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Based on observations during tour of the facility, and interviews with facility staff it was determined that the facility failed to maintain fire protection and occupancy features necessary to minimize danger to residents from smoke, fumes or panic should a fire occur. The facility failed to maintain corridor doors to prevent impediments to closing to limit the transfer of smoke / heated gases should a fire occur. This condition could allow smoke and fire gases to quickly spread, in the event of a fire, endangering building occupants.


Findings include:
On October 18, 2012 at 3:00 PM while on tour of the facility with facility maintenance staff, at the main corridor at room 25, the corridor doors failed to completely close when released from their magnetic hold open devices. These conditions could result in two smoke compartments to become involved in a fire/smoke situation and could result in the spread of fire, smoke, and fire gasses permeating the building and jeopardizing patients and staff. According to NFPA 101 (2000) 19.3.7.6; "Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6. Such doors in smoke barriers shall not be required to swing with egress travel. Positive latching hardware shall not be required."
On October 18, 2012 at 3:00 PM while on tour of the facility with facility maintenance staff, the fire alarm system was activated. While in the main corridor, the fire/smoke doors were observed during the alarm. (4) of (5) doors observed failed to release from their magnet hold open devices. These conditions could result in two smoke compartments to become involved in a fire/smoke situation and could result in the spread of fire, smoke, and fire gasses permeating the building and jeopardizing patients and staff. According to NFPA 101 (2000) 19.3.7.6; "Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6. Such doors in smoke barriers shall not be required to swing with egress travel. Positive latching hardware shall not be required."

Based on observations during tour of the facility, it was determined that the facility failed to maintain fire protection and occupancy features necessary to minimize danger to residents from smoke, fumes or panic should a fire occur. The facility failed to provide fire rated doors to limit the transfer of fire, smoke / heated gases should a fire occur. This condition could allow fire, smoke and fire gases to quickly spread, in the event of a fire, endangering building occupants.

Findings include:
On October 18, 2012, at 1:08 PM while on tour of the facility with facility staff, the fire door at the laundry entrance was released from the open position and failed to fully close and latch. This was repeated three times and the door failed to latch at each attempt. The door was part of a rated enclosure in a hazardous area and meant to be self-closing and latching. Failure of the door to self-close and latch in a fire could result in the spread of fire, smoke and fire gasses to the rest of the building, endangering the occupants. According to NFPA 101 (2000 edition) 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. Hazardous areas shall include, but shall not be restricted to, the following: (2)Central/bulk laundries larger than 100 ft2 (9.3 m2)", and 8.4.1.3; "Doors in barriers required to have a fire resistance rating shall have a ?-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.", and 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."

At 1:12 PM while on tour of the facility with facility staff, the door to the central supply was observed to be held open by a wedge at the bottom of the door. The door was part of a rated enclosure and required to be self closing. Failure of the door to self close in a fire could result in the spread of fire, smoke and fire gasses to the rest of the building, endangering the occupants. NFPA 101 (2000) 19.3.2.1

Based on records review and interviews with facility maintenance staff and facility administrator, the facility failed to conduct fire and disaster drills on a gegular basis as outlined in NFPA 101 Ch. 19. Conducting drills on a regular basis is required to keep employees familiar with drill procedures and to introduce newly hired employees to the facilities fire procedures.

Findings include:

On October 18, 2012 at 10:06 AM while conducting records review, the fire drill logs were observed. The log had records of (4) 1st shift drills for the prior twelve months. The log had records of (2) 2nd shift drills for the prior twelve months. Drills shall be conducted at a frequency of once per shift per quarter. Upon review of the disaster drill records, no evidence of an external or internal disaster drills were provided. NFPA 101 (2000 edition) 19.7.1.2 "Drills shall be conducted quarterly on each shift..." and 4.7.3 "Responsibility for the planning and conduct of drills shall be assigned only to competent persons qualified to exercise leadership."

Based on observations and records review, the facility failed to maintain their fire alarm system in accordance with NFPA 72.

Findings include:
On October 18, 2012 at 9:38 AM while while performing records review, the fire alarm log was located and no evidence of annual inspection and testing of the fire alarm system could be found subsequent to June 20, 2011. While on tour of the facility, the fire alarm panel was observed to have an inspection label dated June 2010. Annual fire alarm panel, initiation and detection devices is required to insure reliable performance of the system Failure of the system or its components could result in the delayed notification of the occupants and fire and rescue personnel. NFPA 72 (1999) 7-3.1, 7-3.2

Based on observations, interviews with maintenance staff, and records review, the facility failed to maintain their fire alarm system in accordance with NFPA 72. Failure to maintain the fire alarm panel could result in system failure and leave the building without notification of a fire to the occupants of the building and fire and rescue personnel.

Findings include:
On October 18, 2012 at 10:00 PM while conducting records review and during subsequent interviews with facility staff, and on observation of the fire alarm panel, the fire alarm panel was observed to have only portions of its designed features operational. Staff indicated that on July 25, 2012 the fire alarm panel went into trouble. The service company responded and was unable to determine the cause of the trouble. The wiring connectors to the circuit board of the panel were then removed and replaced one at a time until the circuit causing the trouble signal was isolated. That circuit was not identified as to its function and remained disconnected until the time of this survey. Fire alarm panel, initiation and detection devices are required to insure reliable performance of the system. Failure of the system or its components could result in the delayed notification of the occupants and fire and rescue personnel. NFPA 72 (1999) 7-3.1, 7-3.2

Based on a review of the facility records, interviews with the staff, it was determined that automatic sprinkler system was not maintained, inspected and tested in accordance with NFPA 25. This in the event of fire could delay or deny extinguishment of a fire from impairments and or lack of required service to the system.
Findings include:
On October 18, 2012 at 10:30 AM while performing records review and observations made while on tour of the facility, no evidence of quarterly sprinkler inspection was able to be provided by maintenance staff. Missing was the prior year fourth quarter, current year second, and third quarterly sprinkler reports. No inspection tags for those quarters were observed on the sprinkler riser while on tour of the facility. Quarterly sprinkler inspection is required to insure the reliable operation of the sprinkler system in the event of of a fire. NFPA 25 (1998 edition) 1-4.2 "The responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed. Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer ' s instructions. These tasks shall be performed by personnel who have developed competence through training and experience.", and 1-8.2; "Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard." 1-9.2; "Inspection and periodic testing determine what, if any, maintenance actions are required to maintain the operability of a water-based fire protection system. The standard establishes minimum inspection/testing frequencies, responsibilities, test routines, and reporting procedures but does not define precise limits of anomalies where maintenance actions are required."

Based on observation, records review, and interviews with facility maintenance and dietary staff, no records of commercial cooking hood system cleaning and maintenance could be produced and evidence of semi annual hood suppression system testing could not be produced. Hood systems shall be installed and maintained per NFPA 96; Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations and suppression systems per NFPA 17A. Failure to maintain systems could result in grease fires leading to structure fire which would endanger building occupants and interrupt food services to the residents of the facility.

Findings include:

On October 18, 2012 at 9:45 AM while conducting records review with facility maintenance staff, no records of commercial hood cleaning could be produced for the current year. The most current records indicated hood cleaning on November 4, 2011 NFPA 96 (1998 edition) 8-3.1 "Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1."

On October 18, 2012 at 9:45 AM while conducting records review with facility maintenance staff, no records of commercial hood fire suppression system inspection amd mailtenance could be found for the time period followning the prior inspection on February 20, 2012. The frequency of inspections shall be every 6 months per NFPA 17A (1998) 5-3.1.1; "At least semiannually, maintenance shall be conducted
in accordance with the manufacturer ' s listed installation and maintenance manual.", and 5-2.1; "Inspection shall be conducted on a monthly basis in accordance with the manufacturer ' s listed installation and maintenance manual or the 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) No obvious physical damage or condition exists that might prevent operation. (f) The pressure gauge(s), if provided, is in operable range. (g) The nozzle blowoff caps are intact and undamaged. (h) The hood, duct, and protected cooking appliances have
not been replaced, modified, or relocated.", and 5-2.2; "If any deficiencies are found, appropriate corrective action shall be taken immediately.", and 5-2.3; "Personnel making inspections shall keep records for those extinguishing systems that were found to require corrective actions."

Based on observation the facility failed to maintain courtyard exit doors doors from impediments to opening and from meeting the requirements of special locking arrangements. This could impede the exiting of occupants in an emergency and result in harm to the occupants from the dangers of the emergency situation.

Findings include:
On October 18, 2012 at 3:10 PM while on tour of the facility with facility staff in the O.R. recovery room, a marked exit door was observed. Attempts to open the door were unsuccessful as the door was stuck in its frame. According to NFPA 101(2000 edition) 7.2.1.4.5; "The forces required to fully open any door manually in a means of egress shall not exceed 15lbf to release the latch, 30 lbf to set the door in motion, and 15lbf to open the door to the minimum required width"

Based on observations and interviews with facility staff, the facility failed to properly store compressed medical gas cylinders (oxygen) in accordance with NFPA 99, standard for Health Care Facilities. Improper storage of medical gas cylinders could result in the rupture of the cylinders and subsequent accelerated development of fire, smoke and fire gasses in a fire situation.

Findings include:
On October 18, 2012 at 3:21 PM while on tour of the facility with facility maintenance staff in the radiology control room, an e-size oxygen cylinder was observed to be free standing. In an interview with survey team members, team members had brought the loose cylinder to the attention of radiology staff. Facility staff failed to correct the situation after one day. According to NFPA 99 (1999 edition) 4-3.1.1.1; "Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.", and 4-5.5.2.1 (27) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart and comply with 4-5.1.1.1."

Based on observations and interviews with facility staff, the facility failed to properly maintain piped in medical gas (oxygen) in accordance with NFPA 99, standard for Health Care Facilities. Failure to maintain piped in medical gas systems could result in the rapid spread and development of fire endangering patients and occupants of the building.

Findings include:
On October 18, 2012 at 1:25 PM while on tour of the 100 wing of the facility at room 126, an oxygen outlet and regulator at the headwall was observed. Escaping gas (oxygen) could be heard and felt at the outlet/regulator. NFPA 99 (1999 edition) 4-2.3; "Manufactured Assemblies. Specific hazards associated with manufactured assemblies are the same as those listed in 4-2.2 as well as additional hazards resulting from improper assembly, separation and leakage resulting from hidden semi-permanent connections, improper connection resulting in cross-connection, and blockage and flow problems resulting from damage to hoses, etc."

Based on observation and interviews, the facility failed to provide a remote annunciator panel for the generator in a manner that would provide for an audible alarm at a monitored location. It was determined that the facility failed to provide required inspection maintenance and testing of the emergency power supply system components in accordance with NFPA 99 and NFPA 110 "Standard for Emergency and Standby Power Systems." This could result in a generator malfunction without staff being aware and resulting in loss of emergency power to the facility.


Findings include:
On October 18, 2012 at 3:40 PM while on tour of the facility with the facility maintenance director, a remote annunciator for the generator was looked for at the nurses stations and other areas of the building. No remote annunciator was discovered. Facility staff and maintenance director indicated that they did not know if the generator had a remote annunciator. NFPA 110 (1999 edition) 3-5.6.1; "A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2 (d). This remote alarm shall be located outside of the EPS service room at a work site observable by personnel."
On October 18, 2012 at 10:40 AM while conducting records review of the facility, no current (within one year) report of generator service could be provided. The most recent report provided was dated June 1, 2011. According to NFPA 99 (1999 edition) 3-4.4.1.1(b) 1.* Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not 20 days or exceeding 40 days.Generator sets serving emergency and equipment systems shall comply with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.

Based on records review, the facility failed to provide evidence of generator maintenance and testing in accordance with NFPA 110 (1999). Failure to inspect and maintain the generator in accordance with these standards could result in the generator malfunctioning with a resulting loss of power to the facility.

Findings include:

Findings include:
On October 18, 2012 at 9:30 AM while performing records review, no evidence of weekly and monthly generator runs was made available by facility staff. Monthly generator runs are a requirement of NFPA 110 (1999) 6-4.1; "Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly." and 6-4.2; "Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods: (a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating (b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer The date and time of day for required testing shall be decided by the owner, based on facility operations."

Based on interviews with staff and records review, the facility failed to maintain a fire watch during a system failure for the complete duration of the failure. Failure to maintain a fire watch could result in the development of a fire in an unattended portion of the building without the activation of initiating devices and the notification of fire and rescure personnel.

Findings include:
On October 18, 2012 at 9:00 AM while conducting records review of the facility with facility maintenance staff and later during interviews with the maintenance director, director of housekeeping and an employee of the facility, it was determined that the fire alarm system failed on July 25, 2012 and remained impaired until the time of this survey (over 80 days.) Staff indicated that a fire watch had been initiated for the first 21 hours of the failure and was then terminated. Staff also indicated that employees were also performing their regularly assigned duties while acting in the capacity of a person responsible for fire watch duties. According to NFPA 101 (2000 edition) 9.6.1.8; "Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the AHJ shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service."