when the deficiency was identified.

Failure to provide emergency lighting as required increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) Minor Surgical Procedure Room.

The facility failed to establish a comprehensive written plan for the evacuation of patients in the event of a fire emergency.

The administration of health care facilities is to develop and distribute to all supervisory personnel written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees are to be periodically instructed and kept informed with respect to their duties under the plan.

Records review determined the written plan for the evacuation of patients did not include calling the fire department.

The facility failed to test the fire alarm system as required.

Review of fire alarm system test records indicated the semiannual load voltage tests of the sealed lead acid batteries were not performed as required.

Failure to test and maintain the fire alarm system in accordance with NFPA 72, National Fire Alarm Code, increases the risk of death or injury due to fire.

This deficiency affected two (2) of two (2) required load voltage tests of the batteries in the last year.

Ref: 2000 NFPA 101 Section 19.3.4.1, 9.6.1.4; 1999 NFPA 72 table 7-3.2 item 6.d.3.

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. Heat from a fire stratifies to the ceiling and travels along the ceiling to activate the sprinkler. When ceiling tiles are removed, it may delay the activation of the automatic fire sprinkler system. Observation determined:1) Missing ceiling tiles in the second floor Housekeeping Room located across from the Social Services Office, Respiratory Therapy Storage Room, and the Physical Therapy Room.2) The shower curtain suspended from a ceiling mounted track obstructed coverage of the sprinkler in Patient Room #101. 3) The shower curtain suspended from a ceiling mounted track obstructed coverage of the sprinkler in the Tub Room across from Patient Room #101. 4) The sprinkler in the west exit corridor by the entrance to the Ambulance Garage was not ordinary rated, but was high temperature rated. The sprinkler was blue color coded which is an indication of a high temperature rating. These sprinklers are to be used only when the maximum ceiling temperature exceeds 225 deg Fahrenheit. The contents of the corridor did not warrant treatment as a high or extra hazard occupancy. Ordinary temperature rated sprinklers must be used throughout buildings unless located in a location which warrants a higher temperature rated sprinkler. 5) One (1) sprinkler in the first floor Medication Room had paint on the sprinkler deflector.6) One (1) of two (2) covers for the fire department connection was missing.7) A cover was missing from a sprinkler outside the Minor Surgery Room.

Failure to ensure there is no delay in time for the activation of the sprinkler system for all portions of the building increases the risk of injury and death due to fire.

Failure to inspect, test and maintain the automatic sprinkler system in accordance with NFPA 25 increases the risk of death or injury due to fire.The automatic sprinkler system serves the entire building.

Oxygen cylinders must be properly chained or supported in a proper cylinder stand or cart. NFPA 99 Standard for Health Care Facilities, 1999 Edition, Chapter 4.The facility failed to ensure oxygen cylinders were secured in accordance with the requirements of NFPA 99. Observation determined three (3) free standing oxygen cylinders in the EMS Office/Storage Room. Failure to secure oxygen cylinders increases the risk of death or injury due to fire.The deficiency affected the entire facility.

The facility failed to ensure the oxygen supply system and all components were in accordance with the requirements for a Type I Gas System. NFPA 99, Chapter 4. Observation determined: 1) The medical gas system alarm was not connected to the oxygen supply system with an audible and visual alarm installed at an attended location. 2) The oxygen supply piping had no markings or labels applied every 20 feet to the piping to indicate the content of the gas line.3) There was no emergency oxygen supply connection located on the main building.4) There were ten (10) oxygen cylinders for the oxygen supply system that were not secured and located to prevent them from falling or being knocked over. Provisions were not made to protect cylinders from accidental damage or dislocationFailure to ensure oxygen supply systems comply with NFPA 99 increases the risk of death or injury due to fire.The deficiency affected the entire facility.

1) Exit and directional signs must be displayed in accordance with Section 7.10 with continuous illumination also served by the emergency lighting system. The facility failed to ensure exit signs were continuously illuminated.Observation determined the east exit sign was not illuminated at the time of the survey.2) Automatic fire sprinkler systems must be installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems 1999 Edition.

The facility failed to install the automatic sprinkler system in accordance with NFPA 13 to provide adequate coverage for all portions of the building.

Observation determined:

a) The coverage for the sprinkler located in the Employee Locker Room was obstructed by a light fixture.

b) The coverage for the sprinkler located in the Restroom across from Treatment Room B-9 was obstructed by a light fixture.

c) Privacy curtains in Treatment Rooms A-2, A-3, A-4, A-9, B-4, and B-5 had mesh panels at the top 18" less than ½" diagonal measurement.Failure to install the automatic sprinkler system in accordance with NFPA 13 for all portions of the building increases the risk of injury and death due to fire.

The deficiency affected the entire facility.

Maintenance of emergency generator batteries must include checking and recording the value of the specific gravity. NFPA 110, Section A-6-3.6

Record review and interview of maintenance staff determined the batteries in the emergency generator were not tested for specific gravity.

Failure to ensure the emergency generator is in compliance with NFPA 110, Standard for Emergency and Standby Power Systems, increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) emergency generator which provides all emergency power for the building.

Flexible cords must not run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors. NFPA 70, National Electrical Code, Section 400-8.

Observation determined the facility failed to ensure electrical wiring complied with NFPA 70.1) A cover was missing from an electrical box housing four (4) light switches in the H.I.S. Storage Room.
2) Powerstrips were "daisy-chained" from one to the next powerstrip in the second floor Conference Room.3) The heated door seal for the Dietary Department freezer was not installed in accordance with NFPA 70. The wiring to the damaged door seal had electrical wiring plugged into a wall receptcle. The wiring had the insulation removed and exposed wiring was attached to the door seal created a fire hazard as well as an employee electrical shock hazard since the metal door could become energized. 4) Electrical wiring extended from an open conduit near the ceiling into the Housekeeping Room located by the Kitchen corridor. Each conductor extended from the wire insulation out of the conduit and had wire nuts attached. 5) An electrical junction box located above the ceiling tile in the Kitchen corridor had no cover.6) A cover was missing from an electrical receptacle adjacent to the refrigerator in the Nutrition Room.7) Powerstrip cords for televisions in multiple patient rooms on the first floor originated adjacent to the televisions and extended upward through the suspended ceilings and back down through the ceilings to an electrical wall receptacle.These deficiencies were acknowledged by the Maintenance Director.
Failure to ensure the electrical wiring complies with NFPA 70 for all portions of the building increases the risk of injury and death due to fire.

The deficiency affected numerous rooms in the facility.